Payer-provider relationships: Pre and post COVID-19 worlds

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Payer-provider relationships: Pre and post COVID-19 worlds

October 27, 2020

Collaboration is not only just between payers and providers, but all allied services like labs, radiology and dialysis centers that constitute the entire healthcare ecosystem required to care for the patient. The greater the communication between payers, providers and patients, the higher the patient outcomes and the less administrative cost and risk of bearing financial loss.

Hurdles in the collaboration journey
Data accuracy and integrity remains a challenge for both providers and payers. The need for an enterprise data strategy is critical in order to collate data and provide it as a single source of truth for all downstream analytics, which continues to be the heart of the ecosystem. As a key driver to effective VBC, data is the primary need to make sure providers understand the full picture of a patient’s health and for potential health interventions.

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VBC models leverage data to drive risk adjustment, which impacts reimbursement and regulatory scoring such as HEDIS or Star Ratings - which again impact reimbursement since many models are closely linked to these quality metrics. However, these identified quality metrics must suit the provider’s patient demographics and their social determinants of health while also being attainable by providers.

Prior to COVID, providers were already challenged by the lack of tools and infrastructure necessary to fulfill contractual agreements. Now, with a combination of increased financial pressure and changing regulations, providers may not be able to or know which metrics they must fulfill this year to meet contractual requirements. To be successful, both payers and providers need to understand each other’s challenges and capabilities, not to mention the administrative burden of reporting and work together to create a plan to move forward.

Payers, likewise, have needed to overhaul operations to address VBC models and incorporate actionable analytics. Data driven actionable insights can help mitigate the operational and financial challenges faced by providers and payers to continue maintaining quality-of-care provided in a post pandemic world. Payers and providers need to have actionable insights in order to assess the status of their partnership. “What-if” analysis can serve as a valuable tool and better predictive analytic algorithms could reduce risk. Apart from these, patient outreach and engagement tools, physician scheduling tools, price transparency solutions and tools for patients to have secure access to data will only improve the collaboration.

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