It’s Time for Payers and Providers to Work as Partners

Once unthinkable, payers and providers are now working together to share data in new ways to benefit patients.

At this year’s Healthcare Information and Management Systems Society (HIMSS) conference in Orlando, Rowena Bergmans, vice president of clinical integration and population health for a three-hospital system in Connecticut, spoke about the gains that can be realized in terms of both finances and improved patient outcomes through such collaborations. Bergmans is with the Western Connecticut Health Network, which serves more than 500,000 people.  Bergmans now works on the provider side, but also served as vice president of medical affairs for Bend, Ore.-based Clear One Health Plans, helping the payer develop its strategy while also overseeing all health-related services and programs.

“Historically, there was some anxiety on both sides of the aisle. Payers and providers didn’t see eye to eye. It was more about negotiating a fee schedule,” she said. “Payer-provider partnerships” might even sound like an oxymoron to some people, she said, and systems within the two entites were not designed for collaboration.

Still, “We need each other to move into this value-based world and away from fee-for-service,” she said. Through value-based payments, providers receive a per-member, per-month payment based on the known risk that that individual represents. If data is missing about that patient, payment may be lower than it should be.

These new, somewhat strange, alliances are being forged as healthcare systems and hospitals face difficult trends, driving the need for novel solutions, Bergmans said. Payers and consumers are choosing lower-cost options for care in the outpatient sphere and, increasingly, hospitals are serving as safety net institutions. Hospital utilization is going down and so is reimbursement, she said.

Furthermore, hospital systems need to invest in services and programs that are not reimbursable today. She gave as an example online cognitive behavioral therapy. “Where are the dollars coming from to do that?” she asked. Yet that kind of service is badly needed in light of widespread shortages of mental health professionals in many regions.

Moving toward better data, better outcomes  

One major motivator for providers to work with payers is accurate capture coding information used to correctly assign risk levels to the populations that a provider serves, she explained.

“The way we get reimbursed will increasingly depend on the right coding,” she said. For example, if a patient is coded as having diabetes, that doesn’t say enough. Is this a morbidly obese diabetic with congestive heart failure, or a generally fit individual who just tipped into diabetes after years as a prediabetic? Whatever the diagnosis, the coding must be complete and comprehensive if reimbursement is to be correct. “These are shared goals of the health plan and the provider,” Bergmans said.

Bergmans said health plans have complete claims data about where the patient went and the care they received. Meanwhile, the healthcare provider has clinical records of the care that they delivered. “By bringing together the EHR data and the claims data, you get a much more accurate picture of the health of a population,” she said.

Such partnerships can be advantageous, both financially and in terms of improved patient outcomes.  Both plans and providers can realize a direct return on investment, she said. This was the result of a pilot study by her system, involving the meaningful aggregation of data from both sides.  That pilot study involved 1,381 Medicare Advantage members, and led to 12.3 percent increases in the premiums paid for those individuals.

While the pilot study did show solid financial gains for her healthcare system, Bergmans said that even if those gains were not worth the effort that it took to realize them, she would still want to go through this collaborative process. “From the population health side, I really want to understand” who our patients are, she said.

She also said that although not all healthcare systems are ready for these collaborations, “those organizations that are holding onto fee-for-service or are very protective of their data are ones that I don’t think will be around in 10 years.”