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Payer-provider relationships: Pre and post COVID-19 worlds

October 27, 2020
Abhay Singhal
By Abhay Singhal and Sheetal Sawardekar

Value-based care: A big wave that changed the U.S. healthcare landscape
Traditional fee-for-service models have long challenged the industry due to conflicting priorities. Providers work to maximize reimbursement for the services they provide, while payers continue to reduce payments. Unfortunately, patient outcomes were not the center of the compensation structure. The evolution to value-based care (VBC) is the paradigm shift that realigns the payer-provider relationship to a more proactive and collaborative one, focused on the patient’s overall well-being.

Over the last decade numerous efforts have been made to encourage VBC models, including interoperability so patient data exchange becomes seamless. However, there is still significant work to do to achieve the ultimate goal of improving patient care. While there is never a good time to undertake more challenges, there are practical things payers and providers can do in the short term that will drive interoperability across the healthcare ecosystem, making it better for consumers, patients, members and the ever-changing payer-provider relationship.

Sheetal Sawardekar
In an independent study conducted by AAFP, adoption of VBC models has been increasing, however implementing VBC has its own challenges. Prior to COVID-19, the industry was making significant headway and evolving payer-provider relationships, however the pandemic caused another shift in priorities. While there is still work to do to transform the industry, there are definitive steps and milestones that organizations can take to ease their journey.

Payer-provider collaboration is key
By definition, VBC rewards providers for the quality of patient outcomes rather than the quantity. The reimbursement ties payments for care delivery to the quality of care provided, shares the risk between payers and providers and rewards providers for both efficiency and effectiveness. The transition to VBC has increasingly emphasized the need for collaboration between payers and providers and underscored the need for interoperability to facilitate digital transfer of patient data at the point of care. In addition, it encourages collaboration to develop treatment plans, identify care gaps and offer high-quality collaborative care, which has the potential to decrease overall care costs and improve the health of member populations.

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