2018-11-08

Bridging the payer-provider chasm with care management technology

It’s no secret that differing strategic priorities, misaligned business interests and lack of incentives to collaborate have formed a sizable chasm between payers and providers. Historically, payers focused on managing financial risk and the health of their member population, whereas providers were committed to improving health at the individual patient and encounter level. However, that narrative has changed.

The management of financial risk is gradually shifting to the health system. Identifying high-risk patients, likely with multiple chronic conditions, and creating interventions at the individual level was historically only a strategic focus for health plans. With the transition to value-based care and the evolving reimbursement incentives introduced by new contracts and arrangements, providers and payers are becoming contractually more aligned and need operational alignment.

However, in operations, the chasm still exists. According to a recent NEJM Catalyst study, 55% of respondents reported that payers and providers are “not very aligned” at their organization, and more than three quarters reported the same at an industry level. Which begs the question: What steps can healthcare organizations take to bridge the divide between payers and providers?

A critical element is enhanced care management supported by technology. A care management platform supports the risk sharing and new incentives that are flowing from payers to providers by enabling data sharing, streamlining communication, and driving population workflows that are empowering providers to take on contracts with downside risk.

Supporting Outcomes with Data

Shared data is the foundation of the bridge between payers and providers. Increased data transparency, with payers sharing claims data and providers sharing clinical data, can lead to more effective population health management, higher quality ratings and lower total cost of care—goals that both payers and providers are working towards.

However, only 22% of commercial payers reported sharing claims data with providers in a study by Premier, a group purchasing and consulting firm. Why, if payers and providers are working towards shared goals, isn’t there more data transparency between organizations? This is where a care management platform comes in.


Case Study: Texture Health and Medical Home Network

Supported by Texture Health’s population care management solution, Medical Home Network (MHN) reduced the total cost of care for 170,000 attributed lives by 3.5% in year one and 5% in year two. Our approach included a decentralized care management model, real-time alerts, enhanced provider engagement and communication, and a dynamic approach to risk stratification. Read the full case study.


The tracking and reporting built into a quality care management platform creates a holistic view into a patient’s health. Payers and providers can use this data to work together to identify high-cost and/or high-risk patients that might benefit from a care or disease management program or greater efforts to reach them and impact behavior. They can also identify gaps in care—such as undocumented conditions or quality reporting gaps—and develop campaigns to close them. Plus, without a platform to aggregate data and deliver reports on outcomes, data sharing can be difficult and an IT nightmare. A care management platform makes this possible by collecting information and generating reporting to support collaboration between payers and providers.

Facilitating Meaningful Communication with Payers

A bridge is meaningless if the two parties refuse to cross it. Finding ways to open the lines of communication between payers and providers is key to improving alignment. Currently, payer-provider communication is a major challenge—in fact, a study from Availity cited 43% of practice-based providers and 29% of facility-based providers reporting difficulty communicating with payers as a major pain point. Knowing this, it’s likely safe to assume that anything that alleviates this pain would be a welcomed relief.

A care management platform helps address this problem in two ways. First, it aggregates diverse and disparate data and converts it into actionable insights to be shared. Depending on the platform, these insights might include risk stratification based on addressable factors, automated care plans to share across care teams, real-time alerts and more. Armed with meaningful strategies and actions, providers can more confidently approach payers to collaborate on value-based initiatives. An advanced care management platform can even include secure messaging to communicate and collaborate directly on an ongoing basis.

Secondly, a care management platform can significantly reduce administrative burden, which is a huge hinderance of payer-provider collaboration according to the Availity study cited above. More than 75% of respondents indicated administrative waste is a significant cause of poor communication between payers and providers. Having an integrated system to manage care eliminates strain on provider resources, encouraging more communication and collaboration.

Increased Opportunities for Risk-Taking

With the bridge built and communication flowing, payers and providers are now on common ground. How can we use this to adopt a culture of value over volume? Generally, providers have been reluctant to take on value-based contracts due to:

  1. The lack of scale and a provider’s obligation to many different payers with various approaches to value-based arrangements
  2. The seemingly significant investment in infrastructure (people, processes, technology) to support these contracts
  3. The incentives of downside risk contracts directly conflicting with fee-for-service success metrics

Despite this, a culture of value is already permeating the healthcare industry. A recent McKesson study found that nearly two-thirds of payers and providers expect value-based payment models to be the norm by the year 2020. To capitalize on this belief, providers can look to their care management platform for support.

Care management technology puts providers in a better position to take on risk. Increased access to data, a better understanding of your population, and enhanced outcomes reporting are all benefits to a care management platform that are crucial when negotiating risk-based arrangements. As more payers push to implement value-based contracts, providers can use their platform to take a proactive approach to contracting. Plus, the investment isn’t as daunting as providers might think. The right care management platform is cost-effective and customizable to your needs.

Why Improved Payer-Provider Alignment is Important

A care management platform is one solution—albeit, a critical one—to the problem with payer-provider alignment. It provides a number of benefits that bring payers and providers closer together, including the sharing of data-driven outcomes, more meaningful collaboration and communication, and increased opportunities for providers to take on downside risk. But the true beneficiary of a more efficient, more collaborative healthcare system is the patient. Ultimately, a care management platform aims to improve patients’ overall health, and that’s something we can all agree is the most important benefit.

So, what are you waiting for? Contact Bill Brody to schedule a demo of our fully-integrated care management and patient engagement platform today.


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