Mend fragmented payer-provider relations: 4 tips

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, her care required 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.

Next: Four tips

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.

• Start simple. 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.

• Clearly define roles. 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.