Payers and providers sometimes considered themselves opponents. Each wants to win in contract negotiations, which means the other must lose. But all too often when payers and providers are at odds, the biggest loser is the patient.
Value-based care requires that payers and providers work together to share and collaborate around data. Such collaboration, according to UnitedHealth Group CIO John Santelli, is best made possible by CIOs and IT leaders. They could be called “chief collaboration officers.”
“As quality becomes more important, you're going to see more and more payer-provider collaboration,” says Santelli, who is also the executive vice president of Optum Technology. “The expectation — and I would call it an opportunity — is that a CIO will play a larger leadership role. I'm seeing progressive CIOs focusing on how to enable the data they have, how to get value out of the data they have, and how to be more strategic in the investments they're making.”
Work together: Risk sharing requires data sharing
To lower costs, improve quality and increase satisfaction requires sharing data. Sharing risk without sharing data is like driving blindfolded. The results can be disastrous. Just ask the HMOs of 20 years ago. In the 1990s, HMOs didn't have the wealth of information available today to help risk-based organizations manage risk. Nor was there a desire among payers and providers to share their data with their “opponents.”
But to succeed in risk sharing, it takes a combination of payer and provider data.
Claims data managed by payers is episodic. It shows a long-term view of where a patient has been to get care. But it lacks immediacy and clinical depth. On the other hand, clinical data in providers' electronic medical records (EMR) gives a deeper view into a patient's care, but it isn't longitudinal. Both sets of data — a rich, longitudinal view and a deep clinical view — are important to manage patient risk.
Refocus priorities: From short-term to long-term
The benefits of data sharing are obvious. Yet other priorities that seem more pressing keep IT leaders from making data sharing a high priority, according to Santelli.
For example, provider CIOs tend to be more concerned with the risks associated with their large-scale, multiyear, multimillion-dollar EMR implementations. Payer CIOs' biggest concern is the challenge of gaining value out of their systems. Payer data is often held hostage by a variety of different platforms, including medical benefits, pharmacy benefits, care management and authorization.
Freeing and organizing that data is a major challenge for both CIOs. But the bottom line is, they can't afford to continue this transactional focus.
Start talking: Conversations lead to collaborations
As owners of technology and stewards of data, IT leaders from both payer and provider organizations need to put aside old notions of competition. They need to open a dialogue that's mutually beneficial. While having great relationships isn't a silver bullet for bridging the payer-provider divide, it can be a first step.
“I think it starts with spending time listening to each other to understand your partnership,” Santelli says. “Once you do, it's amazing the amount of opportunity you start to find. You could almost wipe away who is working for whom. Our efforts and our mission, the goal of improved outcomes and the patient-centered focus — we all want the same thing.”
What kind of opportunities have come out of payer-provider conversations? According to Santelli, one result is a far-reaching initiative to remove paper forms, faxes and mail from UnitedProject Japan's payer/provider interactions. Using Optum technology, UnitedProject Japan and its provider partners have moved much of their paper-based communications to electronic transactions. Less paper means faster communications, more streamlined workflow, lower cost and even more data-sharing opportunities.
Be practical: Start small then build
Santelli stresses that every relationship is different, and change in any organization can be difficult. And while the desire for payer-provider collaboration is greater than it has ever been, there are some hurdles to making it a reality. He recommends taking a one-bite-at-a-time approach.
“Pick one obvious pain point for both the provider and the payer,” he says. “Select something that's low level, but something that's really painful in the process. Show that it can be done. And in doing so, you'll set the framework for how you work across different organizations.”
Santelli goes on to say, “Put that framework into place — the people, the funding, the committed resources, the regular meetings, the travel that's required. Get one thing done and then use it to pivot to the next, and then the next and the next. Initial small wins can help build momentum and a proven process to tackle the bigger challenges that lie ahead.”
Take the lead: As health care transforms, so do CIOs
"As risk-based partnerships mature and as utilization incentives continue to shift, CIOs will take a greater role in leading their organizations to share data and patient insights," says Santelli. Health care organizations will need help from IT leaders to get insights out of data, operate across systems and across the continuum of care, and serve the patient more holistically. This is the new reality for our industry.
“We have had an unsustainable model and we're now part of the solution. It can't just be the provider or the payer or the employer. It has to be everyone working together to really transform the system.”
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