The relationship between healthcare providers and payers has long been a complex and often contentious one. As the industry continues to evolve, with a growing emphasis on value-based care and population health management, both sides are seeking ways to improve collaboration and achieve better outcomes. However, significant challenges remain, from data sharing and quality metrics to reimbursement models and administrative burdens.
One of the key steps in improving payer relations is gaining a deeper understanding of each payer's unique approach and priorities. Will Fletch, Chief Financial Officer at ThedaCare, emphasizes the importance of "knowing your payers well from a rate perspective, what they require from documentation, what their appeals processes are." This knowledge allows providers to work more effectively with payers and ultimately achieve better outcomes for patients.
However, the payer landscape is far from homogeneous. Dr. Jerilyn Morrissey, Chief Medical Officer at CorroHealth, notes that while payers may draw from a similar toolbox, "they all have their own unique fingerprint in how they exercise or use those tools." Identifying these nuances is crucial for developing targeted strategies that address each payer's specific approach.
One area of particular focus in the current payer-provider dynamic is Medicare Advantage (MA). As enrollment in MA plans continues to grow, now exceeding 50% of Medicare beneficiaries, providers are grappling with both challenges and opportunities presented by this shift.
Dr. Morrissey highlights the need for increased regulatory guidance in the MA space, pointing to recent OIG reports and CMS rules as steps in this direction. She also sees potential for greater vertical integration, which could lead to improved accountability and outcomes.
However, the transition to value-based care models within MA is not without its hurdles. The Centers for Medicare & Medicaid Services (CMS) has set an ambitious goal for all Medicare beneficiaries to be enrolled in value-based plans by 2030. This timeline is putting pressure on providers to rapidly adapt their operations and strategies.
"Hospitals need to focus on what they need to do in the next six months to be prepared to get into that value-based space," Dr. Morrissey advises. "How are you aligning your providers? How are you measuring your data, finding those inputs? Because you are going to be at risk and on the hook for this sooner rather than later."
As providers work to improve their payer relations and adapt to new care models, data and technology are playing an increasingly critical role. Randy Farmer, Chief Operating Officer of the Delaware Health Information Network, emphasizes the importance of having a "neutral source of data" that can combine clinical and claims information to provide a comprehensive view of patient care and outcomes.
This type of data integration can help providers close care gaps, improve quality reporting, and reduce administrative burdens like chart chasing. Farmer notes that his organization has been able to help health systems track high-risk patients and provide real-time alerts to care coordination teams, potentially preventing unnecessary readmissions.
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However, Dr. Morrissey cautions against viewing technology as a panacea. "Technology will not solve your process issues. Technology will not solve your internal issues," she states. Instead, she advises providers to first clearly define their problems and goals before investing in technological solutions. |
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One of the most significant pain points in the payer-provider relationship continues to be the administrative burden associated with prior authorizations, denials, and appeals. Fletch provides an example of how these processes can negatively impact patient care: "We go and we get a pre-authorization for a screening colonoscopy. Patients then having gotten pre-auth, patients then having received their physician find something that they want to take a biopsy of. That now changes to a diagnostic colonoscopy, and now we get denied on that because it wasn't pre-authorized."
These types of scenarios not only create frustration for providers but can also lead to delays or denials of necessary care for patients. Dr. Morrissey argues that the industry is "at the precipice of identifying just the obstruction that all this administrative work is causing in blocking access to care for our patients."
Despite these challenges, there are steps that providers can take to improve their relationships with payers and navigate the changing landscape more effectively:
Understanding your own performance metrics, cost structures, and quality outcomes is crucial for effective negotiations with payers.
Fletch notes that striving to be a top-decile provider in terms of quality and cost can strengthen your position in payer negotiations.
Farmer advises providers to move beyond being seen as "ad hoc providers" and position themselves as valuable strategic partners to payers.
Ensure that different departments within your organization are working towards the same overarching strategy in terms of quality, cost, and patient outcomes.
Choose technological solutions that address your specific challenges and align with your overall goals.
Maintain regular dialogue with payers to address issues proactively and work towards mutually beneficial solutions.
As the healthcare industry continues to evolve, the relationship between payers and providers will remain a critical factor in determining the success of new care models and the overall quality of patient care. By focusing on data-driven strategies, embracing appropriate technologies, and working towards true partnerships, both sides can move beyond adversarial positions and work together to improve health outcomes and reduce costs.
The transition to value-based care, particularly within Medicare Advantage, presents both challenges and opportunities. Providers who can successfully navigate this shift, leveraging their strengths and addressing their weaknesses, will be well-positioned to thrive in the changing healthcare landscape.
Ultimately, as Fletch notes, the goal should be to put patients first. By keeping this focus at the forefront of payer-provider relationships, the industry can work towards a system that truly benefits those it aims to serve.