Bridging the payer-provider trust gap

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May 02, 2017

A 2016 Trust Index Survey conducted by Revive Health documented the limited trust between payers and providers and showed, not surprisingly, that insurers tend to trust providers more than providers trust insurers.

Until remedied, this ‘trust gap’ will continue to have negative implications for the healthcare system and its patients. But there are strategies that can help payers succeed in the shift to a value-based approach by collaborating more closely with providers.

Standardized metrics

One strategy is to standardize the metrics payers require of providers. Requiring providers to report different quality measures to different payers results in confusion and reduces time spent on patient care.

While not a new concept as groups such as the Integrated Health Association (IHA) and Pacific Business Group on Health (PBGH) have for many years worked to have a comprehensive accountability program that applies to all managed patients regardless of payer/sponsor, such programs have not expanded to other markets as quickly as expected.

In an effort to advance this issue, the Centers for Medicare & Medicaid Services (CMS) and America’s Health Insurance Plans (AHIP) launched in early 2016 the Core Quality Measures Collaborative.

CMS and AHIP worked with commercial insurers, purchasers and provider organizations to identify and align core performance measures, with the goal of easing the burden on providers and improving the quality of care for patients.

Being able to narrow the measures used can also allow better training and program management with providers who have previously felt there were too many variables to monitor with little financial or performance benefit.

Improved communication and health information exchange

In any healthy relationship, communication is key – and the relationship between payers and providers is no exception. A second strategy payers can employ to bridge the gap with providers is increasing the frequency of communication and the exchange of health information.

Payers have historically guarded much of their claims, lab, imaging and pharmacy data because they were reluctant to share information with competitors.

Payers have also been reluctant to share data with providers due to concerns that it would weaken their bargaining position. To create more of a ‘payvider’ model that can deliver care and accept risk, these practices must change for these two groups to deliver value-based care.

From there, the collaboration can grow into producing value-based insurance design (VBID) models, a growing aspect of patient-centered care.

Value-based care is a driver

Value-based care is creating the need for organizations to focus on outcome measures, more personalized care and patient satisfaction, giving payers the opportunity to work with providers to solve problems with re-admissions and redundant care by sharing data that will result in lower cost of care for both parties.

In the past, payers may have met with provider organizations once or twice a year. Now, the two parties interact more frequently, including at the data sharing level, to improve operations and outcomes.

Improved health information exchange between the two parties is critical when they share responsibility for providing not only high quality care, but affordable care. Frequent and effective exchange can identify and address gaps in care, improve care coordination, increase preventive services and omit unnecessary duplicative testing and services – all of which play a role in potentially reducing overall healthcare spending.

A 2016 FierceHealthcare article cited two successful payer-provider collaborations – Trinity Health with CMS, and Inova Health with Aetna Virginia.

Trinity and CMS have collaborated on patient engagement and care coordination strategies to improve health and outcomes. Inova and Aetna created Innovation Health, a partnership that created simpler, more affordable health plans, including special plans for those with specific conditions such as diabetes.

Innovation Health also resulted in an enhanced care coordinator program where nurses from both partners meet daily to share information and develop care plans for members using hospital or ED services.

Healthcare sustainability, an insurance exchange in flux and VBID growth – in part through a current CMS demonstration model – can converge with gains being made from within the industry to further bridge the mutual goals and collaborations of payers and providers.

About the author

Paul Taylor

Paul D. Taylor, MD, 
CMO, Philips

Paul D. Taylor is CMO for Philips PHM. Board-certified Internal Medicine physician and entrepreneur with experience developing industry-leading Value-Based Care and Population Health Management solutions and implementing clinical quality improvement programs and systems of care at the physician, physician group, physician organization, and community levels.

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