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Closer Payer/Provider Relationships Inevitable, but Evolutionary

Christopher Cheney, for HealthLeaders Media, March 26, 2014

Data sharing is one of the prime benefits of closer payer/provider relationships, and several other healthcare industry executives who have broached the topic over the past two months.


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"Our world has become so complex, we need to come together to look at data to make sure patients are getting the best care," Mischel explained, noting electronic medical records have shown great promise in reducing physician errors. "In the 21st century, data is going to drive our ability to provide quality care."

Mark Caron, senior VP and CIO at Pennsylvania-based Capital BlueCross, told me last week that providers are eager to gain access to claims information that provides the "whole picture" of a patient's medical history. "They're drowning in information, but they don't have that longitudinal record," he said of health systems, hospitals, and physicians.

Caron says data sharing between payers and providers has the potential to help educate patients about their health risks and to boost transparency in the healthcare delivery system. "The more we create an informed consumer, we'll all win as a society," he said. "Consumers have done a really good job in other industries to help them be the best they could be."

Mischel and Caron both told me there is no single dominant model that is likely to emerge from the ongoing evolution of the payer/provider relationship. "It will look different from market to market," the Noble CEO said. "We're really at the beginning of what the payer/provider relationship may look like."

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1 comments on "Closer Payer/Provider Relationships Inevitable, but Evolutionary"


bob sigmond (3/26/2014 at 3:19 PM)
The most effective "closer payer/provider relationship" in the future does not have to evolve. It can be put in place immediately, but only after the two parties have developed the necessary degree of trust and a carefully designed, revised contract reflecting common goals. The new relationship requires two changes only involving the two contracting parties. First, the third party payer takes over the provider's complete pricing, billing and collection functions and staff. Second, the third party payer sends a single monthly check to the provider to pay for all of the services provided to all of the provider's patients, with the check based on a one month allocation of the entire operating income in a collaborative annual budget that is a reflection of a collaborative long range strategic plan to not only improve quality and access but also reduced expenditures; the well known triple goal. For the provider organization, this arrangement has all the advantages of eliminating operating deficits, doing away entirely with any fee-for-service billings, eliminating the negative management incentives associated with fees-for-service, and the often unpleasant dealing with numerous third party payers and difficult patients about fees-for-service and other billing problems, and the benefits of collaborating on the strategic plan and budget with a third party payer that is much more experienced in the necessary shift from volume to value. Truly, very much like a dream come true for provider CEOs and governing bodies. For the third party payer, it [1] assures a new key role for the organization at a time when traditional insurance marketing strategies will be losing effectiveness in comparison with influencing provider behavior, and [2] provides the opportunity to reduce the cost of collection while increasing the rate of collections. Of course, many details must be worked out and included in the contract between the two parties. Most important, the two parties should crete a fund to reward the provider organization in "good" financial years and to support the third party payer in "bad" financial years. One of the advantages of this arrangement is that it does not involve any change in the marketplace or in government relationships, though some government support could be helpful, though not necessary. I would be delighted to hear from anyone interested in exploring this idea in greater detail. Regards, Bob Sigmond 215-561-5730 web site: "sigmond papers.org" or .com