Given that providers are under increased pressure from CMS to take on some form of downside risk by 2025, they and health plans can utilize these four strategies to make the transition smoother.

This article was originally posted on MedCity News’ website on December 6, 2022 here.

According to a HealthSparq survey of 100 hospitals and health systems, 92% of providers want greater collaboration with health plans — believing this will lead to improved patient outcomes and reduced cost of care. This desire underscores the critical importance of strengthening the payer-provider relationship to achieve these benefits.

Although payers and providers share the same goal of providing the highest quality of patient care while lowering costs, historically, federal payment models under which providers have been reimbursed for their services haven’t been aligned with those for payers. Thus, this mismatch hasn’t been conducive to helping either side achieve this desired result of a successful payer-provider relationship.

To help both payers and provider organizations to succeed under this new value-based care model, we’ve outlined four strategies below that will help the two sides collaborate better on shared goals.

Strategy #1: Develop a Data-Sharing Strategy.

Providers are primarily responsible for collecting clinical data, which is used to understand the patient’s health status and medical history. By contrast, payers work primarily with patient claims data, which is used for billing. Currently, many health plans share their data with provider groups but do so in their plan-specific formatting. This leaves provider organizations with the job of aggregating data across payers or working with disparate and disjointed data sets.

One method for sharing data more effectively and efficiently is for payers to fold in any of their data into a provider’s existing data-analytics engine. Payers who are willing to work within a provider organization’s data-analytics engine eliminate the administrative burden of aggregating data or working with multiple disparate lists.

Alternatively, a payer-agnostic interoperability solution with a bidirectional pipeline can be used, allowing both parties to upload and share data within a single system. More often than not, the information in a medical chart is more complete and accurate than what is on a claim. Because payers generally only have access to information on a claim, they often request records for risk adjustment chart reviews on an annual basis. Provider groups may be reluctant to accommodate en masse chart requests, but incorporating payer access to medical records via a bidirectional interoperability solution can reduce or eliminate health information management (HIM) teams’ administrative burden in sending charts.

Lastly, data strategy should not be built within a silo. Early on, payers and providers can form a working group of all stakeholders involved — from risk adjustment to quality teams — and create a shared data strategy. As the partnership continues, the group should be flexible, meeting regularly to measure how the strategy is performing and make improvements as needed.

Strategy #2: Create a Long-Term Plan for Taking on Risk.

Before a provider group even decides to take on risk under a VBC model, payers can implement “triggers” that determine an organization’s readiness for downside risk. One example is a population trigger, which ensures that the size of the group’s population is large enough to sustain a risk-adjusted contract. This is important because if even one beneficiary is extremely high-risk in a very small risk-adjusted patient population, they may have a huge impact on its costs. Another type of trigger is a quality trigger that can demonstrate a provider organization’s ability to execute preventive services and manage chronic conditions, which are key to succeeding under a risk-based contract.

The provider organizations that pass these triggers shouldn’t be expected to take on risk overnight. Many lack experience and knowledge for taking on risk — especially those doing so for the first time. Payers can offer financial incentives for providers to start participating in alternative payment models by starting them off with an upside-only model. Under these contracts, providers only share in savings if they spend below a certain benchmark or budget; if they exceed it, they won’t have to reimburse the payers.

From there, providers can shift to a downside-risk arrangement, under which they still share in savings for meeting or going below costs but must pay reimbursements for exceeding costs. Through this gradual process, small provider groups taking on risk for the first time can be eased into operating under a shared-savings model. Most importantly, they’re given the time to build their own infrastructure needed to succeed independently from the payer.

Strategy #3: Invest in Provider-Friendly Technologies and Services.

In addition to creating financial incentives, payers and provider groups can also invest in technologies and services that enhance performance under risk-based contracts. For example, provider organizations can invest in a point-of-care tool, which administrative teams use to examine a patient’s entire medical history before the visit. The tool then gives the clinician a focused “snapshot” of relevant data points, such as suspected conditions that have never been diagnosed and prior year diagnoses that are undocumented. This reduces administrative burden and gives a clinician access to the data at a time when it can be immediately acted upon — when the patient is in the office.

In addition to investing in technologies that fuel concurrent strategies, payers can leverage those that improve retrospective work by outsourcing coding to vendors. By leveraging the power of machine learning and natural language processing (NLP), these vendors can code charts to validate coding at a very high level of accuracy. Furthermore, the right vendor can help with retrospective submission of coding results to the appropriate payers.

Strategy #4: Initiate Shared Member Engagement Programs.

To create an opportunity for providers to interact with the beneficiaries they cover directly, payers can partner with their local community’s provider organizations to coordinate events like World Diabetes Day or Annual Wellness Days. In turn, provider groups can also invite payer representatives and educators to sponsor and participate in their community outreach efforts. Through these events, payers and providers can meet face-to-face and maximize the resources available to patients.

Often, providers are unaware of extra benefits their Medicare Advantage patients have included for free in their plans. For example, payers and providers can collaborate on bringing awareness to benefits like transportation, meals after surgery, dental or vision coverage, and Silver Sneakers programs. By implementing these member engagement programs, payers and providers can work together to address social determinants of health (SDOH) issues by better understanding their community’s health needs and increasing access to care.

The Future of the Payer-Provider Relationship

Given that providers are under increased pressure from CMS to take on some form of downside risk by 2025, they and health plans can utilize these four strategies to make the transition smoother. And as their payment systems become more aligned, both parties will be able to understand each other better and improve coordination of care.

Explore Episource’s Clarity Platform services and solutions to help strengthen the payer-provider relationship.