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Why payer-provider partnerships need more collaboration


As payers and providers strive for value-based care, all sides need to contribute their part toward better data sharing, improving patient outcomes and delivering quality care.

value based care, healthcare partnerships

The number of accountable care organizations (ACOs) reached an all-time high in 2018, notes an article in the journal Health Affairs. Today, some 33 million patients in the United States are served by Medicaid, Medicare and commercial ACO contracts.

As value-based care models have become the norm within these groups, which share risks and rewards, the quality of payer-provider relationships has taken on new significance. Today, the ability of payers and providers to collaborate effectively is a prerequisite for any healthcare organization’s success.

Yet while physician practices, hospitals, ancillary services and payers are taking steps to collaborate more effectively, a new survey suggests they could be doing more.

Understanding payer-provider challenges

According to a 2019 survey sponsored by SPH Analytics of more than 80 providers and health plans, 94 percent of respondents say they believe collaboration between payers and providers is now a key determinant of success. Most of the care partners surveyed have specific ideas around what they can do to improve their relationships to achieve value-based goals, which include high-quality care, positive outcomes and measurable cost savings. Additionally, 72 percent of those surveyed say they have already taken important steps to improve their collaboration with other constituents in the care chain.

Much of this hard work is already paying off. Providers and payers have made strides in streamlining data sharing and the adoption of collaborative care models, for example. This is a vast improvement from the recent past, when reports of more adversarial relations between providers and payers were common, including payment delays, micromanagement and rationing care through inconvenience.

But while payers and providers both acknowledge the importance of effective collaboration, the actual execution is still a work in progress. Fittingly, 35 percent of payers and 24 percent of providers highlighted the “willingness to collaborate” as their biggest challenge, according to the survey. One-third of providers and payers also noted that technology is still an obstacle.

There are other challenges, too. Payers cited limited resources (14 percent), while nearly one out of five providers said the value-based contracts themselves were the most challenging aspect of collaborative partnerships.

Coming together

Given the disconnect between our intentions and what’s really happening, how can payers and providers align their goals? Based on what we’ve seen from the most successful healthcare industry partnerships, here are three key takeaways:

Measure quality consistently.

Payers and providers entering into an ACO or other partnership often struggle to find common ground when it comes to measuring quality. Payers want to set the standard, but providers don’t want to have to measure or treat patients differently based on each payer’s different benchmarks.

Providers and payers need to discuss quality measurements up front and work together to agree on evidence-based quality measures that will address specific population-health goals, based on the provider’s actual patient polulation and its most pressing needs (e.g., management of chronic conditions).

Emphasize data sharing and make it happen.

Communication is the backbone of all partner relationships, and success requires information to flow in a timely manner across the patient continuum of care. It’s in the area of communication that payers and providers say they have made the biggest improvements in their quest to collaborate more closely, according to the survey.

But while payers and providers are comfortable using information technology solutions to collect and dispatch basic data, they’re still not always comfortable using communications technology to share sensitive clinical and financial information with each another.

More than half (58 percent) of payers and providers surveyed say they don’t have shared population health technology solutions in place, although 19 percent are planning to deploy such tools this year. For partnerships to thrive, it’s crucial that all parties find common ground with technology. Decide what will be shared, how it will be shared and which data-sharing platforms will be used.

Embrace new programs.

New incentive programs are emerging to ease partnerships between providers and payers. Most notably, the National Committee for Quality Assurance (NCQA), which oversees the administration of HEDIS measures for payers based on quality improvement standards, is encouraging payers to incorporate clinical and financial data in their quality reporting, under the recently introduced Population Health Management (PHM) accreditation standards.

The growing use of HEDIS measures among payers and providers is a positive development, but still, a notable portion of care partners don’t share claims data or clinical data. According to the SPH Analytics survey, more than 20 percent of payers are not receiving any real-time clinical data from providers.

Payers and providers have come a long way toward bridging many gaps in collaboration. Still, in order to succeed in the future, they’ll need to increase their focus on communicating, sharing data and aligning goals. By putting some of these suggestions into effect, payer-provider partners will be ahead of the game and raise the bar on what truly collaborative relationships can accomplish.

Collaboration brings so many benefits to all parties including more cohesive clinical data that shows physicians where they can make improvement and supports payer iniaitiatives, such as promoting immunizations. In doing so, collaborative relationships can help physicians and payers truly elevate care while achieving cost savings and other benefits.

Amy Amick is President and CEO of SPH Analytics, an Alpharetta, Ga.-based healthcare and population health management data analytics firm.

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