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Improving Payer-Provider Collaboration

Advanced analytics drives payer - provider collaboration and value-based care success.

"We believe that transparency can help us do better," said Scott Wilkerson, adding that it's not common for doctors to get large amounts of claims data about their patients from insurers.

That's what Scott Wilkerson, the executive director of Lurie Children's Health Partners Clinically Integrated Network, said in a recent Crain's Chicago Business article about successful efforts by Blue Cross and Blue Shield of Illinois (BCBSIL) to increase the number of its members served by accountable care organizations (ACOs).

Like most payers across the country, BCBSIL has embraced ACOs and value-based relationships with participating providers. Today, the company participates in 20 value-based arrangements that serve one in four of its members. The efforts are working as intended. BCBSIL reports emergency visits are down by 16 percent, hospital admissions have decreased 15 percent, and spending has declined by $17 per member per month.

At the heart of all ACOs and value-based relationships are participating providers like the nearly 1,000 physicians in the Lurie Children's Health Partners Clinically Integrated Network. They are the face of the payer for attributed members; they are on the frontlines of managing the quality and cost provided to those members; and they play a fundamental role in delivering results like the ones BCBSIL has experienced. 

As Wilkerson noted, claims data about attributed patients is critical to their success, yet still rare. BCBSIL now understands and appreciates the potential for more collaborative and productive partnerships as a result of sharing this kind of information – partnerships that benefit the payer, network physicians and ultimately members.

There's even more power in advanced analytics platforms that integrate claims, clinical, lab, pharmacy and wearables data and apply predictive and prescriptive analytics to create one comprehensive profile of each member, a profile that includes current health status and predicted health needs, and is shared by the payer and participating providers to improve care coordination and outcomes. The savviest payers have learned that shared analytic solutions create a unique and valued opportunity for relationship- and trust-building with network physicians, which, in turn, drives success in value-based partnerships.

Advanced analytics drives payer – provider collaboration and value-based care success

Not too long ago, payers met monthly with participating physicians and used paper charts to review performance. Too often, physicians were surprised to learn their numbers were trending in the wrong direction, leading to heated discussions and pointed questions about the validity of data. "Prove it" was a common refrain. So the next month, payers brought additional paper reports to back up the findings in the previous month's performance review, which might lead to another round of "prove it." And so it continued, month after month. It's no exaggeration to call these meetings, and these relationships, contentious and distrustful.

It no longer has to be this way. For payers and providers who share an advanced analytics platform, these monthly meetings can be constructive and collaborative.

Providers with an online, on-demand and self-service reporting platform are able to explore the data regularly; many choose to use the tool daily. They leverage the platform's insights and alerts to know, for example, that one of their attributed members has been admitted to a hospital while wintering in Florida or another has visited the emergency department again for recurring COPD (chronic obstructive pulmonary disease) complications. Regular use of the tool means physicians are aware of how they are trending in terms of quality, cost and utilization at an aggregate or detailed level, and in comparison to their peers. If they question the numbers, they can drill down to view the supporting detail, and "prove it" for themselves.

All of this activity happens outside of the monthly payer-provider meetings, and that means these meetings can be dedicated to more focused and fruitful discussions about how to work together, for example, to coordinate care for members with complex healthcare needs. Take Adam Beck, for example. He has heart failure (HF) and diabetes. The advanced analytics platform alerts show he has poor HbA1c control, a recent hospital admission and a high condition-risk score, all of which suggest he needs help managing his condition. Additionally, as the result of the platform's predictive analytics, the payer and provider also know Mr. Beck is at risk for amputations or renal failure. After discussing his case, the payer and provider agree Mr. Beck is a perfect candidate for care coordination and determine the next step is for a representative from the payer's care management program to call him to perform assessments to assist in building his care plan.

As in the case of Mr. Beck, the use of an advanced analytics platform leads to a more collaborative relationship between payers and participating physicians, one in which they leverage each other's strengths and work together to improve the current and future health of their members and succeed in value-based care relationships.

Access more information from this sponsor here: http://www.healthcarefinancenews.com/sponsored/payer-is-reporting-key-to-value-based-care-success

About the Author:

Mark A. Caron, CHCIO, FACHE, CEO, Geneia

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