As value-based care adoption grows, payers and providers must find the right tools to transform adversarial interactions into partnerships that put patients at the center of care.
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Within the health care system, payers and physicians have long operated at odds with one another. While both have a goal to improve patient and member health, their approaches often differ, creating friction. Physicians get frustrated when they have limited information about how data are collected and used to calculate patient attribution and payments. They may feel powerless to control factors for which they are held accountable, and payments are at risk, particularly when there are gaps in electronic health record (EHR) data for cost and quality, or they have limited insights into levers available to impact population health, driving higher costs or lower quality scores.
Payers, on the other hand, grapple with rising costs and the need to minimize premium hikes to remain competitive with members. They understand that most patients have much higher trust in their doctors than in their insurance companies and want to improve their relationship with providers. But they also have to balance protecting proprietary data and sharing only necessary information with physician and other clinician partners. Additionally, because of the structure of the insurance claims process, most of the data they work with have a significant lag — three to six months on average — limiting their ability to address cost and quality shortfalls within a single performance year.
Rajiv Mahale
© Cedar Gate Technologies
To succeed in value-based care (VBC), both payers and providers must address and overcome these challenges. VBC begins with a common goal for payers, doctors and patients: prioritizing preventive care and overall patient health and improving outcomes, which in turn can lower the total cost of care. As VBC adoption grows, payers and providers must find the tools to transform traditionally adversarial interactions into partnerships that put patients at the center of care. There are three key pathways payers and providers can take on that journey.
Technology has transformed medicine in many ways, but nowhere does it have more impact than through the effective and efficient use of data aggregation and analytics tools. Robust data aggregation tools bring together disparate data sources, then normalize and enrich the information and stitch it specifically to each member. Advanced technology platforms can share that information seamlessly through a bidirectional integration between claims and EHR data. This allows both payers and physicians to see — almost in real time — what is happening with each individual member. Providers can use that information at the point of care to address care gaps and quality outcomes that payers consider when calculating reimbursement rates and shared savings. Payers get the benefit of a more robust picture of each member’s care with integrated EHR data.
VBC models provide a pathway through the impasse by shifting the focus from volume to value. Instead of tying payments solely to the number of services offered, VBC links reimbursement to the quality of patient outcomes. Building strong, collaborative relationships between payers and providers is essential for delivering high-quality, cost-effective care. However, managing these complex partnerships in practice can be a challenge.
VBC software platforms that aggregate and share clean, normalized data — and regularly refresh those data within a performance year so everyone has accurate, recent information — improve transparency between payers and providers. Additionally, these tools must facilitate the ability for both parties to drill into the data details, understanding methodologies behind specific calculations and metrics. When everyone can work from the same set of data and trust the underlying structure and integrity of those data, they can agree on priority metrics and performance goals around cost and quality.
Comprehensive, VBC-focused solutions then enable payers to forecast and track contract performance goals, applying artificial intelligence (AI) and machine learning predictive models and analytics to highlight cost-saving opportunities and quality improvement. This data-driven approach ensures payers and providers align objectives, working together to enhance patient care and manage costs effectively.
Having access to advanced analytics is essential, but payers must take the next step to ensure physician and other clinician partners have access to the information and can translate it into actionable steps to improve member and patient care. VBC software that integrates claims and clinical data can provide better awareness for both parties of issues with quality, risk and cost within a performance year while there is still time to adjust to meet performance goals.
When analytics is integrated with care software, it streamlines workflows and reduces administrative burdens. Nurse navigators can access detailed information on patients prior to a visit, doctors have detailed analytics insights available in the electronic medical record at the point of care, and care managers can use the insights generated from analytics for targeted outreach to improve access and outcomes. Advances in generative AI can further streamline these activities in the future, bringing administrative costs down.
An integrated solution that combines powerful analytics with care management tools helps payers share information with providers, including the following:
Another common challenge in the shift to VBC is integrating systems designed for a value-based future with legacy technology. The disparities between these systems can create data silos, slow critical workflows and make it hard to adapt to changing markets. To avoid these challenges, payers need modular, customizable analytics and care management solutions designed to seamlessly share data with legacy technology. This allows for effortless data flow, scalable functionality for future needs and consolidated efficiency without the need to overhaul the entire technology ecosystem.
The shift from adversarial to collaborative relationships between physicians and payers is not only possible — it is increasingly necessary, and the urgency to move to risk-based models is not slowing down. According to McKinsey, payers must evolve from simply administering benefits to managing care and capturing cost savings. In this new reality, physician partnerships (especially in VBC models) become increasingly important. As cost pressures rise, payers must scale proven models and adopt innovative new ones, all while enhancing health outcomes and member experience to adapt to a changing market and meet members’ needs.
Collaborative, end-to-end platforms designed for a VBC future provide a robust framework for this transformation. The right tools help payers and providers focus on quality outcomes, transparency and continuous collaboration. This transformation benefits the entire health care ecosystem, marking a significant step forward in delivering high-quality, cost-effective care.
Rajiv Mahale is the chief product and business development officer at Cedar Gate Technologies.