Podcast: The Convergence of Providers and Payers
Chilmark’s founder and president John Moore recently took some time to speak with the producer of the Relentless Health Value podcast, Stacey Richter, to discuss current strategies of one of the biggest trends in healthcare right now, provider-payer convergence.
The discussion begins by outlining how convergence is unique compared to the many other changes and initiatives sweeping through American healthcare. Most organizations enter into these partnerships as an answer to high administrative costs, the wave of recent consolidations, and unsuccessful provider-sponsored health plans. Most importantly, a successful convergence partnership requires a deep understanding and commitment to the local market served and trust between the organizations. John also outlines some of the challenges to creating successful partnerships and suggestions to overcome or avoid them entirely. For widespread convergence success, health care organizations (payers and providers) will need to systematize both the business processes and IT infrastructure to support data sharing and actionability.
Listen here and be sure to scroll to the end of this post to see some of the content discussed:
00:00 Convergence and the delivery of health care.
02:20 “How do we deliver greater value?”
03:00 Why establishing health plans within a provider organization is often not the best idea.
04:30 How you can get around needing prior authorization and subsequently cut costs.
05:50 The motivation for a payer and provider to form a partnership.
08:00 Why consolidation doesn’t necessarily drive down costs.
08:50 Payer-provider population health management.
09:20 Understanding where the patient might be going outside of the network to get their health care.
10:00 What does it take to be good at collaboration?
10:30 “What is the opportunity here?”
10:40 “Is there a level of trust between the payer and provider?”
18:00 Advice for payers looking to partner with providers.
18:50 Look for someone wanting to deliver high-value care.
19:30 “Trust, then verify.”
23:00 New and interesting innovations coming out of current convergences.
24:00 Things still being worked out in the market today.
25:25 The innovator’s dilemma.
26:30 “How do you scale quickly?”
27:20 “Is that scalable?”
30:20 The path forward for most markets in the United States.
Throughout the program, John and Stacey touch on several Chilmark publications, available here:
John emphasizes how prior authorization requirements are driving up admistrative costs for both providers and payers. Even outside of a full convergence partnership, both parties can begin to work together to reduce these costs and share the benefits.
As a population health management becomes more essential to healthcare, robust solutions are incresingly important for sharing and analyzing data from several sources, including payers, for sustainable value-based reimbursements.
Stacey mentions how difficult, yet important successful behavioral change can be for improving overall health. This report covers both factors driving adoption plus profiles for leading solutions for a variety of conditions and users.
John talks a little about his predictions for the future of the CVS-Aetna healthcare offerings in the podcast, including how MinuteClinics might become the first point of care. Read more in our blog about MinuteClinics, the implications for Epic Systems’ EHR, and challenges both companies face as they ambitiously attempt to transform how Americans seek healthcare.
Matt Guldin · 2 years ago
Liz Gavriel · 4 years ago
Matt Guldin · 3 months ago
Matt Guldin · 3 months ago
Prior Authorization is often viewed as the poster child for throwing the Quadruple Aim off balance with its pursuit of cost reduction at the expense of provider experience, but my latest research for Chilmark Research shows that new PA models and maturing PA technology solutions could benefit both providers and payers.
Traditionally, primitive PA and its associated impacts account for the great divide in provider-payer relationships. The sheer volume of PA requirements is getting increasingly more onerous for providers, as payers attempt to stem cost pressures. Provider PA and payer PA suffer from redundant processes and staffing, burdening the industry with administrative costs in excess of $1 billion annually – despite significant opportunity to use technology to automate and alleviate the burden.
My latest report, Tackling Prior Auth: New Solutions to Address Provider-Payer Friction, provides an assessment of new PA technology coming into the market, along with a detailed look at specific vendors. The report identifies prior authorization market trends, challenges encountered, and includes a specific focus on provider-payer convergence in this market segment. The conclusion offers projections of the future market trajectory for PA technology and vendors, as well as recommendations for providers when evaluating PA solutions.
PA solutions are on the cusp of a breakout moment, partially driven by both the growing adoption of value-based care (VBC) arrangements, as well as sophistication of new enabling technologies, including APIs, NLP, and AI. A new PA model is emerging that promises to deliver mutually beneficial results for providers and payers with far less pain, better integrating CDS, claims, and order workflows at the point of care.
With the dubious honor of being one of the thorniest pain points in provider-payer collaboration, and sitting at the start of the revenue cycle, PA is a logical starting point to establish greater provider-payer convergence. Chilmark Research projects that this new evolution in PA technology will serve as a petri dish for greater forms of convergence that will then spread to other VBC strategies.
Providers and payers will be challenged to step outside past perceptions surrounding the PA process, to look with enthusiasm upon new solutions in the market for innovation to improve results, building new levels of trust in the process. We project that progressive convergence of provider and payer UM proficiencies and technologies will transform the entire PA function over the next 5 years.
Based on briefings with 11 vendors as well as extensive secondary research, this Market Scan Report investigates the market and technology challenges in this high-stakes market sector. The report answers the following questions:
Anyone interested in better understanding how both providers and payers can differentiate with automated PA, how such automation will increase mutual success with VBC arrangements, as well as evaluation criteria for specific vendor solutions, will gain strategic insight from reading Tackling Prior Auth: New Solutions to Address Provider-Payer Friction. HCOs, payers, healthcare IT vendors, consultants, investors, patient advocates, and others will also benefit from this in-depth research report. There will be a free webinar on the subject this afternoon at 1pm ET, which you can register for here.