Systematic collaboration between payers and providers is the key to providing better care at lower cost in the United States. Looking back at the past decade, once-emerging technologies such as electronic health record systems (EHRs), computerized physician order entry (CPOE), and auto-authorization and adjudication showed promise. The goal was to break down communication barriers between payers and providers and help everyone see the same comprehensive data about a patient’s health status. When this occurs, decisions about the patient’s best care—from both clinical and financial perspectives—are more easily and accurately made.
Now fairly mainstream, have these technologies fulfilled that promise? While they have succeeded in creating more digitized, shareable information than ever before, payer-provider collaboration is still thwarted by information silos that exist between organizations—even within the four walls of a single payer or provider organization.
The imperative for this collaboration has never been stronger, and new incentives have appeared to encourage both payers and providers to make better partnership a priority. For example, the National Committee for Quality Assurance (NCQA), which administers the HEDIS measure set that encapsulates the payer industry’s standards for quality improvement, is pushing hard for payers to incorporate electronic clinical data in their quality reporting. Providers, meanwhile, can increase their revenue by participating in value-based reimbursement programs such as the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPM); successful participation in such models demands clinical and financial information-sharing with payers.
As we look out over the healthcare technology horizon, what tools are now the focus, and how do they solve some of the challenges of the past? Technology solutions supporting payer-provider collaboration fall into two primary categories: those that allow payers and providers to securely collect accurate and diverse types of data, and those that allow healthcare organizations to turn that data into collaborative platforms. With the resources, scale, and potential to see the most return on investment from these technologies, payers must lead the way in their implementation.
Breaking down the barriers to collaboration
With claim systems being some of the first data management technologies in healthcare, claims data has been a reliable source of truth for several decades. By examining a member’s claim history, a payer can quickly determine which providers a patient has seen and which procedures and tests have been performed, providing a complete claims picture across the care continuum.
Claims data offers some clinical information but not deep insights into the patient’s clinical status, care, and outcomes. Some of this gap has been filled through the proliferation of provider systems such as EHRs, but the challenge remains in gathering the longitudinal perspective of each person’s care as well as cost across the continuum over time. Did the patient receive the right treatment? Was the treatment cost effective and appropriate? Were the clinical and financial outcomes of the treatment expected and beneficial? Unstructured clinical data as well as the continued prevalence of paper-based information make these questions difficult to answer.
Therefore, the industry is now turning to tools such as natural language processing (NLP), which uncovers clinical and unstructured data to improve healthcare decision making. Organizations are also using optical character recognition (OCR) to bring more paper-based information into the digitized fold.
In addition, payers and providers both are increasingly recognizing social determinants of health, such as socioeconomic status, environment, and geographic location, for their importance in addressing an individual’s care needs holistically. Several large payers recently created the Aligning for Health (AFH) coalition with the goal of eliminating barriers to addressing these factors, noting that up to 90% of health outcomes are determined by them. Mechanisms for collecting and sharing this information are still fairly new but hot topics of discussion in healthcare organizations of all types. For example, health information exchanges (HIEs) enable social services providers to feed social determinant data directly into EHR systems, giving physicians a much broader view of the problems their patients face.