Evolving Relationship Between Payers and Providers

September 8, 2015 Dave Bennett

In this new era of risk sharing, the relationship between payers and providers is rapidly changing. Both parties now are motivated to move beyond their historic differences and work together to make sure that patients receive the best outcome for lower costs. So what does this all mean? Let's break down some of the cultural and technological aspects. 

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Beginning with the cultural aspect, now more than ever before, payers and providers are seeking to collaborate. Both parties are now at-risk and want to achieve good outcomes for patients while reducing healthcare costs. The right care, at the right time, for the right amount are markers for both payer and provider success. But in order to accomplish these goals, there has to be mutual trust between the two parties. This requires a transition from “carrots and sticks” to true collaboration.

Next we have the technology aspect, which is essential to building trust between two parties who historically have been at odds with one another. In the past, technology has been one of the main culprits for this mistrust, with providers often feeling frustrated with payers for relying on inaccurate data to determine care payment. Payers need to measure outcomes based on impeccably accurate data. They also need to give providers access to accurate, up to date, comprehensive data on patients to ensure those outcomes.

There are a few ways providers and payers can work as one to accomplish these interoperability goals. One area of improvement would be IT infrastructure. Payers can go a long way toward overcoming past mistrust by providing truly useful resources to providers, and in doing so benefit their bottom line in the long run. The prime example of useful resources would be complete, accurate, up-to-date patient records that include both claims and clinical data.

Also, alerts to gaps in care that are useful, believable, timely, and accurate would improve the trust between these constituents, though data and alerts must be delivered at the best time and in the best format for the providers. These include:

  • Embedded alerts in the EMR
  • Alerts generated at the time of care (or as soon as possible)
  • Just the right amount of information to be useful; less can be more
  • Customized data and alerts appropriate for each user type (doctor, admin, care manager, etc.)

As the relationship between payers and providers changes, so must the technology. There is a long way to go before true interoperability is achieved, but the good news is we have already come a long way. Healthcare is at a point were payers and providers can share useful, accurate data, and that process is getting more efficient. The doors to collaboration are open, and more importantly, patient care is improving while still cutting costs.

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Hear Michael Wallace discuss Catholic Health Initiatives' migration story and answer your questions LIVE. Register for the webinar now!

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