3 Best Practices for Payer-Provider Collaboration to Improve Patient Care

Team Of Doctors Examining ReportsDuring the past couple of months, I met two clinicians who had recently embarked on careers in the payer sector. The first is a physician who told me that despite her reluctance to confine herself to a desk all day, she loves working with data and is particularly interested in evidence-based protocols. The second is a former nurse executive in a large multihospital environment. She, too, misses the hospital setting but wants to be involved in the new push for value-based care.

Both of these clinicians believe in patient-centric care and the potential of new value-based delivery models to improve quality. They are excited to be part of the shift away from the fee-for-service reimbursement model.

Both are also keenly aware of the importance of payer-provider collaboration in the new era of accountable care and the challenges involved in transforming what has historically been an adversarial relationship. I was able to discuss with these two former clinicians three concepts payers must address when collaborating with providers.

Concept 1: Clinical Measurement and Metrics

When payers and providers collaborate on risk-based contracts, they must agree up front on metrics—what they plan to measure and what their improvement targets are. Though these metrics will require refinement over time, they are needed from the outset as a baseline. Luckily, the Centers for Medicare and Medicaid Services (CMS) has helped this process by defining baselines and thresholds for various measures.

Examples of typical metric categories include:

  • Admission rate per 1000 and patient days per 1000
  • Length of stay
  • Readmission rates
  • Emergency cases per 1000
  • Hospital-acquired infection rates
  • Patient satisfaction scores

Implementing a healthcare enterprise data warehouse (EDW) is the best way to aggregate and then leverage insights from both provider and payer data to:

  • Identify which measures can have the greatest impact on cost and quality so that organizations can determine where to focus improvement efforts
  • Track performance against these measures

Concept 2: Payer-Provider Transparency

Payers and providers need a plan for ensuring transparency. How providers and others are performing against targeted measures must be made available to many stakeholders. This availability helps ensure that targets are hit consistently and that everyone gets paid appropriately in a value-based system.

Any collaboration’s goal should be an infrastructure that makes knowledge easy to access. An EDW that organizes clinical, financial, patient satisfaction and administrative data into a single source of truth is the foundation for establishing this level of transparency. The EDW needs to deliver visualization tools that empower a variety of users to view data and evaluate trends.

Concept 3: Clinical Improvement

Once payers and providers have aggregated data in an EDW, they can visualize trends in the data and jointly establish informed objectives for their population. Providers and payers will benefit most by targeting areas with high variation and those that can be improved by evidence based practices.

A sophisticated EDW platform delivers tools to help organizations identify these areas with the greatest potential for cost and quality improvement. Health Catalyst’s Key Process Analysis (KPA) application identifies the clinical work processes with the highest variation that consume the most resources. By identifying and then focusing on the top 10 to 20 processes, organizations can make significant cost and quality gains.

Many of these areas will require a multi-year approach to attain the level of improvement needed, but starting now is important.

The two clinicians I spoke with who have chosen to work behind the scenes have the same goals as clinicians on the front lines. The same can be said of payers and providers—both want to improve patient care and lower the cost trend. An EDW is the foundation that enables them to collaborate intelligently and effectively to transform healthcare.

Can you think of other concepts you’ve used to drive collaboration? Any other unique challenges you’re finding?


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