Healthcare providers and payers have long had contentious relationships, and some of those battles over claims and reimbursement for care have been bitter. After years of opposition, providers and payers are finding themselves as necessary bedfellows, prodded along by the shifting reimbursement incentives posed by value-based care. For payers and providers to succeed under value-based care, they need each other’s data and cooperation, as they see their financial incentives begin to align around the need to provide high-quality, cost-effective care.
Close collaborative efforts between providers and payers are only beginning to emerge, as pioneers begin to wrestle with some of the technical challenges of sharing data, both for individual patients and for larger populations. Early efforts focus on becoming more transparent in sharing patient data, but they’re finding a growing need for sophisticated IT, especially by providers. These early initiatives are harbingers of future cooperation between providers and payers, but they also show that other issues—including legal and operational obstacles—still need to be overcome. Success in these collaborations is crucial to making a successful shift to value-based care.
Limited data sharing
Problems with data sharing are one of the biggest barriers to future provider-payer cooperation in value-based care. Lack of willingness to share information needs to be overcome. Two healthcare industry surveys conducted in late 2016 found that the lack of data sharing was impeding provider-payer risk-sharing initiatives. One study by Premier, a group purchasing and quality consulting firm, found that only 22 percent of commercial payers shared claims data with providers to better manage cost, quality and coordination of care. The second, by the American Medical Group Association (AMGA), reported that the transition to value-based care actually slowed between 2015 and 2016, in part because of the lack of payer data. Health plans generally balk at sharing their patient information with providers, says Chester Speed, AMGA’s vice president of public policy. That’s important information for providers to access, because payers’ claims and health information can provide a more complete view of patients’ health issues and provider interactions. However, some payers believe that providers are not technologically ready to manage payer data. That puts unprepared providers at a disadvantage, because the inability to take in and manage payer data limits their ability to succeed with value-based care contracts. “Not every provider is set up well to take risk,” says Catherine Field, market president of the four-state Intermountain region of Humana. A risk-based arrangement involving only a small volume of health plan membership puts a provider at an extreme disadvantage, often because the provider is not able to pay for the associated technology and care management overhead. It’s too much risk for many payers to tolerate, because working more closely with providers in these arrangements could increase the risk for both, Field says. “We have to be confident that they’ll be successful at it, and it does take some infrastructure investment to become successful.” After a health system achieves proper scale, “the challenge today is getting data in a format that is easy to access, that’s accurate and is actionable.” What’s more, she says, every provider is at a different level of readiness to receive and use the claims data.
Even though providers and payers see the logic in sharing data for value-based care contracts, there’s reluctance because the industry is in transition on this form of reimbursement—most coverage plans still involve fee-for-service approaches, which often means payers and providers are still adversaries in settling claims. For the most part, payers and providers still have “different sets of business interests,” says William Bernstein, chair of consulting firm Manatt Health. Conflicts also arise when an initiative starts setting up sharing arrangements. “There’s collaboration,” he says, “but people want to control the terms of the collaboration through being the data repository and the source of truth” in the relationship. Gradually, payers are realizing that they can’t dictate how providers should run the new joint programs and that they have to establish true partnerships for value-based approaches to succeed, says Mitchell Morris, executive vice president of OptumInsight, an analytics business that merges claims and clinical data into a useful form for such partnerships. Providers that typically are protective of their clinical data must be as willing as payers to intermingle vital ongoing details of patient information, Morris says. However, some examples are showing that providers and payers can weather this challenge and achieve joint benefits.