Payer Provider Collaboration: What's Working and What Isn't | Geneia

Payer Provider Collaboration: What's Working and What Isn't

October 02, 2019
Mark A. Caron, CHCIO, FACHE, CEO


Helping physicians flag high-cost conditions among members is one of the bright spots in payer provider collaboration.

Without a doubt, the successful transition to value-based care requires payer and provider collaboration. Throughout the past few years, I’ve frequently written and spoken about collaboration and convergence. We believe so strongly in the importance of collaboration that it’s the heart of Geneia’s mission statement:

We provide the technology, training, data and insights needed for health plans, hospitals, healthcare providers and employers to easily collaborate and align around shared values and goals that support personalized, patient-centered care and improved health.

By some accounts, the transition to value-based care has happened more slowly than expected. A Change Healthcare survey, for example, found that nearly 40 percent of health plans believe we’re three to five years away from the majority of value-based relationships containing upside and downside risk. Nevertheless, the payment model continues to grow and is expected to account for 59 percent of healthcare payments by 2020.

That’s why we wanted to know how payers are supporting their value-based care providers. On behalf of Geneia, HIMSS Media surveyed individuals working in a variety of roles at health insurance carriers, third-party payers and health plan administrators. 

Two of out of three payers say they are sharing pharmacy data, medication adherence data and risk scores with network providers. Two-thirds say they are extremely or very effective at helping value-based care providers flag high-cost conditions among members. 

About half of health plans say they are extremely or very effective at helping providers:

  • Enable more proactive, preventive or wellness care (57 percent)
  • Better manage chronic health conditions (55 percent)
  • Identify noticeable gaps in screenings/follow-up (55 percent). Another 41 percent characterize their plan’s efforts as somewhat effective.
  • Identify patients at risk for adverse health events (51 percent.) Another 43 percent say they’re somewhat effective.
  • Identify incidents of medication non-adherence/non-compliance (50 percent and 45 percent somewhat effective.)

Payers admit they are less effective at helping value-based care providers deliver more targeted, personalized treatments (41 percent say they are extremely or very effective, and 48 percent say they are somewhat effective).

Payers are most effective at helping VBC providers flag high-cost conditions

Social Determinants of Health

Social determinants of health (SDoH) are definitely an area ripe for improvement. Notwithstanding a steady stream of health plan commitments to meeting unmet social needs – for example, the recent announcement by Blue Cross of Illinois of a new facility that will house employees and connect “residents with resources that address social determinants of health, such as food insecurity, and offers seminars on diabetes, behavioral health and other conditions” – there is more payers can do to help providers with social determinants. 

The HIMSS Media survey found only a third of payers are creating or managing programs to help their value-based providers address SDoH and only 38 percent are sharing social determinant data. I suspect many payers and providers know the importance of addressing SDoH but struggle with how to get started. That’s why we published two ‘getting started’ blogs this summer for health plans and physicians:

Having worked with health plans for much of my career, I can confidently say that most understand the importance of network providers in their transition to value-based care and want to help physicians succeed. Perhaps more than any other data point from the HIMSS Media survey, I am encouraged that nine out of 10 payers say they believe they have a role in reducing physician burnout. Equally compelling, more than one-third (34 percent) can point to specific actions they have taken and more than half (54 percent) are creating plans to improve physician satisfaction. 


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