The Art of the Possible in Payer/Provider Collaboration

At KLAS, we've observed that the relationship between payers and providers in healthcare is becoming increasingly challenging. Many stakeholders, including patients, health systems, and health plans, have expressed that collaboration is becoming more difficult. However, amidst this challenge, we've also seen progress being made in the payer and provider space. In our recent Points of Light 2023 report, KLAS highlights the art of the possible when payers and providers work together.

Our research approach for the Points of Light report is unique in that we require both the health plan and the health system to agree that their solution has been beneficial and driven value. This is important because frequently one party feels like they're not getting value while the other party is.

The report includes 25 case studies that showcase what organizations can achieve despite the obstacles in this relationship. Our aim is to showcase the good that is happening and inspire others to take similar actions to create positive momentum.

The Challenges Tackled

This year, a significant challenge that the payer-provider partnerships addressed was interoperability, which involves transparently sharing data to provide a more comprehensive view of patients’ health. Payers and providers often operate like two massive icebergs in an ocean, disconnected from each other. Technology partners are frequently instrumental in bridging this gap, as many of our case studies demonstrate. The next biggest category was prior authorization, which was the biggest focus last year. Partnerships that focused on streamlining this process leveraged strategies such as artificial intelligence, interoperability, and clinical decision support.

Additionally, there was considerable effort this year to advance value-based care, which took different forms in the various case studies. Some partnerships focused on improving technology stacks to include care coordination systems and data analytics tools. This improved access to real-time data and outcome and utilization patterns to allow them to accurately assess patient risk, reduce costs of care, and inform HEDIS quality measures and Star ratings.

In these collaborations, stakeholders had to be willing to learn new operational and financial processes and new technologies to effectively support and sustain bundled-payment programs. This involved sharing claims data and being more interoperable with each other.  Others aimed to improve risk adjustment scores for patients and enhance the HEDIS quality measures that payers are held accountable for by CMS.

A Taste of the Outcomes

In the summary of each case study, we list the outcomes that stakeholders are seeing. For interoperability case studies, some outcomes include reducing manual workloads, standardizing the submission process, improving data sharing, increasing visibility of patient coverage, and enabling faster access for patients. For prior authorization case studies, some outcomes include determinations returned in seconds rather than days and the elimination of backlog. There are many, many more. We recommend reading the report and then the more in-depth case studies for specific details.

How to Approach Improving Collaboration

Generally speaking, when it comes to payer, provider, and vendor relationships, there are opportunities everywhere to improve. That improvement can be overwhelming; no one can eat an elephant in one bite. It’s essential to start small and focus on areas where both parties can win. By doing so, you're more likely to get a partner on the other side who's willing to collaborate.

It’s important to remember that the desire to improve comes from all sides of the issue. The innovators in the case studies we highlight are not limited to providers but also include payers and vendors willing to test new technologies, with payers frequently leading the way in investment. That said, regardless of the role a stakeholder plays, collaboration in these cases requires agility, innovation, and an openness to change.

Do More: The K2 Summit and a Regional Opportunity

If you are inspired by the Points of Light report, take a look at upcoming opportunities with KLAS and the K2 Collaborative.

We often meet people in healthcare that truly want to change the status quo and change the narrative in US healthcare. Our National K2 Summit on May 9 and 10 brings together passionate voices from health systems, health plans, and vendors to achieve just that. If you would like to be a part of this event, please reach out to us via email at boyd.stewart@klasresearch.com or aurene.wilford@klasresearch.com.

If you happen to be reading this after our summit, please don’t hesitate to reach out to us for a one-on-one conversation. We have knowledge and insights we can and would love to share with you.

Additionally, while the national summit is an excellent opportunity for stakeholders from different regions to come together and discuss their challenges, we recognize that healthcare is more regional and specific to communities. That's why we also offer regional engagements at KLAS. We bring together a health plan and a provider in a community and perform a premeasurement to determine what needs to be addressed. We then facilitate a conversation to identify next steps and commitments from both parties, measuring the activities afterward and reporting back. This process helps ensure that progress is made and that both parties benefit. If your organization is interested in this service, we're more than happy to discuss it with you.

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