As 2014 progresses and with the implementation of the Affordable Care Act (ACA), both payers and providers are working to best position themselves to navigate evolving payment models, clinical delivery structures and emerging regulations that aim to shift healthcare from volume to value. Gone are the days of status quo and “business as usual.” Payers and providers are now seeking new programs and strategies to cement their financial viability long into the future.
For payers, there are four particular trends worth noting:
Cultivating formalized relationships with providers
As payment reform drives payers and providers to accept more risk, payers are forming more defined relationships with healthcare providers to share that risk and streamline care delivery.
Depending on the market and payer, a relationship may involve the payer purchasing a medical practice or group of practices. Similarly, some payers are forming networks of providers that function as an accountable care organization (ACO), supporting more collaborative care across the continuum.
Acquiring health information exchanges
While numerous states and communities have formed their own health information exchanges (HIEs), many payers have not seen particular value in these as they house mostly hospital data and less provider and patient-specific information.
To gain better access to provider-level clinical data and marry it with financial information, a number of payers are looking to acquire their own HIE, allowing the payer to more efficiently normalize, analyze and leverage data from the point of care.
Partnering with third party medical record abstraction companies
Fostering relationships with data aggregators—third party vendors that employ sophisticated analytics to sift through volumes of clinical data and tease out risk patterns and care gaps—allows payers to pursue the most cost effective and efficient strategies for optimizing Medicare Advantage risk scores, HEDIS measures and ACO quality measures.
Moving beyond payment
Many payers are striving to reinvent themselves as health and wellness companies rather than just financial reimbursement organizations. Consequently, some larger payers are focused on providing different services at various points along the healthcare continuum. Depending on the payer, this may take the form of wellness fairs, patient hotlines and even direct clinical services for members.
Embrace change or get left behind
While the nuances of different payer initiatives will vary from payer to payer and market to market, one thing is clear: the payer-provider dynamic is changing. Those provider organizations that embrace these changes and position themselves to be part of new and emerging relationships will flourish and thrive. Those that don’t may be heavily challenged in the coming years to remain relevant.
Technology and the ability to share clinical and financial information will play a key role in the success of many of these payer initiatives. The electronic health record in particular will be essential to enable effective clinical decision support, risk stratification and population health management. NextGen is committed to continually keeping abreast of new developments and educating our customers on the ever-changing roles of both payers and providers. Through our partnerships with Mirth and Inovalon, we will continue to provide state-of-the art solutions that ensure our customers are well placed as the market evolves.