Payers understanding the provider perspective in a rapidly converging marketplace

As you’ve witnessed, rising medical costs and developing regulations have led to new initiatives to target clinical quality outcomes and manage financial risk. These and other market forces are transforming the way we [payers, providers and consumers] interact:

  • Payers are accelerating risk-contracting efforts.
  • Plan distribution is moving to direct-to-consumer.
  • Care models are increasingly consumer oriented.
  • Risk is shifting to consumer and providers.
  • Payers and employers are increasing use of tiered/narrow networks.

It’s too late to ask “if” the system will change — instead, we must ask how quickly will it be radically transformed, and more importantly, are we ready?

Transitioning to value-based care

While payers and providers are no strangers to value-based reimbursement approaches, new challenges and opportunities are emerging as VBR gains more traction under the Patient Protection and Affordable Care Act (PPACA). It’s important for providers to determine where they are in this process, and what they still must do to get there.


The good news is that all providers are at some point on this continuum. Many seek to move forward, but not all will move to the full-risk model. It’s not a one-size-fit-all approach; each provider must identify and pursue the appropriate level of risk for their organization. That starts with asking these critical questions:

  • How much risk can I successfully manage?
  • How fast should I move across the continuum?
  • How far is my organization prepared to go?

Attributes for success

The providers most likely to thrive in this changing marketplace share key attributes and payer-supported development of successful characteristics.

For example, a shared infrastructure, one that allows payers and providers to collaborate in support of their common clients, is critical for a successful transition to VBR. Connectivity, performance management, product information and claims/payment transformation must be in place. Providers will need to co-invest in innovation that will enable payers to connect to and share data with them.

Under the PPACA, reimbursement change is inevitable. Payers and providers are challenged to adapt or risk getting left behind. It’s important payers embrace the unique position they are in by helping to enable providers to identify, and implement, innovative ways of providing care that will be less costly and more effective.

To learn more, download our payer/provider convergence executive summary, “Understanding the provider perspective in a rapidly converging marketplace.”

–Chris Pricco


About the author

Chris Pricco, Senior Vice President Risk and Quality Solutions, Optum

bio_pic_chris_priccoChris started with OptumHealth in 2005 as Vice President of network development and product management. In this role, Chris developed strategies for contracting with transplant and dialysis providers, and served as the operations lead for the network development department. Chris then moved into a role of Vice President of disease solutions where he was responsible for product development and management of care coordination and chronic disease management programs. In 2007 he moved into the role of Chief Operating Officer for OptumHealth Care Solutions’ Complex Medical Conditions group before taking on the role of Chief Operating Officer of Risk and Quality Solutions at Optum in the fall of 2011. Chris took on his current role as the Senior Vice President of Risk and Quality Solutions in the summer of 2012.

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