There has been a huge focus on different kinds of bias in healthcare in recent years, but there is one type of bias that does not get much attention and yet sits at the heart of some of the healthcare system’s greatest challenges: the biases that payers and providers have with regard to each other. There are long-standing misconceptions and deep mistrust between these two pillars of the US healthcare system, which result in thousands and thousands of daily frustrations and inefficiencies across the nation, resulting in great unnecessary expense and burnout.
While there are very understandable historic and market-driven reasons for these tensions, the advent of value-based care programs may be opening a path to reconciliation and replacing bias with trust.
Having worked both sides of the fence as a practicing nurse, care manager and care pathways guru for health plans, I see the disconnects between payers and providers more clearly than most. But I am also a caregiver to an elderly parent who sees firsthand through that lens just how much silliness, waste and needless frustration and clinical jeopardy healthcare consumers face in the middle of all this. I see bias and mistrust as the underlying cause of these problems, but I also see a path to reducing those factors.
In caring for my father, whose condition requires frequent visits with our excellent provider, I see over and over again the time wasted on ticking bureaucratic boxes that detract from care, aggravate patient and provider alike, and undermine patient confidence in the sanity of the system. Things like enduring routine questions such as “Do you smoke?” when the answer is clearly in the chart or awaiting artificial deadlines for a new treatment plan to start, are common examples of the kind of silly steps our healthcare system requires. As a seasoned case manager who knows the value of precious provider time and patient trust, these things frustrate me deeply and I worry for all the patients out there that do not have an advocate knowledgeable in healthcare-speak.
Ultimately, most of the bureaucratic rules that gum up care stem from fundamental bias and mistrust between payers and providers. Payers treat providers like they are trying to game the system and bill for work that is not really needed or actually being delivered. Providers treat payers like all they want to do is save money by shortchanging doctors and limiting care. Interestingly, both sides do have the best interests of the patient at heart but mistrust the motives of the other side so much, they cannot see it.
Part of this disconnect is that payers and providers come from adjacent worlds with totally different perspectives: payers tend to see things in terms of risk while providers see everything in terms of optimal care. These worldviews are really two sides of the same coin and are not too hard to reconcile. The deeper problem is that both sides suffer from some very toxic, ingrained cultural traditions and opinions, and old habits are hard to break.
Payers have a long tradition of highly bureaucratic organizational styles, which tend to value rules over reason, and see members and providers more as adversaries than customers and partners. Not caring too much about member relationship abrasion due to lack of competition, these cultures tend to perpetuate a “those are the rules” mentality that is rigid to the point of ridiculousness and hurts top and bottom-line performance.
Providers too can suffer from toxic cultures, seeing payers as the enemy and justifying milking private insurance sources to compensate for lower government reimbursement. Patients are often seen as lazy and entitled, and doctors as being the best and only arbiter of what is best for everyone.
These toxic cultural elements are increasingly under scrutiny today and organizations are trying to change and re-orient around shared goals and consumer experience, but change comes slow in very large and long-established organizations. Ultimately, payers care about their members and know that good care reduces risk, and providers know that too much care can be just as bad as too little, and they want care to be affordable for their patients and for the nation. So, there is definitely common ground to work from.
It’s important to note that payers and providers are far from the only propagators of rules and processes that detract from quality and efficiency. Regulators and litigators bear at least as much responsibility as anyone else, and for the healthcare system to begin to bring common sense back to the fore, our government institutions need to also step back and rationalize the way they operate. Most regulations and court rulings, at the time they were implemented, were well-intentioned and made sense, but often the evolution of the application of these decisions winds up resulting in negative consequences for today’s care.
Regulations are not all bad, though, and the growth in value-based care adoption driven by legislative and regulatory changes is pushing the entire industry toward a tipping point today between regulation, revenue, and how payers are paid that promises to align everyone around a common goal: Just the right care (no more no less) and just the right time (as soon as possible but not at the expense of more urgent needs) and just the right place (least expensive care venue consistent with good care – home, clinic, ASC, hospital, etc.)
In such a system, payers and providers that work together with a commonsense approach to appropriate patient care will find remarkable success
Thanks to innovations like value-based care, payers and providers are increasingly aligning everyone around these common goals and see the real enemies as their own hide-bound cultures and well-meaning but onerous overlapping regulatory hoops that do more harm than good. Rules, regulations, and old practices need to give way to practical personalization of care, and we must re-humanize the way we care for our patients – that is where the hard work of cultural change comes in.
We need to bring human compassion back into care and keep administrative mindsets out of the way. Organizations that do this well will reap the benefits of better outcomes and consumer experiences and sweep up high value market share at time of transition in the industry.
Payers and providers will surely continue to exhibit biases that impact care – that is appropriate to a certain extent. But if we can all shift the focus from our own internal workings and truly orient around the patient, and place common sense above paperwork – we can finally transform as an industry.
Sandra Hewett, RN, BSN, CCM
As Chief Nursing Officer of ZeOmega, Sandra oversees all aspects of the development, use, and interpretation of clinical content and intelligence. She also helps architect strategy for population health management and value-based solutions, as well as ensuring compliance with all state, federal, and local regulations, laws, standards, and protocols. Sandra also has over 25 years of experience as a pediatric nurse and certified case manager in the provider, payer, and vendor domains.