The payer-provider partnership: AI a bridge to better outcomes

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The relationship between healthcare payers and providers has at times been contentious. While seemingly on opposite sides of financial incentives, both stand to gain through greater collaboration ––yet lingering friction persists.

The crux of payer-provider collaboration lies in alignment. When incentives are misaligned, they often lead to conflicts and inefficiencies which negatively impact patient care. Historically, payers held a tight grasp on premiums. Today, the focus is shifting towards better understanding population health risks, sharing data, while fostering a more cooperative environment.

At its core, US healthcare revolves around financial transactions. Providers deliver care, but altruism doesn’t keep the lights on. Payers, whether for-profit or non-profit, ensure services are reimbursed. However, the landscape is not static. What we’re seeing now in terms of value-based care and risk-based contracting is no different than it was back in the 80s and 90s with HMOs. The essence remains the same: a shared pie that requires equitable distribution to keep both parties afloat while providing great healthcare to patients.

Bridging divides: Keys to successful collaboration

The core of the payer-provider relationship revolves around revenue and risk. Providers aim to furnish healthcare services to their patients while remaining financially viable, as do payer organizations. With margins tight and chronic diseases driving ballooning costs, the system struggles in silos. Creative partnerships are emerging –– payers acquiring providers, payer-provider joint ventures, accountable care organizations, integrated delivery networks –– reflect recognition from forward-thinking leaders that system incentives need realignment. Still, skepticism haunts innovation.

The goal is to take care of the patient and provide the best care possible. But change is notoriously glacial in healthcare, despite the unsustainability of the status quo being increasingly self-evident. Yet gradual blurring of the payer-provider distinction hints the path ahead remains one of inexorable integration.

Empowering decisions: Leveraging big data and AI

So where should leaders double down first? Data sharing and risk analytics rise to the top. As population health management and personalized medicine advance in tandem, understanding who to care for and how requires insights from across patient journeys. Yet providers hold the clinical keys while payers sit on claims data warehouses. Pooling collective intelligence promises superior risk stratification, better anticipation of needs and costs. However, reluctance around releasing control stymies progress.

Joint ventures between payers and health systems are on the rise, with one example being Minnesota’s Allina Health Aetna collaboration. Meanwhile, Optum’s ongoing acquisition of physician groups also seems telling. The vision taking shape convenes cross-functional teams –– combining technical strengths to meet clinical/human priorities via shared data. It’s the oft evoked but seldom achieved “no wrong door” for seamless member experiences.

Critically, these next-generation entities recognize AI and automation’s potential to streamline systems. AI, when responsibly applied, can help patients traverse today’s disorienting healthcare maze to access appropriate care intuitively. After all, everyone’s goal should be to ensure a healthcare future based on the “four Rs” –– the right level of care, at the right time, at the right place, for the right cost.

We are already witnessing AI nudging silos toward constructive collaboration, witness remote patient monitoring. Data-synthesizing algorithms flag biometric warning signs otherwise missed, keeping recently discharged patients from deteriorating and requiring readmission. Home health also illustrates AI boosting efficiency - enabling a single nurse to clinically support more patients simultaneously without compromising care. Transitioning clinical monitoring from manual to automated liberates practitioners for richer human connections at that vaunted “top of license.”

AI and big data are becoming instrumental in navigating the complexities of healthcare. By sharing data on patient populations, both payers and providers can better manage patient care, improving access and efficiency. AI aids in streamlining clinical pathways, adhering to the four Rs—ensuring optimal outcomes.

AI’s impact extends to clinical decision-making and patient triage, enhancing patient experiences and reducing unnecessary ER and Urgent Care visits. It offers a means to navigate the healthcare system more effectively, ensuring patients receive the appropriate level of care at the right time.

In essence, thoughtfully deployed automation allows doing more with less while elevating quality - a compelling value proposition across healthcare, but only realizable via joint payer-provider adoption efforts. It requires both provider clinical insights and payer population analytics to nurture technology’s best expression. And from rural pharmacist care expansion to telehealth proliferation, keeping communities vital with limited resources will hinge on complementary competencies rather than clashing financial incentives.

Positive precedents for collaboration have already emerged; earlier hospital discharges helped by home-based monitoring demonstrate tremendous potential. But indifference toward addressing many frictional points remains an industry hallmark.

A unified vision for healthcare

We are at a pivotal moment in healthcare: a move towards a more unified, patient-centric model facilitated by AI. As healthcare continues to evolve, the synergy between payers and providers, powered by technological advancements, will be crucial in navigating the future of patient care.

With this acknowledgement as a guide, payers and providers can allow enlightened AI adoption to illuminate their shared priorities –– attuning systems to function in synchrony rather than opposition. Their linked destiny demands nothing less in matching increasingly consumerist patients with support for seamless self-care. Automation is merely a means, but collaboration stands as the goal –– and AI offers bridges long awaiting construction.

Matt Mesnik, MD, is an accomplished physician and healthcare executive with over 35 years of healthcare experience. He is an emergency physician and former emergency department and urgent care medical director and was the chief medical officer of CVS/MinuteClinic. He is also the former CMO of an EHR company and has a reputation for bringing innovative solutions to market, leveraging technology, developing strategic partnerships, practice management, and leadership. He currently serves as a medical advisor to Infermedica, an AI-powered care navigation tool for payers and providers.