Special post featuring Dr. Lee Mills, VP of Clinical Operations and former Senior Vice President and Chief Medical Officer of CommunityCare Oklahoma
A collaborative, trust-based relationship between payers and providers is a prerequisite for delivering value-based care. However, a recent survey by Beckers and VirtualHealth found that payer leaders cited a lack of provider engagement and active collaboration as a top barrier to delivering value-based care.
Meanwhile, payer leaders responding to a January 2024 survey by Gartner ranked quality improvement as “very important”, but fewer than two-thirds ranked the provider experience as high-priority (Bishop, M, 1Q24 U.S. Healthcare Payers Enterprise Benchmarks: Priorities and Technology Deployments, Gartner, 1 March 2024- ID G00809883).
But the two are directly related. And payers must address this disconnect.
Here we explore how payers can build stronger relationships with providers by taking action to improve some of the biggest detractors from the provider experience.
A Rocky Payer-Provider Relationship: What’s at Stake?
A lot.
When strong collaboration and communication aren’t present between payers and providers, they tend to perform poorly in value-based care delivery, noted Dr. Lee Mills, former Senior Vice President and Chief Medical Officer of CommunityCare in Tulsa, Oklahoma.
“True value-based care is only possible at the highest stages of collaboration, which is why so many organizations that are barely communicating or cooperating struggle to deliver it,” Dr. Mills said. “By definition, value-based care requires both the provider and payer to have clear, open communication, understand each other’s roles and actions, and be fully aligned on shared goals.”
A weak provider-payer relationship negatively impacts the member experience and drives higher costs of care, too.
- Delays in treatment
- Communication gaps that leave the member feeling out of the loop regarding important aspects of their care
- Poor continuity of care
These are all downstream impacts that sabotage good health outcomes and drive up the cost of care.
Top Barriers to a Good Provider Experience
Dr. Mills weighed in on some of the biggest challenges impacting the provider experience that can lead to a lack of trust and an adversarial relationship between payers and providers. They include:
- Data interoperability issues resulting in poor data transparency and not enough information sharing
- Cumbersome paper or spreadsheet-driven quality reporting that doesn’t benefit providers
- High administrative burden on providers that contributes to widespread physician burnout
- The fractured nature of healthcare, with providers dealing with multiple payers, and often dozens of different health plans. This leads to disparate programs, goals, and metrics – and even different metric definitions for the “same” goal.
- A relatively small number of patients in any given value-based or QI program with any given payer
- Provider-side challenges that prevent engagement even when the desire to do so is present. These include:
- Chronic staffing shortages
- Staff sophistication that doesn’t match need (e.g., medical assistants instead of registered nurses)
- Office operations built for fee-for-service turnover
- Health plan-side requirements that prevent good provider engagement. These include:
- Challenging claim run-out periods (e.g., 6 months minimum before using data)
- Unwieldy, confusing reconciliation processes
- A complex patient attribution process that providers typically misunderstand
How Can Payers Improve Provider Experiences?
As with any relationship, it takes work to build trust and alignment. Payers may not be able to fix every problem impacting the provider experience, but here are top suggestions on focus areas for maximum impact.
1. Establish Transparency and Goals
- Identify a starting point for collaboration, then be transparent about securing agreement from stakeholders on both sides.
- Implement a mechanism to govern collaboration. A “joint operating committee” is a common way to accomplish this, Mills noted. This committee will facilitate transparent sharing of insights, best practices, challenges, and data, as well as accountability for setting – and working toward – goals and next steps.
- Jointly define the goals of the program, contract, or initiative.
- Work to develop and emphasize multi-payer initiatives and cohesive metrics, goals, and definitions. This streamlines the provider workflow to meet everyone’s needs. It also allows a much larger portion of a given practice to be included and impacted.
2. Consider Integrating Care Management Programs with Providers
In an example of boots-on-the-ground collaboration, Blue Cross Blue Shields Michigan (BCBS MI) discovered that integrating their care management team with provider practices resulted in better care continuity and more targeted member care, according to Michelle Fullerton, Vice President of care Management, Customer Consulting, BCBS MI.
With this program, BCBI pays providers to have care managers on staff, which has helped build trust among the provider community in addition to improving care delivery.
“We can help those provider-delivered case managers with things like benefits and continuity of care … I would tell you that working with our providers and double-delivering [care management] through the health plan has become a very wonderful program because we just try really to capture a patient where they are and address that need,” Fullerton said during a recent webinar presented by VirtualHealth and Becker’s.
Level up Data and Technology Practices
Focus on improving data interoperability and data access. It’s absolutely critical for providers to have data readily available in their routine workflow, both corporately and patient by patient.
Our recent conversation with HL7 emphasized this:
- Leverage technology such as:
- Tech platforms that put data at providers’ fingertips and reduce duplicative data entry
- Automation to decrease the burden of reporting
- Telehealth and other virtual health services
- Automation for prior authorization to reduce admin burden for providers and speed care delivery for members
- Explore technology that will de-silo data and streamline quality reporting. It’s nearly impossible for providers to obtain all the correct data when they’re forced to manually search through multiple systems.
HELIOS by VirtualHealth can help payers improve communication and transparency with providers, streamlining data sharing, quality reporting, and more.
Get more information here about HELIOS and VirtualHealth today.