Payer and Provider Collaboration Ensures the Industry is Tracking Towards Value

Collaboration between payers and providers is an important asset to improving quality of care across the healthcare ecosystem, while simultaneously keeping costs down. For example, payers have access to a significant number of claims data that creates a holistic view of patients’ information, while providers typically have discrete clinical data information. By working together to exchange this information, payers and providers can stay on top of patients and ensure they are getting quality care and avoiding high-cost events, such as visits to the emergency room. Also, with value-based care top of mind, payers and providers need to work together to leverage data and analytics to reach that end goal. We talked to Bruce Carver, Associate Vice President of payer services at MedeAnalytics, for his insight on the current challenges that prevent payer-provider collaboration, best practices to achieve it and why it’s useful.

Challenges that can arise within collaboration

When it comes to payers exchanging information with providers, storing clinical data received from an electronic medical record (EMR) is very expensive. There is no standard format across the U.S. for providers to implement that information simultaneously. Oftentimes, payers don’t want to add another system to store that information, instead integrating it through an EMR that can be sent out from a provider’s system and to a payer. In addition, providers have access to more timely data as well, enabling immediate outreach to patients. Ultimately, collaboration is needed so both the payer and provider are on the same page when it comes to treating patients. If either doesn’t have the complete information, it can result in gaps in care and ineffective treatment.

How analytics can help

Analytics can provide additional ways that a provider and payer can exchange that clinical information. In an EMR, there are hundreds of different measures and metrics that are collected within that provider’s system but oftentimes only a small portion of that is necessary to be able to collaborate effectively for the value-based programs that are in place. MedeAnalytics has enabled external use of its platform by a provider to be able to attach and upload that information straight into an analytic tool that is used to measure results of the program, which makes for a more cost-effective solution.

Additionally, focusing analytics on three areas can help save costs:

  • The individual market – Analyzing the market can allow payers to make strategic decisions on how to approach and cater to specific member populations.
  • Gaps in care – A prospective look at gaps in care ensures that patients are getting the care they need, both preventative and specific to any chronic conditions. The goal is keeping healthy patients healthy and managing those with chronic conditions to keep them from requiring high-cost services like emergency room visits or hospital admission.
  • High costs – If organizations can establish where they are spending the most, they can work to lower those expenses throughout the year.

How patients can be managed

With quality care for patients being top of mind for both payers and providers, exchanging valuable information to stay on top of at-risk and high-risk patients can also lower costs. For example, if a diabetic patient stopped attending physician visits, or stopped refilling prescriptions, payers can alert providers to get that patient back on track. That in turn could save individuals from future emergency room visits which are costly for the payer, and potentially catastrophic for the patient. And with a value-based care mindset, it is in a provider’s best interest to keep that patient well and on their health plan. Further, providers can alert payers to which patients are not being treated in preventative care appointments, and by remedying this, can prevent at-risk patients from becoming high-cost, by putting them on a long-term plan to keep them healthy, which saves money for the payer.

When done effectively, payer and provider collaboration can mean better care for the patient and a drive towards value-based care. It’s all about making the most of your analytics investment, building trust and effective communication, as Bruce outlines here. To learn how MedeAnalytics can help your organizations collaborate with payers and providers, visit our population health solution page here or our healthcare economics solution page here.