Payers and providers have long had ups and downs in their relationships, even before the Affordable Care Act. But prior authorization and data interoperability demands, coupled with patient volume and clinical documentation needs, mean payers and providers feel under more pressure than ever before.
Value-based care (VBC) offers a care model alternative to the traditional fee-for-service model, incentivizing providers to treat their patients more prospectively which can require them to take on more risk. VBC reimburses providers based on patient health outcomes and the quality of care rather than the quantity of services. But for VBC to be effective, providers need to have a holistic picture of their patients’ health, which will support better patient management and comprehensive treatment, and unfortunately doing this can also require use of multiple and disparate systems that are often a heavy administrative burden.
When VBC is effective, it spurs patients to be more active in their healthcare and improves patient adherence to treatment plans. The goal is to reduce hospital re-admissions and control escalating healthcare costs by basing reimbursement on patient outcomes. Although fee-for–service continues to dominate the healthcare industry, VBC has made inroads into the mainstream of healthcare.
In a recent webinar, Veradigm Senior Manager of Provider Performance and Tech Utilization Amanda Banister shared insights on how payers lead the next phase of VBC implementation and how they can collaborate with providers more effectively.
Collaboration between providers and payers is key
“Value-based care isn’t just a policy shift. It’s transformation and how we deliver, measure, and reward care. But transformation requires connection. Too often payers and providers are working from disconnected systems, incomplete data, and misaligned incentives — and patients caught in between experience fragmented and reactive care,” Banister said.
A holistic view of patient data is critical for VBC to succeed. But this data is often siloed or delayed and lacks the context needed to drive decisions at the point of care. Fragmented and incomplete data, especially when it lacks context, prevents providers and payers from seeing the full picture of the patient. Misaligned incentives are also problematic. Although providers are asked to take on more risk, financial and operational supports often aren’t in place to do so.
Clinicians are expected to close gaps, manage quality, and document risk, but often through clunky portals or manual processes that increase friction and reduce their efficiency. Workflow disruption and provider fatigue also pose challenges to VBC adoption and implementation. All parties have a lack of transparency. This is exacerbated by a lack of clear communication and shared visibility which hinders collaboration between providers and payers. Without clear communication, collaboration feels like oversight, not partnership. Broader industry growth drivers shape how we think about innovation in healthcare, Banister said.
“Providers often feel like they’re being second-guessed by health plans, administratively burdened to gather important information about their patients for whom they need to make informed decisions and follow best practices. Payers often feel ignored when they deliver reports and data to providers without a response in a timely manner, if at all,” she explained.
Banister emphasized that when VBC works, the balance of managing a patient’s health relies heavily on both payers’ and providers’ knowledge and ability to collaborate.
“And let’s be real, that just isn’t easy,” Banister added.
For payers, there’s significant investment in quality and risk adjustment programs. These initiatives rely on better data, tighter provider engagement, and tools that can support decision-making at the point of care, said Banister.
EHRs as a vehicle for improving payer and provider collaboration
Banister highlighted ways EHRs can breach the divide between payers and providers and be the vehicle for improving payer and provider collaboration.
“EHR vendors sit in a unique intersection with capabilities that can assist both payer and provider workflows. We’re seeing the evolution of native platforms that can make clinical and payer data actionable in real time. That’s a major shift from where we were even a few years ago, and it’s creating new possibilities for how we support both providers and payers,” she said.
For VBC to work, it’s incumbent upon providers to figure out how to help patients close care gaps, such as chronic condition management, missed care events like annual physicals, immunizations, or preventive screenings. That requires providers and payers to have better partnerships to share all relevant patient data.
“We know that preventive screenings and early interventions can reduce downstream emergency room visits and in-patient stays,” Banister noted. “We also know that shared data reduces duplicative testing and unnecessary referrals.”
Embedding actionable patient care gaps directly into provider workflows and capturing real world data from EHRs to inform care quality enables payers to drive the collaboration, shared understanding, shared accountability, and shared outcomes. To improve chronic condition management, providers need to receive timely care gap alerts and medication histories that they can then use to escalate treatment plans before the patient’s condition deteriorates. Payers have visibility into longitudinal claims — but that’s not beneficial for providers if they can’t see it and aren’t aware of it at the point of care. Care gap alerts while the patient is with the provider are the best opportunity for intervention with a patient because they’re in the office, face to face. It offers a timely opportunity to address and eliminate these gaps.
Banister also offered some advice to payers aiming to improve collaboration with providers.
“Don’t expect providers to do everything all at once. Deliver asks and goals that are attainable, scalable, measurable asks that are easy wins. Providers will get on board when they see how value-based care improves patient outcomes, not just cutting costs. You need to give them good data, real-time insights, not spreadsheets. Help them to identify gaps, risks, and opportunities without drowning in the administrative work and overflow,” Banister urged.
She also encouraged payers to make incentives clear to providers. Transparent, achievable goals tied to shared savings or bonuses would be meaningful to providers, she said.
“Support them, don’t micromanage them. Offer tools and guidance but let providers lead care decisions. The real bottom line with providers is when they feel heard and equipped and rewarded, they’re going to lean in,” she added.
Banister summarized how payers and providers can move toward better relationships to succeed this way:
“First, we need to create less friction and more trust, meeting providers where they are and providing pathways to support their efforts. Second, having a culture of ecosystem thinking – increase interoperability and provide actionable, timely and accurate data to providers that will then drive results that payers need.”
Photo: Luis Alvarez, Getty Images
