Leveraging Technology to Create Payer-Provider Collaboration
By Andrew Underhill
Although providers and payers play a critical role in elevating US healthcare, these two entities have not traditionally worked collaboratively, especially when it comes to sharing information. Up to this point, the two groups have shied away from exchanging data, with providers holding on to patient clinical information and payers protecting patient financial information. However, the walls are slowly but surely coming down as more providers and payers begin to partner in delivering accountable care.
There are both operational and patient care benefits to smoother provider-payer information exchange. For example, when providers are given access to claims data, they are able to garner a more longitudinal perspective of the patient’s health and treatment to date. This enables more informed care decisions and also reduces the likelihood of duplicative or unnecessary tests. It also limits the reliance on patient memory and perspective, ensuring care decisions are based on facts rather than educated guesses.
On the payer side, having access to clinical data allows the organization to adjudicate claims more effectively, improving efficiency and ensuring the most appropriate care for members. Clinical data also helps payers proactively manage their members’ care rather than responding to issues after the fact.
Despite the advantages, there are some significant roadblocks to payer-provider information exchange. Although some would suggest technology shortfalls have been the primary hurdle, it is the business barriers that present the greater obstacle. Providers in particular have been hesitant to share data with payers because it includes competitive and pricing information they would prefer to keep internal. Moreover, some physicians are concerned that making this kind of data available to payers may open the physician up to criticism on how he or she treated the patient.
To reap the benefits of information exchange while still acknowledging provider and payer qualms, organizations should take a well-considered approach to any data sharing arrangements. Following are a few tips to ensure these agreements meet all parties’ goals.
- Appoint an advocate. To truly realize provider-payer data exchange, organizations must have an advocate who will push the idea forward and raise awareness of the strategic, financial and patient care benefits.
- Develop a strategic roadmap. The advocate should work closely with organization leadership to identify the business drivers for data exchange and craft a strategic plan to lay the cultural and operational groundwork. Basically, this plan should be a roadmap that underscores the importance of provider-payer information sharing and defines how to achieve success.
- Establish trading partner agreements. Before actually exchanging information, providers and payers must set up trading partner agreements that define the types of data to be shared, the appropriate data-sharing standards, and how the data will be used. This should be a customized agreement that reflects the unique needs and characteristics of the institutions involved. By setting the parameters upfront, both parties can be confident any data exchange will meet their needs and not violate internal strategic goals.
- Define an exchange framework. Once organizations have a forward path, they can search out solutions to enable seamless information sharing. Providers and payers may want to consider using health information exchanges—such as those provided by the state or a local entity—to securely share data. A commercial product that facilitates payer-provider information exchange can also be a good option.
Greater transparency will ultimately drive better healthcare, and a key to transparency is robust data exchange between providers and payers. Organizations that embrace this idea now can be on the forefront of collaborative care, improving the patient experience and driving better health outcomes.
Andrew Underhill is a chief technologist at Systems Made Simple of Syracuse, NY.