Transforming the provider-payer relationship from adversarial to collaborative through value-based 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.

Invest in the right technology

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.

Build trust and create common goals

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.

Remove barriers to action

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:

• AI-powered insights: Leverage AI and machine learning algorithms to identify cost savings and quality improvement opportunities, empowering collaboration on shared goals.
• Cohort management: Surface opportunities to prioritize key populations or members based on condition burden, predicted costs, health risks and more.
• Resource allocation: Shift focus and allocate appropriate resources to specific high-need populations with seamless data sharing between analytics and care tools, and data from a single unified data lake to eliminate inconsistencies.
• Care gaps: Address gaps in quality, hierarchical condition category coding, access to care and more when you combine clinical and claims data in a single platform.
• Tailored user experiences: Customizable access control, self-service dashboards and reports protect proprietary data and protected health information while ensuring everyone has the correct information at their fingertips.

Integrating with legacy systems

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.

A collaborative future

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.