Bridging the Gap Between Providers and Payers

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By Rodney D. Reider

Cheryl, a patient of a large, multi-city health system, received a call from her insurance company. Looking at Cheryl’s medical history, you’ll find her Type 2 diabetes is well-managed with oral medications. She sees her endocrinologist every six months to monitor her blood glucose and lipid profiles.

One day she received a phone call from her health insurance provider indicating that she could save substantially on her insurance copay by switching one of her daily medications. In the same week, she received a phone call from the local pharmacist who said the insurance company had contacted him asking he suggest changing this same medication.

Cheryl was frustrated and confused by the conversations because she adheres to her doctor’s care plan, and her diabetes is well-maintained. At each appointment, the endocrinologist indicates there is no reason to change any of her medications.

So, at her next appointment with this doctor, she mentioned both phone calls. After discussing the suggestion, her doctor indicates he doesn’t see a need to change medications if the current medication is not creating a financial burden on Cheryl.

In the end, Cheryl is pleased with the care she receives from her doctor, trusting his judgment and knowledge of the care she needs. However, she’s frustrated by the insurance company’s persistence in wanting her to change medications (because this wasn’t the first time they called about it) and drawing her pharmacist into the conversation to attempt persuading her. She assumes the insurance company is motivated by the financial gains they can make with the pharmaceutical companies, which then trickles down to the local pharmacy.

And, her perception is her reality, correct or not: Her doctor cares about her health, and the insurance company cares about money.

Just like Cheryl’s reality, here are some perceptions that the general population may have that can be overcome through the intentional and conscientious approach to care.

Relationships with insurance companies are always adversarial. 

Patients and medical providers think the insurance companies are trying to make as much money as possible.

If you meet with a group of insurance company CEOs and doctors, you’ll find they have access to a phenomenal amount of data and information about patients. Doctors have first-hand access to patients and directing their care. Rather than being adversaries, there is a synergy that can happen to improve patient outcomes while reducing costs.

Insurance companies offer patient incentives with little influence.

A gap exists between patients and payers––even those patients who are astute about the medical profession. (For example, those aware of the star rating system that determines levels of reimbursement.) If you ask senior adults if they make decisions about their medical care based on the star rating system, the answer is “no.”

Patients, instead, evaluate physicians and their staffs based on whether they are kind and listen and provide feedback about test results. But, for seniors, “silver sneakers” programs and patient portals may not have the desired intrinsic value. These may be areas where the payers are spending money on access that doesn’t elicit the desired participation and that aren’t perceived as value-rich by patients.

Payer innovations can drive partnerships with providers.

I recently had the opportunity to interact with insurance industry executives in a think tank setting. As we discussed opportunities for innovations in healthcare, they were incredibly intelligent and dedicated; however, they expressed some frustration with not utilizing technology at the same level as other industries. 

A few possible visions: What if, through the combination of aggregated electronic medical records and predictive analytics (AI), insurance companies could collaborate with care providers to better predict health trends and care? What if smartphone apps could empower a patient to be more actively engaged in making healthcare decisions? Granted, you cannot pin all your hopes on apps––there are distinct generational differences in usage. This type of predictive technology could lead to earlier interventions, which are often far less expensive than treatments.

Looking at these prior patient perceptions, there is a way of putting the patient/member first and building the systems and structure around them.  We can utilize innovation to prevent negative perceptions from becoming the patients’ reality through the following innovative ideas where payers and providers can improve care together. 

Where could innovative thinking lead us?

Through predictive analytics, insurance companies can capitalize on the volume of data they hold to determine what members need and where interventions can occur. For example, an insurance company pays for a patient monitoring device and the provider monitors a condition (i.e. a monitoring device for COPD). The device regularly sends feedback to the physician and treatment team, who can intervene before the patient requires an ER visit. The benefits are the patient’s well-being is the central focus of care, and the less costly interventions reduce ER visits.

What’s the incentive for this collaboration? The patient’s incentive is receiving much better healthcare in addition to a reduced premium discount. The provider’s incentive is the partnership with the insurance company which provides the monitoring device so the physician can monitor a patient more consistently for better care. The earlier interventions often mean care is provided in settings less costly than hospital stays benefiting the insurance company by providing better access for their members at a lower cost.  

What is the catalyst for change?

Insurance companies can be the catalyst in a variety of ways:

  • Patients are demanding pricing transparency.
  • Patients have a consumer mindset when selecting care providers and insurers.
  • Insurance companies have financial resources to engage in partnerships with physicians and health systems.
  • Insurers have employers and group managers looking for cost savings.
  • Early intervention provides better healthcare.
  • Insurance companies have a storehouse of valuable data that is useful to providers that can be aggregated and segmented by age, disease, and countless categories and shared.

Ultimately, insurance companies can continue to place the patient/member in the center and build the systems around them for better care and lower cost. 

There are also more non-traditional ways insurance companies can contribute to the overall health of communities it serves by evaluating hot spots in care utilization and patient populations. 

  • What are the highest health risks?
  • Are there factors driving ER visits?
  • Are there issues with food insecurity, and how does that affect the patient population’s overall health?
  • Are there issues related to access to health care, often found in more rural communities?

By sharing aggregated data, the focus becomes less about cost-control and more about making patients’ lives better. Insurers can ask, “What can WE do in this community to improve care delivery and support?”

So, let’s return to our opening example of Cheryl. Changing medications was not on Cheryl’s radar because, in all her interactions with her physician, she believes she is following the best course of treatment and she TRUSTS her doctor. She PERCEIVES a phone call from the insurance company, followed by an additional call from the pharmacy on behalf of the insurer, is driven by the payer’s desire to save money. Again, there is a naturally occurring adversarial perception of insurance companies––They aren’t focused on quality patient care.

The lesson here is understanding the necessity of the patient/physician relationship. Through collaborations with health systems, however, insurers can give information to physicians based on their patient populations that can help physicians provide the best care at lower costs.  Ultimately this is the best for the entire community and healthcare ecosystem.

And, in the end, that’s everyone’s goal.

For more than 25 years, Rodney has been involved in the healthcare industry and has positioned organizations to adapt to the continuously and rapidly changing healthcare environment. An International Scholar twice-over, he has a thirst for knowledge and a drive to explore, create and support innovative solutions within the healthcare space that make a lasting impact. He writes about healthcare innovation and leadership at rodneyreider.com.

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