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What is Payer-Provider Collaboration?

What is Payer-Provider Collaboration?

Collaboration between payers and providers has traditionally been for payment and reimbursement of claims. As healthcare costs have increased, this collaboration has been impacted by incentives to providers for higher quality care and payers’ efforts to manage patient care. Managed care has created administrative burden for providers to submit documentation in support of claims and prior authorization. To ease the burden and make collaboration more efficient, providers and payers have adopted standardized electronic data exchange for both claims and clinical data.

Electronic data exchange has significant potential to deliver additional value as more recent technological advances are adopted. Electronic data exchange has improved care coordination, and these improvements can be extended to underserved communities. Nonetheless, security and privacy risks introduced by electronic data exchange must be continuously confronted. Defenses should also be enhanced to preserve the trust and effectiveness in the relationships between providers, payers, and the patients they serve.

Importance of Payer-Provider Data Exchange

Payer-provider data exchange speeds up the collaboration and makes it more effective. Healthcare delivery is both evidence-based and information-driven; decisions that practitioners and patients make require the body of medical knowledge and information specific to the patient’s case. Health outcomes are improved by providers having access to the right information, for the right patient, at the right time and having engaged and informed patients. Access to this information is made possible by providers exchanging data with each other and even more so by payers sharing information with providers and the patients they serve.

Sharing information across these systems brings together those providing care. A primary care physician gets up-to-date patient information from an orthopedist. A payer lets the provider and patient know the prior authorization for physical therapy is approved and for how many visits, so the primary care provider can incorporate appropriate follow-up for the best outcomes.

This also helps the patient stay engaged in their care and may help avoid subsequent treatments for a worsened condition. As providers work in their respective information systems, electronic data exchange helps them be mutually informed. Adding data sourced from the payer can complete the picture of the patient and ensure the delivered treatment accounts for a comprehensive understanding of the patient’s health conditions and other social and economic attributes.

Improving Care Coordination

As patients often receive care across provider organizations (e.g. from an independent community practice, specialty practices, hospitals, or ambulatory surgical centers), assembling a comprehensive patient record for these providers to understand the patient’s health requires coordination across organizational boundaries. Extending the concept of care teams across organizations requires health information exchange and several means are available to accomplish it.

Electronic medical records can send and receive data directly or with the assistance of health information exchanges. Health information exchanges have developed locally, regionally, and within and across states, reaching to the national level as well. Examples include Manifest Medex in California, the Michigan Health Information Network (MiHIN), the Chesapeake Regional Information System for our Patients (CRSIP), eHealth Exchange, or the CommonWell Health Alliance.

Organizations such as these deliver health information exchange for treatment, quality, payment, and healthcare operations or individual access use cases. They exchange information for millions of patient lives, equating to billions of transactions, on a robust and secure infrastructure utilized by thousands of providers and hundreds of payers. Access to this information helps providers prepare for new patient visits, coordinate care via care teams spanning organizations and geographies, and support emergency incidents such as natural disasters or mass casualty events.

Secure Healthcare Data Sharing

Healthcare deals with intimate and emotionally challenging aspects of a person’s life, often when the patient is vulnerable and acutely sensing diminished control of their health despite every effort to care for themselves. Providers and payers sharing identifiable data in these circumstances increases apprehension and threatens patients’ trust with their providers and payers. Patients are concerned about how data sharing can impact their essential relationships, particularly loved ones or employers.

News of data breaches at health systems and insurers heightens patient worries over data sharing. While laws such as the Health Insurance Portability and Accountability Act (HIPAA) and state privacy laws to protect sensitive health data require much in protections for data sharing, only sharing the minimum amount of necessary information and using encryption and authentication technologies help preserve privacy and are sufficient steps to supporting care coordination and enhanced collaboration between providers and payers.

Key Points

Review these key points that will help you create an insightful plan for improving care collaborations.

  1. Collaboration is not the default, and the combination of HIPAA security and privacy and technology safeguards make for the “sweet spot” of right-sized data sharing where providers have the information and context to understand the medical and non-medical factors in a person’s health. It also enables practitioners in various care delivery roles to collaborate better.
  2. Data sharing and use supports whole-person care. Patients will be more engaged if providers understand them holistically, not compartmentalizing medical specialty issues, costs, or socioeconomic factors but seeing the bigger picture of health in context of these other factors that impact the patient’s life. Just as family and social history are part of patient assessments, financial history and a comprehensive view of patient health need to be in focus when delivering care.
  3. Provider time constraints, demands for high quality care, and payers’ efforts at value-based care underscore the need for continuously improving care coordination. Essential to enhancing care coordination is the timely, secure, and accurate exchange of data into provider and payer workflows — where it is best accessed and utilized.

Help Is Nearby

In all, providers and payers will need to collaborate more on data exchange to make it effective in reducing burden for both providers and payers and the patients they serve. The HL7 Da Vinci Project has been an accelerator for payer-provider collaboration on data exchange and has made tremendous progress in recent years. With greater adoption, testing, and implementation, more payers and providers can reap the benefits of standard FHIR API exchange. Find out more at https://www.hl7.org/about/davinci.

Want to help your organization improve payer-provider collaboration in 2024? Contact ZeOmega to learn more and read this powerful white paper, “How Health Plans and Providers Can Collaborate to Improve Care Transitions and Reduce Hospital Readmissions.