How HIT Can Bridge The Payer/Provider Divide

By Donna Martin, Senior Vice President, Global Health Services, Hinduja Global Solutions (HGS)

The era of outright tension between provider organizations, seeking to maximize payments in fee-for-service arrangements and payers, seeking to minimize unit costs, has begun to dissipate. In this new world of value-based care, the two sides have incentives that are more aligned than ever. New payer contracts reward providers for helping to rein in costs, and penalize those who order unnecessary tests or procedures. The urgency for both sides to work together to bend the cost curve is greater than ever.

But all too often, health IT is a stumbling block to creating truly integrated, coordinated care. Data siloes, interoperability issues, and duplication often hamper collaboration efforts that could improve healthcare outcomes through better medication adherence or timely preventive screenings. Better integration of health IT resources could also help achieve cost savings by appropriately triaging patients to the most appropriate care setting or by alerting providers to duplicative tests.

The Data Integration Challenge
The amount of data attached to every patient has grown exponentially—and all of it has to be gathered, integrated, and interpreted according to compliance guidelines and processes that can vary widely between payers and providers. In addition, the datasets held by payers and providers can be different. For example, payers possess data on claims, financial analytics, and risk models. Providers have administrative and clinical data that includes case histories and outcomes.

Each data set is valuable, but in isolation doesn’t provide a holistic and contextual perspective of the patient. Providers need to leverage health plan data in order to move from episodic care to delivering care focused on the continuum. Payers need access to patient information in order to work with providers to establish appropriate care plans for their members.

The key is to forge pathways where these two data spheres overlap, turning the data into rich, actionable information that benefits both stakeholders, and more importantly, their customers.

HIT has the power to bridge the payer/provider divide once and for all to improve both costs and outcomes, but also patient and provider satisfaction with the interdependent payer/provider ecosystem. Here’s how:

Better Customer Service
As patients have more and more skin in the game financially, they increasingly demand personalized, consumer-friendly information. One of the consequences of health reform, social media and the general consumerization of healthcare has been a need to meet the same 24/7 customer service expectations as other industries, including retail, financial services, telecommunications and entertainment. This focus is only expected to increase in the coming years.

This shift has incented insurers and providers to collaboratively approach the patient both clinically and as a consumer. However, if a collaborative effort based on consumer experience is to work, it’s critical for these healthcare entities to focus on creating alignment in key areas consumer-focused services.

Tools like self-service portals allow both payers and providers to access complete, actionable information (as opposed to raw data), reducing administrative burdens for both parties, achieving higher-performance goals, and identifying coding and care gaps more quickly.

The area of chronic care management, for instance, begs for new solutions to make sure the patient is getting the best ongoing care for the best price across months or years of claims. And while clinical coordination is important, payers and providers can also do more to improve billing and claims adjudication processes. This would solve patient headaches such as receiving a bill for one amount from a provider, and seeing a different amount on the payer’s website.

Automation For Workflow Efficiency
The increasing use of automation is also fundamentally changing the healthcare business. Automation reduces or eliminates manual processes for many tasks with data-intensive processes, across multiple domains and verticals. Automation can drive tremendous accuracy while simplifying a much more robust view of our patients, members, and customers’ unique healthcare needs. With the right technology, health plans can align with providers by offering more efficient care and administrative processes. At the front desk and in the back office, payers can help provide tools that enable staff members to submit claims electronically rather than manually and to check what is authorized at (or even before) the point of care.

For example, automating utilization management and other transaction processes can streamline workflows, as well as speed the exchange of clinical, financial and patient data to near-real time.

Through the aggregation of member and clinical data, insurers and their provider networks gain the ability to continuously evaluate the customer lifecycle needs and the likelihood that members are in need of more customized health services.

However, this is more than a question of consumer experience. The tremendous amount of data produced by patients is a treasure trove of opportunities for uncovering new ways to use data in order to improve outcomes, identify care gaps, and ensure patients/members have access to the care services they require in more of a high-touch, highly personalized manner.

New Service Lines
While true collaboration between payers and providers should help reduce layers of bureaucracy for providers and patients, it also yields opportunities for new lines of business that can help both sides achieve their goals of efficient, effective care. Health IT can be the backbone of these new services, connecting all stakeholders to get the most out of each healthcare dollar.

One example of these opportunities is nursing triage: a service that can easily be structured to meet and exceed members’ consumer-based expectations with enhanced service levels and minimal cost impact.

Nurse triage services help to achieve the goal of “right care, right place” by sending acute or life-threatening patient conditions to the emergency room while diverting others to urgent care or primary care facilities. They can help shorten lines at the ER, and increase patient satisfaction by providing immediate answers to member/patient health concerns. Implementing a nurse triage service can help payers and providers address this need while managing members/patients more effectively, reducing readmissions, building a more positive reputation, and driving down costs. That’s a lot of value from one investment.

A nurse triage service staffed by registered nurses and others with the proper healthcare certifications can provide evidence-based guidance on whether a current or developing condition is an immediate cause for concern or can wait for either a call from or visit to the physician.

Health IT can boost the impact of these interactions by tracking them through a CRM and linking directly to claims data for that particular member. In this case, there will be a clearly defined ROI as well as quantifiable figures that can be used to measure the effectiveness of these interactions and assist with future improvements to the service.

Collaborating with a credible business process outsourcing (BPO) partner can bring nurse triage services to market quickly and effectively, with seamless support of seasonal highs and lows. The technology is already in place, the staff already hired and trained, and reporting will be quickly enabled. With a minimum of transition work, the nurse triage service can begin answering member/patient questions and delivering an outstanding customer experience almost immediately.

Health IT has the power to accelerate the thawing of relations between payers and providers by reducing the administrative burden for both sides, and helping healthcare to become more consumer-friendly. Both sides now want the same thing: safe effective care at the best price for the whole system.

Data duplication and disconnect can create hurdles for seamless integration between the two sides. But there is significant value in joint investments to achieve better customer service, increase automation and add new service lines to streamline care delivery.

By adopting a mindset of collaboration to reach larger goals, payers and providers can engage patients/members more effectively than either could alone.

Source: Health IT Outcomes