Improving value-based care depends on better payer-provider collaboration
Even before the Affordable Care Act, the relationship between payers and providers has long had its ups and downs. But prior authorization and data interoperability requirements, coupled with patient volumes and clinical documentation needs, mean payers and providers are feeling more pressure than ever.
Value-based care (VBC) offers an alternative to the traditional fee-for-service model of care, incentivizing providers to treat patients more proactively, which may require them to take on more risks. VBC reimburses providers based on patient health outcomes and quality of care rather than volume of services. But for VBC to be effective, providers need a comprehensive view of a patient's health status that will support better patient management and comprehensive treatment. Unfortunately, doing so may also require the use of multiple disparate systems, which often creates a heavy administrative burden.
When VBC is effective, it motivates patients to be more active in their health care and improves patient compliance with treatment plans. The goal is to reduce hospital readmissions and control rising healthcare costs through reimbursement based on patient outcomes. While fee-for-service continues to dominate the healthcare industry, VBC has entered the healthcare mainstream.
In a recent webinar, Amanda Banister, senior manager of provider performance and technology utilization at Veradigm, shared insights on how payers can lead the next phase of VBC implementation and work more effectively with providers.
Collaboration between providers and payers is key
“Value-based care is more than just a policy shift. It's a shift in how we deliver, measure and reward care. But that shift requires connections. Too often payers and providers work with disjointed systems, incomplete data and misaligned incentives, while patients are left with fragmented and reactive care,” Banister said.
A holistic view of patient data is critical to the success of VBC. But this data is often siled or delayed and lacks the context needed to drive decisions at the point of care. Fragmented and incomplete data, especially data that lacks context, prevents healthcare providers and payers from understanding the full picture of their patients. There are also problems with misaligned incentives. While providers are being asked to take on more risk, financial and operational support often fails to do so.
Clinicians need to close gaps, manage quality and document risk, but this is often done through clunky portals or manual processes that increase friction and reduce efficiency. Workflow disruptions and provider fatigue also pose challenges to VBC adoption and implementation. There is a lack of transparency on all sides. This is exacerbated by a lack of clear communication and shared visibility that hinders collaboration between providers and payers. Without clear communication, collaboration can feel like oversight rather than partnership. Banister said broader industry growth drivers shape how we view healthcare innovation.
“Health care providers often feel like they are second-guessed by health plans and overburdened administratively with the need to collect critical information about patients for whom they need to make informed decisions and follow best practices. When payers provide reports and data to health care providers without a timely, if any, response, they often feel ignored,” she explained.
Banister emphasized that when VBC comes into play, the balance of managing patient health depends heavily on the knowledge and ability of payers and providers to collaborate.
“To be honest, it's not easy,” Banister added.
For payers, there are significant investments in quality and risk adjustment programs. Banister said these initiatives rely on better data, closer provider engagement and tools that can support care decisions.
Electronic medical records as a tool to improve payer and provider collaboration
railing It was emphasized that electronic medical records can break down the divide between payers and providers and serve as a tool to improve payer and provider collaboration.
“EHR vendors are at a unique intersection with capabilities that can assist payer and provider workflows. We are seeing the development of native platforms that can make clinical and payer data actionable in real time. This is a significant shift from where we were just a few years ago, and it creates new possibilities for how we support providers and payers,” she said.
For VBC to be effective, it is the provider's responsibility to figure out how to help patients close gaps in care, such as missed care activities such as chronic disease management, annual physicals, immunizations, or preventive screenings. This requires providers and payers to develop better partnerships to share all relevant patient data.
“We know that preventive screening and early intervention can reduce downstream emergency room visits and hospital stays,” Banister noted. “We also know that sharing data can reduce duplication of testing and unnecessary referrals.”
Embedding actionable patient care gaps directly into provider workflows and capturing real-world data from the EHR to inform quality of care enables payers to drive collaboration, shared understanding, shared accountability and shared outcomes. To improve chronic disease management, providers need to receive timely care gap alerts and medication history, which they can then use to escalate treatment plans before a patient's condition worsens. Payers can learn about vertical claims, but it does the provider no good if they can't see it and aren't aware of it at the point of care. Care gap alerts while the patient is with the provider present the best opportunity to intervene with the patient since they are face to face in the office. It provides a timely opportunity to address and eliminate these gaps.
Banister also offered some suggestions to payers aimed at improving their work with providers.
“Don't expect providers to do everything at once. Provide achievable, scalable, measurable requirements and goals that are easy wins. Providers will get on board when they see how value-based care improves patient outcomes rather than just cutting costs. You need to give them good data, real-time insights, not spreadsheets. Help them identify gaps, risks and opportunities without drowning in administrative work and overflow,” Banister urges.
She also encouraged payers to clearly offer incentives to providers. Transparent, achievable goals tied to shared savings or bonuses would make sense for providers, she said.
“Support them and don't micromanage them. Provide tools and guidance, but let providers lead care decisions. The real bottom line for providers is that they are engaged when they feel heard, empowered and rewarded,” she added.
Banister summarized how payers and providers can build better relationships to succeed:
“First, we need to reduce friction, increase trust, meet providers and provide ways to support their efforts. Second, foster a culture of ecosystem thinking—increasing interoperability and providing providers with actionable, timely and accurate data that drives the outcomes payers need.”
photo: Luis Alvarez, Getty Images
