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Off the Sidelines: How Consumers, Employers, and the Government Are Driving Payer-Provider Collaboration


Emad Rizk, MD, president and chief executive officer of Cotiviti

True alignment between payers and providers is the most critical success factor in securing improvements in both the cost and the quality of care. Over the last decade, progress toward this alignment has occurred, observable primarily in the many functional partnerships that have formed at the regional level. However, it has been slow and has not yet achieved the desired systematic impacts.

Annual health care spending has risen to a staggering $3.3 trillion and continues to climb at more than 4% per year, according to the latest CMS expenditure data—influenced in large part by changing demographics and an explosion in medical innovations. Quality metrics have improved in some areas and declined in others, with overall US quality of care indicators still showing significant room for improvement. Providers remain hesitant to take on risk due to their lack of retrospective and complete longitudinal claims and clinical data. Payers, on the other hand, continue to wrestle with how to leverage financial data, obtain and incorporate associated clinical data, optimize provider network efficiency and performance, and implement important interoperability and single-patient identifier initiatives.

In this complex environment, the ability to aggregate, analyze, visualize, and operationalize horizontal data has become a critical success factor. To build true trust, payers and providers must begin to work with the same set of data and the same truths. Yet the lack of interoperability between electronic health record (EHR) systems, applications that collect data about social determinants of health, and payer systems for claims adjudication, network and care management, and member engagement continues to hamper essential data-sharing efforts. In addition, the industry is becoming increasingly sophisticated in its study of social determinants and genetic predisposition factors, as well as in its ability to leverage artificial intelligence to gain deeper insights. 

The good news, however, is that over time other health care stakeholders have taken steps to bolster this core relationship, recognizing the toe-hold it provides in the climb toward better, more affordable care. Consumers are now more at risk financially and have gained significantly more access to payer and provider data. This access enables them to better articulate their expectation of improved performance at lower cost. In addition, employers are requiring data from their health plans to demonstrate that they are providing employees with access to the most appropriate, highest-performing providers. And while its tactics may change fluidly, the government has successfully spurred collaboration through several recent initiatives centered around data and risk sharing models.

The Educated Consumer

When it comes to their health care spending, consumers have more “skin in the game” than before as employers seek to shift costs and accountability to their employees. According to a Centers for Disease Control study, the percentage of adults under 65 who are enrolled in a high-deductible health plan rose from 39.4% in 2016 to 43.2% in 2017. Consumers enrolled in such a plan are highly motivated to find low-cost providers who will deliver good outcomes. How do they accomplish this? In many cases, simply by logging into their health plan’s website and comparing providers by zip code.

This creates both an incentive and disincentive for providers to share data with payers. Given a choice between Provider A, who ranks high on quality and low on cost, and Provider B, who has no data available at all on the health plan’s website, the consumer will generally choose Provider A. Further, if a major health plan determines that a provider is not meeting its cost or quality standards, it may place that provider in a lower network tier, requiring members to pay a higher copay. Obviously, as consumers look to control their own costs, this will cause a significant decline in patient visits.

Consumer choice has also put more pressure on payers. Through quality improvement initiatives such as HEDIS® and Star Ratings, consumers can access a significant amount of data on quality and member satisfaction. Performing well in these programs requires close collaboration with providers to ensure that members are receiving the highest quality of care, and care gaps are appropriately addressed.

Proving Value

According to the latest data from the Kaiser Family Foundation, 49% of the total US population receives health insurance coverage through their employer, by far the largest percentage of any option. While the number of smaller employers offering health coverage has declined in recent years, likely driven by requirements under the Affordable Care Act, larger employers are required to offer access to health insurance plans. They also recognize that their ability to attract the best employees hinges upon the coverage options they make available to them.

What do employers want to see when selecting which health plans they’ll offer their employees? Data. Cost is obviously a crucial factor, but employers also want to know that their employees will have access to a high-quality provider network at a reasonable cost. This again spurs providers to collaborate and share data with payers, because large employers have a significant amount of leverage over how the payer’s provider networks are designed.

The federal government has been and continues to be a primary driver of innovation and collaboration, particularly around EHR adoption and interoperability. According to data from the Office of the National Coordinator for Health Information Technology, the percentage of office-based physicians with EHR systems rose from 48.3% in 2009, when the HITECH Act was passed to spur EHR adoption, to 86.9% 2015.

More recently, the bipartisan 21st Century Cures Act passed in late 2016 significantly promotes the flow of information between EHR systems while penalizing those who engage in information blocking.  

As we look ahead, we can expect that the barriers standing in the way of effective collaboration will continue to fall. Technologies such as natural language processing can bring forth information from once-static clinical documentation and parse this information for more thorough data analysis. Once the health care system has solved the problem of data aggregation across stakeholders and uses, the focus will turn to finding ways to make the data so easily digestible and trustworthy that each stakeholder will be compelled to take action. Artificial intelligence and machine learning are already proving their value in this process. As these technologies become mainstream, the pace will accelerate, changing payer-provider collaboration from an unfulfilled imperative to the norm in the American health care system.  

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