Payer-provider convergence hinges on data integration

A dynamic data duo

Broadly, payer-provider partnerships combine two historically separate concerns: health systems delivering care and insurance carriers shouldering the financial risks for patient populations, along with all the data incumbent to each of those missions.

Niyum Gandhi

As the idea of value-based care takes further root -- largely due to government nudging, at least in the U.S. -- payer-provider cooperation can be an advantage because the collaboration yields a truer view of patient data.

For some health systems, this approach means creating their own insurance plans, with all aspects controlled by one party. That setup can be an expensive and difficult undertaking, Gandhi said.

However, in Mount Sinai's case, the system decided to co-design patient networks with carriers such as Aetna, UnitedHealthcare and New-York-based Oscar Health. "It's one of the models for payer-provider convergence," he said.

There are some roles -- traditional payer roles -- that we're going to take over.

"There are some roles -- traditional payer roles -- that we're going to take over" because the health system is better equipped to do so, he added. One example is patient care management, in which patients receive help coping with chronic illnesses or transitioning to home-based care, with the idea of not duplicating services. These have been activities that insurance companies usually handle with mixed results, Gandhi said. Through its partnerships with carriers, Mount Sinai now deals directly with care management efforts.

"If you have that approach with [providers and payers], it fits in very nicely with value-based care," Gandhi said. Behind the scenes, the success of such setups hinges on data structure, he added. At its peak, the payer-provider convergence allows both sides to rely on the best patient data from any given source, as determined by algorithms within integration software.

Third-party involvement adds to the mix

For Contessa, providing hospital-based care at home for patients is an activity under strict guidelines from insurers, similar to criteria for admitting a patient to a hospital. The company's model was typically not reimbursed in the past until payer-provider partnerships emerged that spurred analysis of the underwriting risk for home recovery care, Messina said.

From that regard, a transparent exchange of claims and service pricing data is important, and data analytics and healthcare economics come into play.

As Contessa and similar companies attempt to make these risk-based models more efficient for hospitals and insurance carriers, their role "is largely dependent on payer-provider convergence," Messina said.

Improved customer service, too

When done well, payer-provider methods can also fuel a growing effort to improve the patient experience. For example, today it's common for a patient to call a physician's office about a billing question only to be told, "You need to call your health plan." That type of runaround demoralizes patients, but it could be more seamless if providers and carriers worked off the same set of data, Gandhi said.

A study published in April by Chilmark Research suggested that the payer-provider convergence would drive increased interest in new patient relationship management technology. Such software aims to help patients manage their care in between visits with clinicians, in many ways through automation.

When clinicians and insurance companies come together under a shared business model, there is a mutual interest in reviewing patient data and taking health-based action when necessary, said Brian Eastwood, an analyst at Chilmark and author of the study.

"There are more entities that want to be aware of a person's progress towards hitting [their treatment] objectives," Eastwood said.