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The New Rules of Engagement

News  |  By Optum  
   February 09, 2017

Value-based care is changing how providers negotiate and partner with payers

“[Payers and providers] must understand that they need to collaborate, operate off of shared data, and have a shared source of what is true.” — Amanda Skinner, vice president and general manager of managed value and risk analytics at Optum

As providers design value-based care strategies, some are exploring unique solutions to age-old problems, such as how to partner and negotiate effectively with payers. “Payers and providers have maintained disparate data and held different vantage points, and now we are moving to a world where providers must adopt some of the capabilities of health plans,” says Amanda Skinner, vice president and general manager of managed value and risk analytics at Optum. “As a result, providers are evolving to take on accountability that payers have historically had,” she adds. The challenge is also to operate in a fee-for-service environment while focusing on alternative payment models. “It’s a skill set that is hard to find, and one that requires integrating clinical and business analytics,” says Skinner.

The Art of Cooperation and Competition

To that point, provider organizations are increasingly seeking actionable information about their clinical and financial performance to negotiate better risk-based contracts and form stronger partnerships with payers. “It’s essential that they now see the whole enterprise, including the sensitive interplay between acute care, ambulatory operations, physician practices, clinical outcomes, and their postacute care networks, as well as the financial impact of their value-based contracting strategies,” says Skinner.

Having a blended view of clinical and payer data is important. “People often try to pit the data against each other, saying clinical data from the EMR is better than claims data or vice versa,” says Skinner. Both are critical to providers when it comes to value-based contracts. Clinical data from the EMR and ancillary systems offers real-time detail on what is happening with a patient. “This is important to building both an individual patient and a population-level view,” says Skinner.

At the same time, claims data often includes information about care delivered in settings that use a different medical record, which means it can provide a more comprehensive picture of patient care and reimbursement across the continuum, particularly if patients haven’t received all their services within a closed delivery system. “So the greater partnership around integrating these data sources in real time is becoming more significant,” says Skinner. “This is all leading to a place where payers and providers need to find a way to not just converge, but to move towards ‘coopetition,’ which means to cooperate while competing,” she adds. “They must understand that they need to collaborate, operate off of shared data, and have a shared source of what is true.”

Providers and Payers Collaborate to Serve Self-Insured Populations

With this in mind, many providers and payers are starting to forge common ground through new partnerships that focus on improving value for a hospital’s self-insured employee population. The hospital contracts with payers to be a third-party administrator. “This is where provider organizations and payers work well together and are able to develop a lot of expertise around succeeding together in value-based care,” says Skinner. Provider organizations that self-insure their employee population gain access to claims data because they are both employer and payer. “Also, as payer and provider, they have aligned financial incentives. The result is provider organizations are starting to bend the cost curve of their own self-insured population, while improving the quality of care and health of their employees, and seeing a real partnership form with payers,” adds Skinner.

Moreover, these partnerships can help create more flexibility in allowing providers and payers quicker access to each other’s real-time data. “However, payers will have to accelerate their claims adjudication process for this to be completely effective,” says Skinner. “Having up to a three-month lag for adjudication makes it challenging.”

As providers take on more risk, explore new relationships with payers, and gain access to new data, they will need to determine the best analytics strategy for value-based care and decide whether it makes sense to work with a partner, says Skinner. “An advanced healthcare services organization that has navigated complex provider and payer partnerships will have the expertise to integrate clinical, operating, and financial information, along with claims data, into a comprehensive picture. They will have not just data, but knowledge.”


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