Skip to content
Sök för att lära dig mer om InterSystems produkter och lösningar, karriärmöjligheter med mera.

Crossing the Payer-Provider Chasm: Getting to Shared Risk, Shared Data

by Lynda Rowe

stethoscope and pen lying on a medical form

I recently read an article in New England Journal of Medicine (NEJM) Catalyst1 that showed that the “alignment” between providers and payers does not seem to be closing, despite the industry shift to value-based payment. The survey, conducted among executives, clinical leaders, and clinicians, finds that three-quarters (77%) of respondents do not consider payers and providers aligned toward realizing improved value in care delivery. More than half (58%) feel their own organizations are not aligned. Moreover, only three percent of respondents say payers and providers are extremely or very aligned at the industry level.

According to this survey, this lack of alignment hampers integration of care and services and is a primary driver of our high healthcare costs. The study highlighted key areas where payers and providers should be able to collaborate or align along with the percentage of respondents who thought there was alignment:

 

Key Areas Where Payers and Providers Should Collaborate% Aligned
Quality58%
Patient/Member Experience45%
Care Coordination37%
Cost33%
Data for Decision Making33%

 

In some ways, I don’t find these results too surprising, given that there is still a lack of financial incentives between payers and providers. Despite all the talk about the shift to value-based payment, just under 30 percent of all health care payments in the US are tied to alternative payment models (APMs).2 This is a six percent increase over data collected the prior year — good progress, but lower than expected.

To look at the current data of APM adoption, the Healthcare Payment Learning and Action Network LAN APM Measurement Effortdetermined the following results for 2016 payments:

 

Alternative Payment Model (APM) 2016 Payments

43%
of health care dollars in Category 1
(e.g., traditional FFS or other legacy payments not linked to quality)
28%
of health care dollars in Category 2
(e.g., pay-for-performance or care coordination fees)
29%
of health care dollars in a composite of Categories 3 and 4
(e.g., shared savings, shared risk, bundled payment, or population based payments)

 

As another NEJM Catalyst article recently stated, many providers find themselves with a foot in two canoes — a very challenging place for the industry. As long as they continue to see consistent revenue in the fee-for-service model, there’s no burning platform for change.

However, herein lies the problem: if payers and providers are not aligned on the shift to shared risk and financial accountability, they also won’t be lined up to work together on quality, cost, and operational efficiency — that is, better care at a lower cost.

To succeed, we need to close the gaps. Many of the existing barriers stem from a history of misaligned goals and incentives and lack of transparency between organizations. As noted above, payers and providers are least aligned on leveraging data to make better decisions for system improvements, and that’s a solvable problem.

data chart

So what is the path forward to cross the chasm? Based on current trends, value-based care — although moving slowly — appears to be part of the new fabric of healthcare. As providers and payers continue to take on more shared risk, the alignment gaps will close. To achieve the outcomes we want, payers and providers will need to show more transparency, which requires two-way data sharing. My observation has been that, although barriers exist to providers sharing their data with payers, data needs to fl ow in both directions to get to a win-win scenario. Payers can help their provider network perform better against quality, cost, and utilization measures by sharing that information. Conversely, having access to clinical data will allow health plans to streamline some administrative processes such as pre-authorization and HEDIS/STARS reporting to drive cost and wasted time out of the system.

We have heard from our forward-leaning customers that two-way data sharing leads to success. The best outcome, however, will be better, more coordinated care for patients.


Sources: 1 https://catalyst.nejm.org/new-marketplace-survey-payers-and-providers-remain-far-apart/ 2 According to an October 30 report from the Health Care Payment Learning & Action Network – a public-private partnership launched by the US Department of Health and Human Services. 3 https://hcp-lan.org/groups/apm-fpt-work-products/apm-report/

Other Resources You Might Like

Nov 21, 2024
Make Your HIE Vision a Reality
Specifying Requirements, Evaluating Technologies, and Selecting Partners Download the Planning Guide
Oct 31, 2024
BLOOR Research Opinion Article
This article from UK Analyst Bloor Research recognises the capabilities and advantages of InterSystems IRIS data platform as an "innovative and powerful data management platform" and it’s Smart Data Fabric capabilities offering a market differentiator.
Oct 31, 2024
HIMSSCast
How to get the most benefit from machine learning and AI How can healthcare organizations best leverage artificial intelligence (AI) tools, including generative artificial intelligence (GenAI)? Join Alex MacLeod, Director of Healthcare Solution Innovation at InterSystems, as she discusses key steps and challenges for organizations interested in adopting AI and other advanced technologies, as well as use cases that can improve care delivery and drive operational efficiencies.
Oct 30, 2024
A Benchmarking System to Spark Companies to Action
Download the Report
Oct 23, 2024
Market Note
This report explores how advancements in AI, including large language models and natural language processing, are revolutionizing every aspect of capital markets, from trading strategies to compliance and portfolio management.
Oct 22, 2024
Fact Sheet
Unified Data has the Power to Transform
Oct 22, 2024
ISG Research
This Ventana Research Buyers Guide: Data Platforms is an assessment of how well software providers’ offerings address enterprises’ requirements for data platforms software, evaluating software in seven key categories that are weighted to reflect buyers’ needs based on expertise and research.
Oct 16, 2024
Migration Options for Application & Solution Providers
Migrating InterSystems IRIS® and InterSystems IRIS for Health™ from on-premises to the cloud offers many advantages for Application Providers and Solution Providers. These advantages include simplified operations, access to flexible resources, and enhanced resilience. Companies no longer need to worry about the physical constraints and expenses associated with maintaining on-prem infrastructure, such as power and space requirements and expensive computer hardware.
Oct 16, 2024
TabbFORUM’s Market Structure Wave
In this edition of TabbFORUM’s Market Structure Wave video series, InterSystems Irene Galperin, Senior Advisor, Financial Services, discusses how firms in the capital markets have been investing and experimenting with AI, particularly most recently with the advent of ChatGPT. In this interview, conducted by TABB Group CEO Bruce Morris, Irene offers several use cases and explains that data is at the core of implementing AI, as data needs to be "high quality and consistent," essentially "AI-ready."
Oct 10, 2024
Get Your Data AI-Ready and Simplify Development and Deployment
Unleash the power of AI in healthcare with InterSystems solutions for seamless FHIR integration and development.

Ta nästa steg

Vi vill gärna prata med dig. Fyll i några uppgifter så kontaktar vi dig.
*Obligatoriska fält
Highlighted fields are required
*Obligatoriska fält
Highlighted fields are required

Genom att skicka din kontaktinformation till InterSystems via detta formulär bekräftar och godkänner du att InterSystems kan behandla denna information, i syfte att uppfylla din förfrågan, via ett system som finns i USA, men som upprätthålls i enlighet med alla tillämpliga dataskyddslagar.



** Genom att välja ja ger du ditt samtycke till att bli kontaktad för nyheter, uppdateringar och andra marknadsföringsändamål i samband med befintliga och framtida InterSystems produkter och evenemang. Dessutom samtycker du till att dina kontaktuppgifter för företaget förs in i vår CRM-lösning som finns i USA, men som upprätthålls i enlighet med gällande dataskyddslagar.