Kelly Rakowski

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	Payers and providers have traditionally operated on opposite sides of the tracks with limited collaboration, resulting in a disjointed and complicated experience for patients when accessing care.

Related: Healthcare’s quest for greater payer-provider synergy

	My colleague Kevin recently saw this firsthand when his wife suffered a relatively routine tennis injury and broke her wrist. In the months following her accident, 

two ER visits, six surgeon office visits, one surgery, six X-rays plus a CT scan, 17 physical therapy sessions, and nine prescriptions. The total charges were over $34,000, of which her insurer paid 60%, she paid 16% and providers wrote off the balance.

	Each one of those visits required phone calls and scheduling, answering repetitive questions, and filling out redundant paperwork. As if that weren’t enough, she also received about 40 mailings from providers and her insurer and had to keep this overwhelming amount of paperwork organized-not so easy with a broken wrist. 

	Simple cases like a broken wrist shouldn’t have to be so complicated, and unfortunately in today’s system, they are. So many challenges-lack of transparency, an inability to inform patients of costs in advance of a given procedure, and confusion and delays in billing and payment-make encountering the healthcare system a consumer experience on par with dealing with cable companies.

Related: Payer/provider collaboration is a key to improving care

	The good news is the industry has recognized the importance of removing structural and economic barriers and is making changes to encourage better collaboration among the parties and improvements in quality and experience by aligning incentives.

	The industry is moving toward replacing fee-for-service payment models to focus on quality, outcomes of care, and the patient experience. In other words, paying for value, not just for volume. This shift to value-based healthcare creates incentive for both the payers and providers to streamline complicated policies and procedures, and encourage better coordinated care. Patients like Kevin and his wife will be the winners.   

Related: Five ways to improve payer-provider relations

	The Centers for Medicare & Medicaid Services (CMS) is playing a large role in driving this change through mandated value-based programs, bundled payments and shared savings programs. And commercial plans are following suit with several new payment model changes.

	The intent is to increase quality of care, improve patient satisfaction, and eliminate cost and waste through increased collaboration. CMS is creating financial incentives for integrating and coordinating care to reduce unnecessary utilization and place a greater emphasis on outcomes and the patient experience.

	These payment system changes are only one factor in transforming healthcare. As payers and providers begin working more closely together, they also must educate and enable patients to take on a more significant role in their healthcare. Patients have to be adept at managing their own health, which can be supported with the appropriate tools and the right technology.

	Here are several ways payers and providers can work better together to benefit the patient:

Identify what will benefit the population. 

Payers and providers should look to what is most important to their population, and at current performance in quality, experience and cost.

It’s important to align around a specific, short set of goals, such as reducing readmission rates or improving the management of a disease. Set specific goals based on the population and where improvement is needed.

Identify challenges and create incentives. 

By having shared goals and focusing on existing roadblocks, payers and providers can find new ways to address them and meet their goals.

In the process, it’s critical to define the responsibilities of the various players so they can each focus on the specific area/ways they can make the most impact.

	Increased collaboration between payers and providers should help patients in a variety of ways. If successful, Kevin’s wife will not only have a healed wrist, she will also have fewer headaches.

Kelly Rakowski is senior vice president, healthcare payer services, Xerox. 

Articles

Payers and providers have traditionally operated on opposite sides of the tracks with limited collaboration, resulting in a disjointed and complicated experience for patients when accessing care.

Mend fragmented payer-provider relations: 4 tips

	An estimated 16 million more Americans have health insurance under the Affordable Care Act-many for the first time. The online insurance marketplaces have given Americans more choice and control over their own healthcare than they’ve ever had before.

	However, entering into this new market with purchasing power can be fraught with confusion, leading to consumer frustration associated with making decisions, navigating applications and enrollment, and understanding available benefits and services.

	Health plans are scrambling to respond to this shift in the healthcare economy by finding ways to engage this population of newly insured Americans. They are finding that today's plan members have different needs and expectations than they had in the past.

	Payers must meet the changing demands in customer service, and provide more education and guidance to support individual and population health management needs.

Here's a closer look at three areas health plans should focus on to improve the member experience. 

	Payers are selling more directly to individual consumers, who are driving selection of their own 

	coverage. Consumers are often inexperienced in health insurance coverage and don’t have a benefits manager helping them navigate.

	This presents an excellent opportunity for payers to provide personalized, two-way communication to educate consumers about healthcare plan options that meet their individualized cost and care needs, and guide them through the application and enrollment process.

Next: The second area health plans should focus on

	As consumers become more empowered, to actively manage their own healthcare, they are looking for greater price transparency.

	The rise in high-deductible plans encourages consumers to play a more integral role in selecting healthcare services, with affordability playing a larger role in decisions. 

	This increased awareness and focus on pricing also means more scrutiny and reliance on statements and bills, which are getting more and more complex.

	Consumers are often bombarded with multiple mailings about the same visit or episode, making it difficult to sort through it all to understand what’s in network vs. out-of-network; what’s covered and what is not; and, what is owed out-of-pocket. They are left to advocate for themselves and identify errors or discrepancies, and the task is more overwhelming given the confusion of the paperwork.  

	This is an area ripe for change and improvement-from both the payers and providers of service. Providing clear information and appropriate levels of service and support to answer customers’ questions about statements and personal financial liability and to quickly address complaints and appeals is paramount to an excellent consumer experience-ensuring a stress-free and convenient process for the consumer.

	As new members enroll in health plans through the online exchanges, payers typically have little or no information about their health, history, or care needs. This creates a challenge in supporting their individual health needs, as well as understanding and managing their member population as a whole. 

	To fill in these gaps and create a better understanding prior to any services being rendered, payers should take an individualized approach to member engagement. They should create vehicles to engage early with members, utilizing technology as well as clinically trained customer care agents who directly engage new members to provide guidance on benefits, identify existing barriers to care, and offer assistance in scheduling appointments.

	The results of these conversations, when combined with population-health focused data analytics, will help health plans identify member medical conditions and other risks factors early in the relationship.

	The payer will then be armed with all the information needed to engage the member with an individualized care management plan for maintaining wellness and/or managing chronic conditions.   

	Ultimately, we have to make it easy for consumers to utilize and pay for healthcare services and make their coverage work for them. For the payers, this requires engaging customers with a personalized experience and providing them with smart insights that will help them be a more active and educated participant in their own healthcare.

	This targeted engagement creates a positive experience for members so they are more likely to select the same insurer during the next open enrollment cycle. This is critical to the long-term success of payers in this new healthcare economy.

Kelly Rakowski is senior vice president, 

Three areas health plans can improve the member experience

RakowskiHealthcare reform and the increase of high-deductible health plans (HDHPs) have resulted in many substantial changes in the healthcare industry. Among the most significant changes today is the transformation of patients to health consumers.

 Eight ways to retain high-deductible members

	These new health consumers have more information about healthcare available to them, are becoming more conscious about their healthcare spending, and are taking a more active role in their care.

	They want more price transparency, particularly as they encounter higher deductibles. In a 

recent PricewaterhouseCoopers (PwC) study

, 83% of employers reported offering a high-deductible plan. These plans, by nature, encourage consumers to consider all options before selecting and utilizing healthcare services.

 Consumerism increases retail opportunities and access to coverage and care

	Healthcare “consumerism” is only one of many areas of focus for the industry. A call to action from industry stakeholders is prevalent, largely based on the fact that the U.S. 

 more than $2.9 trillion annually (or $9,255 per person) on healthcare, more than any other country. Even so, Bloomberg 

 on its “World's Healthiest Countries” list.

	To reduce costs and create a healthcare system that works better for consumers, the healthcare industry needs to cater to the consumer, become more connected, and better manage risk. The following outlines some of the ways U.S. healthcare can and should evolve.

NEXT: Facilitate patient-centric healthcare

	Consumers have more purchasing power in their healthcare choices than ever before. So, if health insurers want to increase engagement and satisfaction to retain members, they must redesign processes and services through the lens of a consumer.

 Price Transparency: A significant force in healthcare

	This requires better coordination and collaboration from the two biggest stakeholders in healthcare-payers and providers. These two groups have an opportunity to work together to enhance the consumer experience by providing meaningful information that empowers the health consumer to become more educated and active in their own care.

	Finally, consumers have more incentive to engage in products and services to help them better monitor and manage their health and well-being. They want access to tools and products when and how it’s convenient for them, and they desire the same retail experience in healthcare that they do in shopping for other products and services.

	To achieve healthcare interoperability, payers and providers must break down long-standing silos and become more connected.

 Four ways managed care executives can advance interoperability

	By improving the flow of information and making the care management process easier, organizations can reduce costs and become more efficient, while simultaneously improving the consumer experience.

	One area of opportunity ripe for improvement is claims processing and payment. Despite significant improvements in the use of technology and electronic data interfaces, process errors and waste continue. Providers still submit incorrect or incomplete claims that are denied for clinical or administrative reasons, and these denials result in wasted time and resources spent on inefficient communications between payers and clinical staff.

READ: Five private sector interoperability initiatives to watch

	When communication and information flow is improved on the front-end, this unnecessary rework can be significantly reduced and more claims accurately submitted and paid the first time.  

	Fraud, waste and abuse in the U.S. healthcare system costs an estimated $60 billion to $80 billion annually due to either a deliberate attempt to deceive the system or inefficient administrative processes and systems, according to Gartner, an information technology research and advisory firm.

 Under attack: Arm yourself against hackers

	Payers must have audit and compliance systems to 

 losses before they occur, and if necessary, recover funds quickly. The “pay and chase” model of today needs to be replaced with analytics and surveillance that identifies potential fraud before money flows to the perpetrator.

	Data breaches are another area of concern. In 2014, data breaches cost the healthcare industry an estimated $5.6 billion in losses, according to the 

Fourth Annual Benchmark Study on Patient Privacy and Data Security

 by Ponemon Institute. The use of wearables, mobile, and remote devices means there is an enormous amount of sensitive personal data floating around “in the cloud.”

	Payers and providers must develop more effective strategies to protect patient privacy.

Among the most significant changes today is the transformation of patients to health consumers. Here's how plans and providers should adapt.

Author | Kelly Rakowski

Articles

Mend fragmented payer-provider relations: 4 tips

Three areas health plans can improve the member experience

Three ways the health insurance industry must evolve