Payer/Provider Collaboration: What Works?

Should population health management solutions be backed by a neutral third party to drive adoption?

My role as Chief Strategy Officer for ZeOmega gives me the opportunity to regularly speak with executives from various healthcare organizations, including payers, providers, industry analysts, and fellow IT companies. It is always interesting to see how the discussions converge around a common theme. Last year it was the heated debate around the lack of interoperability and the role of electronic health records (EHRs). In fact, I opined on this very topic in a previous blog back in February. In recent months, leaders from both payer and provider organizations have begun to express intense interest in solutions that will enable them to collaborate better and more seamlessly.

Payers have readily embraced the concept of aligning provider payments to outcomes. In fact, several payers, including large national and regional plans, have publicly announced strategies to transition the majority of their business to value based-care arrangements over the next few years. Payers are now experimenting with a dizzying array of value-based contracts ranging from bundled care arrangements, risk carve-outs, and capitated payments to full risk.

At the same time, CMS recently announced that it would pay providers for certain chronic care management activities. For example, CPT 99490 allows providers to bill up to $42.60 per patient per month for care management activities on patients with co-morbid chronic conditions. And where CMS leads, other payers follow. Payers are also beginning to realize that some other primary care coordination and chronic care management activities are best delivered by providers for best outcomes and some are even considering capitated payments for primary care.

The initial round of “provider collaboration” initiatives among payers centered on value-based care contracts, coupled with delivering technologies that would enable payers to bring in clinical data from several EMRs/EHRs and deliver analytics, gaps in care, and other performance metrics to providers. Some payers even offered these platforms at no cost to the provider in the hopes of driving adoption. But adoption has been mixed because the solutions the payers have proposed do not really address the provider’s needs. Looking at the situation from the provider’s perspective, adding a new technology only adds to their workload because, chances are, they are being asked to adopt similar solutions from every payer they work with. Having to log in to a different technology platform for each individual payer is understandably burdensome, so it is not surprising that adoption has been marginal.

Further, there is also inherent mistrust on part of the provider that prevents them from using payer systems. Many of the provider executives I have spoken with have indicated that a lack of neutrality in “payer-provided” systems is the primary reason behind their hesitation to adopt them. They just aren’t sure what the payer will do with the data. However, these same providers were the first to express a desire to work with payers to drive better outcomes. They also expressed the need for a single solution that works across all of their contractual arrangements, whether it is Medicare, Medicaid, or any of the various payers they work with.

Some forward thinking payers are beginning to recognize the shortcomings of the initial approach and are tweaking their strategies to empower the provider with a solution that removes handcuffs of payer specificity. These organizations also recognize the inherent mistrust of providers and are looking to sponsor neutral third-party solutions/systems over which they would have no control. The idea is to increase comfort among providers and, in the process, encourage them to utilize the system for patients across all of the payers they contract with. These payers also recognize that convenience is the biggest driver of provider adoption. Providing a financial incentive to the provider to deploy a scalable PHM solution, while allowing them to retain full freedom and control of the solution, may be the answer. I recently spoke with the chief medical officer of a regional Blue plan who echoed this thinking. In fact, she stressed that such neutrality is key to any effective provider collaboration strategy.

Ultimately, I believe any solution that seeks to bridge the gap between the payer and provider must be backed by a neutral third party that appreciates the value of such connectivity between the two parties. Our mission at ZeOmega is to empower both our payer and provider clients to best serve the people in their communities. If this means being that neutral third party, as we are beginning to be asked to, by providing a solution like Jiva that cannot only address the problems of interoperability, but also deliver PHM and care coordination capabilities to drive more effective collaboration – we will do it. In fact, nothing would be more delightful or fulfilling for us.