How payers, providers can unify around patient-centered care

What does it mean to be patient-centered?

Nobody goes into medicine for any other reason than to center the patient, Dreyer contended.

"It's really about getting patients what they need in the way they want to receive it," she said in a recent interview. "When I think about patient-centered care, I think, 'what do I want for my parents to experience?'"

Did they like their doctor? Were they treated with respect? Could they pay for their care easily and seamlessly?

At the crux of patient-centricity are access, quality and how patients feel about their total experience.

But in an industry defined by efficiency, it can be easy to lose sight of those things. To drive a more patient-centered health system, stakeholders need to consider what patients want and prioritize for themselves. From there, they can reimagine policies to address those needs.

However, with misaligned incentives, payers and providers can struggle to orchestrate a unified approach to patient-centered care. According to Dreyer, value-based care offers a key solution.

Under fee-for-service, patient-centricity is an uphill battle

The key friction point for payers and providers working toward patient-centered care is fee-for-service’s (FFS’s) grip on the healthcare landscape.

"Value-based care is a really good opportunity to collectively work together as an industry with the payers and the providers and the patients all working toward common goals of this patient centricity," Dreyer explained during a recent interview.

"But we do live in a world where fee-for-service remains the dominant payment structure. Under fee for service, one of the only downward pressures on cost is the negotiation between payers and providers."

Data shows that healthcare is still stuck in its FFS past. In one 2023 assessment by the
Commonwealth Fund, primary care providers reported receiving more FFS reimbursement than value-based reimbursement. A separate report from the Health Care Payment Learning & Action Network found that around 58.7% of payments were FFS in 2022, the most recent year for which the organization has data.

Dreyer estimated that, currently, only around 35% of payments are value-based.

The industry's continued emphasis on FFS is limiting because it lacks the incentives for prevention and well-being that are baked into value-based reimbursement models.

"It's important to understand contextually that if we want to see lower costs, that negotiation between payers and providers is the bedrock of the dominant system in the United States," Dreyer said. "What we at the Task Force hope to see is more value-based care."

Value-based care ripe for patient-centricity

Value-based care models have a lot of levers both payers and providers can pull to foster a more patient-centered approach to care, Dreyer argued.

"One would be around preferentially contracting with the highest quality providers so that patients are more likely to go to providers that are going to do really high-quality work that meets their needs," she said.

That contracting would need to be complemented by certain benefits or incentives to compel patients to visit with those preferred, high-quality providers. For example, patients might not have to pay as much out-of-pocket to see the highest-quality providers in their areas, Dreyer suggested.

More innovative payer-provider negotiations could also re-examine the role and function of prior authorizations. Often the thorn in healthcare providers' sides, prior authorizations are considered impediments to timely patient care, surveys have shown. Dreyer said they can add undue stress to the patient who might worry that a treatment isn't covered.

What she pitched instead was a model in which payers streamline or reduce the amount of prior authorization for high-quality providers. When a payer can trust that a provider delivers high-quality care, they can know that there aren't misaligned incentives. Therefore, the payer might not see as much of a need for prior authorization.

"That can help providers deliver the care that they need to be delivering, and it's also more patient-centric," Dreyer stated. "The patient isn't left in limbo wondering what's going to happen or if treatment will be covered. It either isn't required or happens very fast."

The flexible benefits design possible with value-based contracts also allows for wraparound services that address social determinants of health (SDOH).

"Wraparound services could be specifically for supplemental services, which are allowed in many value-based care arrangements," Dreyer explained.

"Supplemental services refer to those nonclinical things like support for medically tailored meals, housing, transportation and even being able to pay your utilities," she clarified. "These SDOH prevent patients from being able to fully invest or fully care for themselves and have clinical consequences even though they aren't clinical care."

Payers are managing and addressing SDOH sometimes by making direct payments to the patient, Dreyer acknowledged, but more often by using value-based care models to contract with community-based organizations that have experience with a certain SDOH. The crux of the programming is the value-based contract, which allows for increased flexibility and innovation in addressing patient care needs.

Fostering collaboration with the patient at the center

Getting to a future where value-based care models truly drive patient-centricity, healthcare payers and providers need to collaborate based on what patients need most -- stronger preventive care.

"That's what everybody wants, but because of all the misaligned incentives, it's not what we're getting," Dreyer asserted. "That's because preventive care, by its very nature, takes a long time to play out."

Take, for example, a patient with diabetes who struggles to afford medication and pay for the utilities needed to keep treatments refrigerated. Getting the person the care they need, including primary care, treatments and SDOH assistance, will have real and meaningful effects down the line, Dreyer said.

"But you're not going to see that this year," she pointed out. "You're going to see it five or 10 years in the future. And so, consistent investment across the industry in preventive care would help patients because they will be getting what they need now, and it will help them later."

There is ROI for payers and providers, too. In addition to the tangible financial gains made by promoting well-being, payers benefit from their investments in value-based care.

"By investing in that preventive care, to get that prevention baked into the whole business structure, will also help payers feel like they're not the bad guy," Dreyer noted. "They are getting the support that they need in terms of their larger business model by investing in value-based care to be able to all be playing in the same direction."

That helps payers and providers alike get to the core of why they entered the healthcare business to begin with. Providers didn't go to medical school because they wanted to fill out paperwork; they went because they wanted to help people get and stay healthy. Getting support from payer partners to achieve those goals will improve payer-provider relationships.

"The reason for the whole industry is to help people be healthy, stay healthy and get healthy when they're sick," Dreyer concluded. "It's so easy to get lost in the minutia of the industry, of this player versus that player. But, ultimately, most people working in healthcare want to do right by patients and their loved ones."

Sara Heath has reported news related to patient engagement and health equity since 2015.