• Drug Coverage
  • Hypertrophic Cardiomyopathy (HCM)
  • Vaccines: 2023 Year in Review
  • Eyecare
  • Urothelial Carcinoma
  • Women's Health
  • Hemophilia
  • Heart Failure
  • Vaccines
  • Neonatal Care
  • Type II Inflammation
  • Substance Use Disorder
  • Gene Therapy
  • Lung Cancer
  • Spinal Muscular Atrophy
  • HIV
  • Post-Acute Care
  • Liver Disease
  • Pulmonary Arterial Hypertension
  • Safety & Recalls
  • Biologics
  • Asthma
  • Atrial Fibrillation
  • Type I Diabetes
  • RSV
  • COVID-19
  • Cardiovascular Diseases
  • Breast Cancer
  • Prescription Digital Therapeutics
  • Reproductive Health
  • The Improving Patient Access Podcast
  • Blood Cancer
  • Ulcerative Colitis
  • Respiratory Conditions
  • Multiple Sclerosis
  • Digital Health
  • Population Health
  • Sleep Disorders
  • Biosimilars
  • Plaque Psoriasis
  • Leukemia and Lymphoma
  • Oncology
  • Pediatrics
  • Urology
  • Obstetrics-Gynecology & Women's Health
  • Opioids
  • Solid Tumors
  • Autoimmune Diseases
  • Dermatology
  • Diabetes
  • Mental Health

Tools That Promote Payer-Provider Collaboration


Reasons organizations have traditionally had for not sharing data with each other are breaking down, opening a new type of conversation between payers and providers. Here’s how.



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.

The good news is that as data has proliferated, the technologies for data management and integration have advanced as well, giving organizations the ability to effectively handle both massive quantities of data and diverse data types with equal ease. For example, a data lake, or centralized data storage repository, enables a health plan to assemble many disparate sets of data for different uses across its enterprise. And since the data can remain in its native format, it can be accessed at greater volume and speed than with a traditional enterprise data warehouse.

Data security remains a concern, with troubling data breaches unfortunately remaining a regular news item. However, the industry has made major investments in data security, with organizations such as HITRUST setting the standard for healthcare organizations to follow. A decade ago, data security concerns often prevented collaboration; today, organizations have a clearer path forward.

Meanwhile, blockchain technology is enabling consumers to securely share and even monetize their own data. Empowered by a requirement in the 21st Century Cures Act to require EHR systems to have open application programming interfaces (APIs), a new marketplace has opened for consumers to sell their own data directly to health data brokers.

Simply put, the reasons organizations have traditionally had for not sharing data with each other are breaking down, opening a new type of conversation between payers and providers.

Facilitating the conversation

Why is this relevant and important? Because when payers have clinical and financial data as well as the ability to analyze that data at an enterprise level, they can achieve a more comprehensive, 360-degree view of the value and cost of care.

However, that information still must be served up in such a way that it compels action. Analytic tools to pinpoint insights from data have been used by healthcare organizations for several decades. For much of that time, however, these tools have required a high degree of technical expertise to operate, making it difficult to extract insights that can be consumed by multiple disciplines and turned into tactical strategies for patient and provider outreach and communication.

To make insights more rapidly or even proactively accessible across their enterprise, payers need persona-based data visualization tools that adapt to the end user’s areas of concern and level of expertise. The chief financial officer and the chief medical officer both need to access the same data, but from different perspectives. Providers need tools such as workstations with single sign-on (SSO) technology that enable them to access insights as rapidly as possible at the point of care, so that their attention is not divided between the patients they are seeing and the technology they are using to help them.

The greatest challenge, however, is finding the right tools that work with the same set of data to enable true interaction with providers. Sharing data and insights is a good start, but two-way communication about what to do with those insights is what will drive down the cost of care while improving outcomes. This is truly the next frontier in healthcare.


Emad Rizk, MD, is president and CEO of Cotiviti.

Related Videos
Related Content
© 2024 MJH Life Sciences

All rights reserved.