It’s the Dawn of a New Day for Healthcare Payors

Customer Experience

By

February 22, 2019

With the momentum of value-based reimbursement, disruption is knocking at healthcare’s door, and particularly for payors. Disruption means that they will need to elevate their partnerships with providers to build networks that leverage reimbursement trends and models. At the same time, they will need to deliver the clinical and financial outcomes that sustain system viability and improve member experiences. Moving forward, success in risk-based contracts will require a different model for collaboration in which payors and networks are equally committed to each other’s success.

Payors are uniquely positioned to guide and influence their members’ healthcare journeys. In partnership with providers, they can take the lead in producing the outcomes needed for success in a value-based world. Armed with a full ecosystem of data and a direct line of sight into the whole health of individual members, payors possess data which is a valuable asset for providers. With analytical insights enabling more effective and efficient individualized care, the exchange of whole health data between payors and providers can set the foundation for a higher-value relationship between them.

As the market storms ahead in the value-based era, the payor-provider dynamic is taking a 180-degree turn towards more collaborative and synergistic relationships. For payors and providers to engage in mutually beneficial value-based contract arrangements, both parties need to elevate their expectations and behaviors based on trust and an understanding that they each play a significantly important role in delivering value across the healthcare experience – for their members/patients as well as plan sponsors.

Payors have an opportunity to evaluate their provider engagement relationships and the experiences they intentionally or unintentionally have created with their provider partners, recognizing that years of tough contract negotiations have yielded an almost expected model of behavior where one side “wins” and the other side “loses.”

Today, we are seeing the beginnings of an evolved collaborative as payors and provider networks are discussing new ways to serve the Medicare Advantage (MA) market. For many, this means creating an integrated model where a hybrid entity may offer new options for beneficiaries. Those payors that are successfully developing co-branded MA offerings are realigning their provider partner strategies through a lens of mutual dependence and trust. At the same time, those that succeed are recognizing, that in order for the new entity to thrive—both in capturing/retaining new members and then delivering quality care at the best cost possible—relationships with provider partner(s) need to evolve from dominate-subordinate to one of equal partners. Doing so creates a new level of transparency and trust

Where can payors get started in fostering higher-value provider engagement?

  1. Facilitate data-sharing. Our research indicates that data and analytics is the second-highest strategic priority among healthcare payors, cited by 83 percent of respondents. When it comes to provider engagement, data sharing and access is a key opportunity within this strategic domain. Payors can elevate trust with providers by arming them with added insights (this includes data across the member’s entire claims experience and medical records) needed to improve outcomes and performance in a healthcare system defined by value-based contracts.
  2. Evaluate your current provider engagement approach. Map your current-state experience to identify gaps in your approach to working with your provider partners, and surface opportunities to embed greater empathy in provider interactions. Build mechanisms that make it easier for providers to connect with you. This makes it easier to gain access to the insight needed to improve patient care and thrive in value-based contracts.
  3. Examine processes and policies related to reimbursement. According to our research, operational efficiency is cited as a somewhat or very high strategic priority by 80 percent of respondents in 2019. Yet, efficiency should not come at the cost of appropriateness of service approval or denials or lagging claims payments. Evaluate how thorough your healthcare service approval or denial process is and if it is creating a positive or negative experience for your provider network partners. Similarly, are providers having to go through extra steps to ensure that they are being reimbursed accurately or are they too often having to negotiate on their patient’s behalf to have their claim paid appropriately?

The benefits of trust-based, collaborative provider engagement include:

  • Greater interest and buy-in from providers around at-risk, population health-based network contracts
  • Improved data sharing, which is necessary for optimal health outcomes management
  • Improved patient care and experience through greater interaction between payors and providers
  • Market reputation leadership and improvement, which ultimately shows up on the bottom-line

Payors and providers have a common rallying cry and a fundamental purpose for collaboration: performance in risk-based contracts. To prosper in a value-based world, it’s in payors’ best interests to engage and restore trust with providers, arming them with the support needed to effectively manage risk and deliver outcomes. At the end of the day, providers will be rewarded for keeping patients out of the hospital, and payors keep reimbursements costs down: a win-win for the healthcare industry’s bottom line—and ultimately—for patient outcomes.


This blog was co-authored by Dave Trettin

Dave is an Associate Vice President at Sparks Grove, North Highland’s Experience Design Division. He has fourteen years of business strategy, product and service development, strategic planning, and customer experience strategy expertise. With an extensive background spanning product development, operations, and marketing, Dave is adept at helping our clients create strategic growth initiatives based on a human-centered design methodology.

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