Transforming care through payer-provider collaboration

We’ve been watching the shift from fee-for-service to value-based care for years. However, the strategy to ensure both payers and providers succeed in a quality-focused care delivery system is not well defined. While I don’t have the definitive recipe for success, one thing I have seen throughout my time in this space that significantly improves the odds is a strong partnership between payers and providers

I realize this is easier said than done, especially as payers and providers face different barriers to complete and accurate risk capture. For example, providers face extensive administrative tasks, including delivering and scanning forms, performance monitoring and incentive program management. While essential to the value-based care model, such tasks can erode physician engagement and limit action on insights that improve patient care.

Payers also face significant challenges, including the inefficient flow of information, ineffective processes and evolving regulations. Additional issues can emerge when financial incentives are misaligned, or payers and providers don’t share a cohesive strategy for success.

Despite the challenges on both sides, payers and providers ultimately want the same thing — positive patient outcomes. I’ve worked with many providers in the last few years as they transition to the value-based care model. I’ve come to rely on 3 key things to improve collaboration: people, processes and technology.

Having a well-trained team is crucial for value-based care success. Ideally, each team member should operate at the peak of their capability within a continuous learning environment that fosters their development.

Health plans that offer training and education resources, either directly or through a third-party vendor, are more likely to see enhanced provider engagement and an improvement in complete and accurate risk adjustment. For example, one Optum Health Care Advocate (HCA) worked directly with a private group physician practice in New York and helped them achieve a 98% health assessment return rate for more than 1,200 patients. Optum HCAs provide in-person or virtual coding and documentation training by certified coders, performance monitoring, strategic guidance for program success and regular touch points to understand practice goals and alleviate potential roadblocks.

Effective staff training and managing administrative overload are key factors that distinguish between simply participating in a risk adjustment program and achieving success in it. I have worked with primarily paper-based practices that wanted to transition to digital to enhance efficiencies and free up staff for additional tasks. However, they faced challenges with digital adoption because their team found it difficult to navigate the new technology. While adopting digital tools is not an overnight success, it is achievable with proper training and support.

People and technology are essential, but without workflows to connect them, you won’t get far. On the road to value-based care, workflows are the pavement under our feet to get us to our destination. That said, the road can either be laden with potholes and speed bumps, or it can be a smooth journey. How efficient and effective your workflows are will determine that outcome.

For this reason, workflows are coming under increased scrutiny for their ability to make or break value-based care progress. And while advancements in technology are still the more headline-grabbing topic, innovations in workflows are gaining momentum as an area not to be overlooked, and in some cases they can deliver an even bigger impact than having the latest and greatest tech.

The key to optimizing workflows lies in aligning them with the administrative availability of the provider practice and their level of digital integration. For example, a practice could have fully digitized capabilities, but if the office is short staffed then the administrative burden of risk adjustment programs will still likely prevent advancement to more complex risk models.

For health plans, it’s important to take these factors into consideration when offering a risk adjustment program to providers in your network. An ideal offering would either have customizable options or a tiered approach, with different levels of workflow support that providers can choose from to best fit their needs.

For example, most prospective in-office assessment programs, whether offered directly from the health plan or through a vendor, will include some type of support for providers, such as call center resources or analytics. If a practice already has established workflows, this level of support is likely sufficient to achieve complete and accurate risk adjustment.

However, the idea of workflow innovation looks beyond the base-level approach and helps providers develop workflows from the ground up that serve patients at every point of care. These workflows might include clinician chart reviews prior to the patient visit, coding and documentation of new suspect conditions, timely access to actionable patient insights and, eventually, reduced retrospective retrieval due to increased documentation accuracy.

It’s frustrating when different technology platforms don’t “talk” to each other or when straightforward tasks require multiple steps. These simple breakdowns can kill productivity and morale and require too much energy for administrative tasks.

It’s essential to utilize technology that enables the open and seamless sharing of data within the provider’s workflow, providing a complete and accurate overview of the patients and populations they serve. For both payers and providers, accessing diverse datasets including claims, clinical, pharmacy and lab is crucial for gaining a comprehensive perspective on both the overall population and individual patients under a provider’s care.

Here's an example of how to integrate actionable data and insights throughout the entire patient experience, from pre-encounter and point of care to post-encounter:

Before the patient encounter

Preparing for the patient visit is a crucial step in the process, as it enables providers to maximize the effectiveness of their face-to-face interactions with patients. The following processes help assess and identify areas for potential conditions that can be addressed in the patient visit:

• Pre-encounter suspect condition identification
• Utilize natural language processing (NLP) advanced analytics to flag potential gaps in care
• Engage in patient outreach and activation strategies to help support timely wellness exams

During the patient appointment

Payers can provide resources at the point of care to help providers and patients interact with each other in a positive, meaningful way. Critical processes include:

• Documentation and capture of Healthcare Effectiveness Data and Information Set (HEDIS®)
• Delivery of patient data through providers’ preferred method, such as electronic health record (EHR) or native workflow
• Questionnaires that gather patient-reported information
• EHR-embedded and EHR-agnostic workflows for gap closure after the patient encounter

Post-encounter, key workflows include:

• Gap closure with appropriate and sufficient documentation /span>
• Integration with chronic disease management programs
• Prioritized work queues for coding staff
• Retrospective reviews/chart audits

Risk adjustment is complex and there’s no one right way to do it. However, based on my experience, achieving better outcomes hinges on strategically focusing on people, processes and technology. A well-trained practice staff, equipped with the necessary support and resources to manage administrative tasks, can be your greatest asset. Streamlined and efficient processes not only reduce risk and improve performance management, but also help providers and staff adapt swiftly to new systems. Technology will continue to play a crucial role in transitioning from mere participation in risk adjustment to achieving full success in value-based care.

Every provider group begins its journey in a different place, with unique challenges and opportunities. Health plans must gain a deep understanding of where each practice stands in their journey toward value-based care and provide customizable solutions tailored to meet the specific needs of providers. By consistently prioritizing people, processes and technology, both parties can concentrate on what is truly important — better patient care.