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Payers must change dynamic with providers to survive in the post-Affordable Care Act world

Finding the path to success in the post-Affordable Care Act world of healthcare represents a great opportunity and challenge for payer organizations. Part of that journey is changing the relationship dynamic between payers and providers.

In the era of guaranteed issue and value-based reimbursement, payers and providers are increasingly aligned around the same goal: getting patients/members just the right amount of care at just the right time to get the best outcome for the best cost. 

Alignment is great, but if payers really want to collaborate with providers to put effective population health programs into action, they have a lot of work to do. This includes overcoming payers' historic distrust of providers, and getting their data house in order to meet the demands of today's population health management initiatives.

Other critical success factors for payers in the post-ACA world include: being able to offer products on and off the public exchanges that are attractive to employers and individuals; and retaining members by generating high satisfaction, all the while ensuring that their products are economically sustainable.

Designing and deploying successful health plan offerings is inextricably entwined with the issue of transforming relationships with the provider community and collaborating for effective population health.

You can make a narrow network plan attractive and retentive while still delivering on great care coordination, prevention and early intervention --all hallmarks of effective payer-provider collaboration and population health.

Although the challenges presented by the post-ACA world are complex, the solutions don't have to be.

Payer/provider collaboration

While this new era of risk sharing through ACOs, bundled payments, and capitation models aligns payers and providers around the shared goal of achieving best outcomes as efficiently as possible, there is still a great deal of mistrust and misunderstanding to overcome.

In the past, data has been a major source of the friction between payers and providers. Payers sought to make providers accountable, but the limited and inaccurate data that many payers provided severely undermined trust.

This can be improved through IT infrastructures that allow payers to give providers complete, accurate, and real-time updates based on both claims and longitudinal clinical data. Getting the data house in order can help transform the payer-provider relationship by giving providers not just accurate data, but insights that are truly useful and otherwise inaccessible.

Putting population health into action

Good population health programs require more effective information sharing, care coordination and patient-centered care, which leads to a larger picture of each patient's clinical "story," and also incentivizes clinicians across care teams to keep each other apprised of patient updates in real-time.

One of the largest challenges in this collaboration is gathering data from the wide array of sources and consolidating it in a way that benefits providers and patients.

To overcome this obstacle, payers need to develop an information sharing platform that provides up-to-date data and generates a comprehensive, longitudinal medical record for both providers and patients.

Designing and deploying sustainable products

Technology plays a critical role in a payer's ability to offer efficient yet attractive products. The key to post-ACA success for payers is the ability to design and deliver products that are attractive to the exchange market, yet still profitable.

This means striving for maximum efficiency, but also prioritizing member retention. Technology can free up health plans to create products with the cost efficiencies of a narrow network and the attractive benefits of tightly-integrated care teams sharing knowledge and delivering care based on evidence-based, data-driven best practices.

In this way, an economically efficient narrow network plan can be not just tolerable, but attractive and retentive.

The good news is that cultural transformation is already underway for many payer and provider organizations, and this is changing the way the entire industry thinks about care quality, risk management, cost of care and patient/member satisfaction, just to name a few. 

The other side of that cultural change is transforming technology infrastructures to enable, support and sustain that change. With these key factors in mind, payers and providers can find success through their newfound camaraderie in the post-ACA world.

Suzanne Cogan is vice president of Orion Health.

 

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