Payer-provider communication is a core innovation investment focus for health plans and hospitals today, because lower clinical costs and better quality care require communications that go beyond administrative transactions to meaningful interaction and true collaboration.
Payers, hospitals, physicians, employers and consumers need to share information and workflows in real time and in formats that are accessible and easy to understand.
When compared with the electronic collaboration tools broadly adopted in society today, healthcare professionals struggle with outmoded and insufficient technology for communication.
To overcome both historic antagonisms and clinician reluctance to accept external clinical guidance, the industry is placing increased emphasis on linking clinical information exchange to established communication flows connected directly to reimbursement.
Lack of adoption
Over the years, state and regional health information exchanges promised to improve payer-provider communications. While a recent study released by the Office of the National Coordinator for Health Information Technology showed 58 percent of hospitals have exchanged data across an HIE, both the quality and quantity of data being shared are limited. For example, only one third of hospitals had exchanged clinical care summaries or medication lists with outside providers, according to the study.1
Standing in the way of participation in payer-provider communication is a lack of reimbursement for increased data sharing. Providers understand the care coordination and cost reduction benefits of communicating with payers and outside providers, but substantial incentives from payers need to be in place to encourage meaningful behavior change. Such incentives, at adequate financial levels, are showing up now across the country in some accountable care organization, shared-risk, Medicare Advantage and patient-centered medical home programs.
There are numerous healthcare quality and financial benefits to such collaborations. A 2012 study of a program between a Maine independent physician association and a Medicare Advantage plan that focused on shared data, financial incentives and care management found fewer hospital days, fewer admissions and less than half of the readmissions of an unmanaged Medicare population. Moreover, the per-member per-month costs were 16.5 to 33 percent lower than costs for members not in this provider organization.2
Three collaboration stages
To reach the type of results referenced in the study, an ideal payer-provider collaborative relationship would need to follow the three stages described below, which leverage network communications technology available today.
1. Transaction. The payer-provider collaborative relationship starts with confirming basic demographic and eligibility data about the patient and the health plan, answering such questions as the following: Is the patient a plan member and registered at the organization? What are his or her benefits? Will that payer authorize the services that the physician and hospital intend to perform?
2. Interaction. After the preliminary information has been exchanged between provider and payer, a deeper interaction often needs to occur. For example, an oncological treatment typically needs more than a simple authorization, supported by clinical document exchange and commentary from the patient's physicians. This exchange can occur over a secure communications network, coupling the above-mentioned eligibility and authorization transactions with exchange of the associated clinical documents, test results and other supporting materials.
3. Collaboration. True collaboration involving multiple providers and the payer requires robust healthcare communications, making full use of modern networking technologies, such as direct secure messaging, real-time event detection, discussion threads, dynamic "e-room" formation, et al. In a hospital setting, accessing such a network would improve efficiency — for example, after a shift change when the attending physician and nurses need updated and accurate patient histories and health status. Through this network, a private electronic "e-room" could be generated in real time where all the members of the care team, both in the hospital and off-site, would be alerted, have HIPAA-safe access to relevant information, and consult each other online about a best course of treatment if the patient has an unexpected reaction or outcome.
Benefits to all stakeholders
As shown in the previously referenced study, payer-provider collaboration bolstered by electronic communication benefits all stakeholders. Not only do providers have faster access to clinical data from other providers to enable quality patient care, but involving payers ensures that the financial incentives are in place to encourage data access and analysis.
In the coming years, hospitals need to carefully evaluate the bundled payment or accountable care programs offered by payers to ensure that they will be in the best interest of their patients and the hospital. They need to consider how the organization will monitor its patient care quality and financial performance in the program. Will the hospital have the communications tools necessary to effectively collaborate with the payer and outside providers to ensure they will meet the program's guidelines?
It is a challenging environment for hospitals, but effective collaboration with payers is possible through the real-time sharing of transparent data and analyses in which all stakeholders can monitor and ensure that coordinated, cost-effective care is being delivered.
Frank Ingari is the CEO of NaviNet, America's largest healthcare network community. The network is sponsored largely by healthcare payers, who benefit from the efficient communication of common provider-to-payer interactions, such as insurance verification, reimbursement investigation, referrals and authorizations. NaviNet Open is a SaaS-based enterprise-class software product line designed to serve payer customers and provider users. It consists of a series of layers: a platform, a set of network services, a suite of applications, and a set of tools that customers can use to configure and customize the system.
1 "Hospital electronic health information exchange grew substantially in 2008-12." Health Affairs. 2013 Aug;32(8):1346-54
2 "Payer-provider collaboration in accountable care reduced use and improved quality in Maine Medicare Advantage plan." Health Affairs. 2012 Sep; 31(9):2074-83.
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