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

October 27, 2020

For the last few years, payers have worked to create clean data sets, but now must assess if data is accurate and then design appropriate payment algorithms and the reports sent to providers. Over-reporting or providing too little data impacts a provider’s ability to make informed decisions. With VBC still in play, payers are equally required to understand the treatment recommendations in order to identify what is necessary and what is not.

Improve transparency and enhance communication
Contracts are signed between payers and providers to define rules in an attempt to increase transparency and create policies to avoid any surprises post-claim, which includes reimbursement costs, denial reasons and partial payment procedures. Adopting analytics tools for identifying high risk patients, preventing avoidable admissions, avoiding unnecessary medical services and improving population health outcomes is a growing trend.

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One such important analytic tool to have in your organization’s repertoire is a PHM analytics solution. Around 5-10% of the population are high cost utilizers. Although such patients represent a small proportion of the entire patient population, they account for a substantial proportion of healthcare costs. Managing high risk, high cost utilizing populations and pushing for preventive care is the key to containing costs. Additionally, every patient cohort has separate needs. PHM is proven to be important for operational and overall financial success for providers, however payers are also seen to be leveraging PHM for preventive and proactive engagement. The roadmap defined by NCQA demonstrates how PHM can be a model of care for managing populations in VBC contracts.

However, a “one-size-fits-all” approach does not work with all contracts between payers and providers. Customization is required based on patient demographics and social determinants of health and it’s important to leverage tools and technologies like predictive analytics and population health management preventive services to ensure this is properly executed. All contracts should also be supported by actionable insights to regularly assess the effectiveness of the rules agreed on by both parties. While regular reevaluation of the contractual terms and rules defined is necessary, an oversight of how patient outcomes and financial risk sharing is impacted is also important in order to maintain a successful payer-provider relationship.

Give patients access to their secure data
Payers and providers are exploring additional VBC models like Accountable Care Organizations (ACOs), Patient-Centered Medical Homes (PCMH) or bundled payment models for better savings and effective reimbursements. VBC aims to reduce the overall cost of healthcare, which directly correlates to lower utilization rates for direct healthcare services. While the structure of the models differs, such initiatives are based on fundamental layers of interoperability and data standards. Sharing patient data across the care continuum has become a mandate for successful integration. Patient education, their knowledge of their health problems and how to care for themselves are key determinants to reduce healthcare service utilization while maintaining the quality of care. In essence, making patient data available is a must as it could improve patient engagement. Boosting patient outcomes is an aim for both payers and providers to reduce overall costs, which is impossible without collaboration.

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