3 strategies for transforming care through payer-provider collaboration

Value-based care is not a new concept, but the strategy to ensure both payers and providers succeed in a quality-focused care delivery system is not well defined.

If there is one thing I have seen in my career, it’s that strong payer-provider relationships enhance value-based care success.

I realize this is easier said than done, especially as payers and providers face different barriers to complete and accurate risk capture.

Despite the challenges on both sides, payers and providers ultimately want the same thing — positive patient outcomes. I’ve worked with many providers in the last few years as they transition to the value-based care model. I’ve come to rely on three key things to improve collaboration: people, processes and technology.

People: Having the right capabilities and expertise on your staff

Having a well-trained team is crucial for value-based care success. Ideally, each team member should operate at the peak of their capability within a continuous learning environment that fosters their development.

Health plans that offer training and education resources, either directly or through a third-party vendor, are more likely to see enhanced provider engagement and an improvement in complete and accurate risk adjustment.

For example, one Optum Health Care Advocate (HCA) worked directly with a private group physician practice in New York and helped them achieve a 98% health assessment return rate for over 1,200 patients. Optum HCAs provide in-person or virtual coding and documentation training by certified coders, performance monitoring, strategic guidance for program success and regular touchpoints to understand practice goals and alleviate potential roadblocks.

Effective staff training and managing administrative overload are key factors that distinguish between simply participating in a risk adjustment program and achieving success in it.

Process: Optimizing workflows to reduce administrative burden

People and technology are essential, but without workflows to connect them, you won’t get far.

For this reason, workflows are coming under increased scrutiny for their ability to make or break value-based care progress. And while advancements in technology are still the more headline-grabbing topic, in some cases, workflow innovation can deliver an even bigger impact than having the latest technology.

The key to optimizing workflows lies in aligning with the administrative availability of the provider practice and their level of digital integration. Even with fully digitized capabilities, a short-staffed office may face administrative burdens from risk adjustment programs, hindering progress to more complex models.

For health plans, it’s important to take these factors into consideration when offering a risk adjustment program to providers in your network. An ideal offering would have customizable options, or a tiered approach with different levels of workflow support that providers can choose from to best fit their needs.

For example, most prospective in-office assessment programs, whether offered directly from the health plan or through a vendor, will include some type of support for providers, such as call center resources or analytics. If a practice already has established workflows, this level of support is likely sufficient to achieve complete and accurate risk adjustment.

However, the idea of workflow innovation looks beyond the base-level approach and helps providers develop workflows from the ground up that serve patients at every point of care. These workflows might include clinician chart reviews, coding new conditions, accessing patient insights, and reducing retrieval through accurate documentation.

Technology: Data and insights can help paint a complete picture of patient health

It’s frustrating when different technology platforms don’t “talk” to each other or when straightforward tasks require multiple steps. These simple breakdowns can kill productivity and morale and require too much energy for administrative tasks.

It’s essential to utilize technology that enables the open and seamless sharing of data within the provider’s workflow, providing a complete and accurate overview of the patients and populations they serve.  Accessing diverse datasets, including claims and clinical data, is crucial for payers and providers to understand patient and population health.

Bringing together payers and providers under a common vision

Every provider group starts from a unique position, each facing distinct challenges and opportunities. Health plans need to deeply understand each practice's current stage in their transition to value-based care, offering tailored solutions that meet their specific needs. By focusing on people, processes, and technology, both parties can prioritize what matters most: enhancing patient care.

If you are a provider looking for ways to effectively manage cost and quality of patient care, visit optum.com/RiskIdentificationCapture

If you are a health plan and want to learn how to advance value-based care for your providers, visit optum.com/prospective