4 Key Strategies to Promote Effective Payer, Provider Alignment

Interoperable data-sharing

Clear communication on every level between healthcare professionals can help ensure members have a positive care experience. Sharing data is perhaps one of the most critical forms of communication in healthcare.

Transferring claims and clinical data allows payers and providers to coordinate care, manage population health, address health equity challenges, and reduce costs, according to the American Journal of Managed Care.

Payers and providers must maintain honest relationships with one another to facilitate data-sharing. However, data-sharing also hinges on proper technology resources. Embracing healthcare interoperability makes it easier for organizations to exchange electronic data. 

When providers adopt interoperable electronic health records (EHRs), payers can access patient data more efficiently and use the data to improve care coordination for members.

Value-based contracts

Value-based care is a two-way street, making it a perfect opportunity for payers and providers to partner and improve member health outcomes.

Establishing value-based contracts can help align the goals and practices of payers and providers regarding reimbursement and care delivery. Value-based arrangements promote preventive care in an effort to keep patients healthy and reduce the need for expensive services.

Moving the focus from quantity to quality encourages collaboration between payers and providers, as both stakeholder groups aim to improve outcomes and reduce costs.

Additionally, the risk-sharing arrangements that often come with value-based contracts can strengthen the relationship between payers and providers. When both entities share financial risk, they are more incentivized to work together to reduce costs.

Data from the Integrated Healthcare Association (IHA) found that healthcare costs declined and clinical quality increased for California residents when payers and providers shared financial risk. The total cost of care was 4.9 percent lower for patients receiving care from risk-sharing providers, while clinical quality composite rates for these providers were 6.2 percentage points higher than for providers not sharing risk.

Negotiating contracts that include shared risk can solidify long-term partnerships between payers and providers that will ultimately benefit members.

Prioritize technology

Over the past few years, it has become clear how useful technology can be for payers and providers, whether that technology assists in delivering patient care, streamlining utilization management processes, or assisting with administrative tasks.

Payers investing in technologies that benefit providers and vice versa can be a strong driver of alignment for the two entities.

The COVID-19 pandemic put a spotlight on telehealth and the ways it facilitates care access for patients. Providers have also expressed positive views on telehealth services.

When it comes to virtual care, payers can support providers by including telehealth and other virtual services in their benefit offerings, establishing virtual-first health plans, and supporting telehealth payment parity.

Prior authorization is another area where payers and providers can leverage technology to help each other out. Prior authorization requirements from payers often lead to high administrative burden for providers and care delays for patients.

Automating prior authorization can streamline the process for providers and payers, reducing claims denials and minimizing costs. Payers have also started to scale back on prior authorization requirements, which could help foster stronger relationships with providers.

Standardize quality measures

Aside from cost, care quality is a top priority for members, making it a top priority for payers and providers as well. However, the two stakeholder groups rely on different performance metrics to determine quality.

Healthcare Effectiveness Data and Information Set (HEDIS) measures and Medicare Advantage star ratings are common performance metrics for payers. These quality measures include healthcare utilization, member outcomes, consumer satisfaction, and overall health plan performance.

Providers also report data for quality measurement, but they do so through various programs, such as the Merit-based Incentive Payment System (MIPS), the Hospital Value-Based Purchasing (VBP) Program, and the Hospital Readmission Reduction Program (HRRP).

While there is no doubt payers and providers aim to deliver high-quality care, the groups may have different versions of quality as they prioritize different quality measures.

Aligning quality measures across payers and providers may encourage collaboration between the stakeholders and allow them to use the same performance metrics to assess care quality.