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In today’s current state of health care in the U.S., the payer-provider relationship is like two sides of the same coin. And, the dollars and cents that make up that coin have come under greater scrutiny amid calls for increased health care transparency.

In June 2019, President Donald Trump issued an executive order that directed the U.S. Department of Health and Human Services to increase price and quality transparency in health care. Creating greater transparency in pricing allows providers to compete and leads to lower prices for patients. But that effort can only be achieved through fostering improved relationships between payers and providers, and understanding what such a relationship would yield.

Transparency for Payers

There are many critical areas in healthcare that need to be addressed through increased transparency. Among these are issues related to billing, treatment recommendations, and variations in care. Doing so would create greater understanding between those who provide care and the payers who monitor and manage patients’ care coverage.

Payers would certainly benefit from improved understanding and transparency about treatment progression and anticipated outcomes. Such information would help them efficiently manage claims throughout their lifecycle. I believe that this would help to accomplish greater processing, faster approvals, and enable patients to receive care faster. 

Bringing together payers and providers help to expand care delivery models for its members, especially with complex and chronic conditions. As more organizations look to unite these two entities it creates a more aligned network of players where the focus is on delivering the most effective form of care and less centered on fee-for-service medicine.

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Fostering Relationships

Using transparency in costs and case management efforts, payers and providers can strengthen their relationship in a union of better understanding and commitment to enhance the delivery of care.

For payers, greater clarity and insight of provider treatment plans, recommendations on exams, and patient history can help to improve processing times and reduce case delays. Conversely, payers can also educate providers on the claim processing cycle, areas where certain therapies may be more cost-effective, and plan options unique to a patient’s coverage.

While a single-payer system or “Medicare for all” continues to be floated as a potential option for the challenges in America’s health care system, there can be many advantages achieved through fostering stronger relationships between payer and provider in the current state. Payers act as an advocate for the insurance company as well as the patient who may face additional costs for treatments or medications that may not be covered. By creating a greater connection between the provider and payer gatekeepers, patients can reap the benefits of coordinated care that also helps to reduce the total cost of care.

Personal Impact

Providers and payers stand to gain further insight through increased patient history, including demographics, family history, and social-economic factors that could be contributing to their current health state. With both providers and payers working collectively to understand elements of individuality about a patient, it provides greater opportunity to deliver better care, while also creating value for patients in their health plan and leads to increased treatment adherence.

Patient satisfaction and effective patient-provider communication are key to improve engagement for all parties. I’ve seen patients receive faster treatments and enrollment in medical studies and teachable moments for physicians as a result of increased collaboration between patients and providers.

When it comes to creating patient satisfaction, payers must also gain a greater understanding of patient choice and external factors such as cultural or personal needs. This also includes compassionate and respectful handling of patients and their families.

By establishing open communication channels between patient and provider, the two critical entities in the US health care system can help keep patients engaged in their treatment and monitor outcomes. Working together from all sides is how we will begin to shift to value-based care, strengthening patients’ commitment to improving their well-being.

Patient Empowerment

Patient engagement doesn’t lie just with the provider, health insurers also have a unique opportunity to boost patient engagement. It’s essential to think about the delivery of care from both the patient and their family’s point of view.  In many cases, health systems have begun to develop patient advisory panels to help foster these types of cross-functional communications, enabling a more comprehensive system of patient touchpoints.

This begins by ensuring patients have adequate information about their diagnosis, how to care for themselves, and insightful information on improving their health. For more serious issues, that level of information may extend to communication with a patient’s primary care provider or specialist, or more long-term care needs. By involving a payer in this communication, they serve as an additional resource to manage patient progress and ensure the patient is moving toward improved health.

Through proper patient education, increasingly delivered in digital formats via email or video, physicians start the handoff of the process of empowering patients in their health. When that empowerment extends to payers and other points in the health care system, patients gain a supportive network to take action and begin to see positivity in their situation.  Adding in more personalized care with respect to individual concerns and family situations, we can remove barriers to doubt and empower patients. 

This effort requires joint commitment, with education for staff on how to engage patients. It requires maintaining that communication loop with feedback from the patient and family about their experience, to continually improve gaps in service.

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Transparency in Costs

Greater transparency into cost-effective treatments and programs also aims to help health plans identify providers who routinely deliver the highest quality care while keeping costs low.  With a greater move toward a value-based care system, all parties can benefit from improved health knowledge on what typical treatments yield the greatest outcomes, the most cost-effective measures, and treatment options within case duration.

To establish greater clarity for payers, we need to ensure that they have the latest tools that offer transparency into the clinical process. Uniting payers and providers into one digital environment can connect patient health data with provider networks for expedited review and processing. For example, the company I work for, StayWell, launched a new application that integrates directly into care management systems that allow payers to easily connect into provider systems for this purpose. 

As pressure from the federal government to improve price transparency increases, supporting stronger relationships between provider and payer will lead to improved care across the board. When a provider better understands patients’ coverage options and costs, they can work with payers as a care team to ensure patients receive proper treatment that won’t bankrupt them. As a result, providers see less push back and denials, leading to greater productivity. This simpatico relationship leads to improved patient satisfaction and treatment adherence. It’s a critical next step in the evolution of the nation’s health care system.

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Financial disclosure: The author is the Chief Medical Officer of Stay Well mentioned in the post. The company could benefit from this mention. TDWI did not receive payment to publish this article. Rather, it was published because we think it has information that is valuable for our readers.

David Gregg, M.D.
David Gregg, M.D., in his role as Chief Medical Officer, oversees StayWell’s population health management programs, leveraging behavioral science as the foundation for helping clients – corporate enterprises and health systems – drive lasting change that improves health outcomes. Most recently, he led a healthcare consulting business focused on business strategy, population health management, clinical care delivery, provider quality, and cost containment. He was previously a principal and national physician consultant with Mercer Health & Benefits, and also served as vice president and medical officer at HealthPartners. Dr. Gregg holds a Bachelor of Science from Harvard University and a medical degree from the University of Minnesota School of Medicine. He is a member of the American College of Physicians, the American College of Physician Executives, the American College of Occupational and Environmental Medicine, and the American Public Health Association.

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