With new reimbursement models, changing regulatory dynamics and broad quality initiatives, providers and health plans are feeling the pressure to increase their focus on the value of health care services delivered for premium dollars. Risk is now being transferred from payers to providers, blurring the distinction between the two entities. Increasingly, both groups face the need to forge relationships that maximize mutual resources — experience, tools, technology and data — lower costs and improve the quality of care. IT plays a fundamental role in this convergence, called value-based reimbursement (VBR).
Optimizing information management will improve quality of care.
Payers have a wealth of information within their existing infrastructure to support their own risk management, such as actuarial services, decision support services, data management and claims capabilities. Technology is essential to getting information flowing among payers, providers and members. The more advanced functionality of shared data assets results when utilizing the payer’s clinical analytics platform (fueled by collected claims data), the member/patient engagement interface, the provider engagement interface and significantly, the real-time health information exchange (HIE) infrastructure.
HIE allows multiple organizations to share clinical information electronically, which improves the timeliness of data. Another HIE benefit is that providers can consume and process clinical information using their own systems, instead of those belonging to someone else. As providers are increasingly being asked to participate in, or even own, specific core management functions, underlying technologies and functions will help them meet expectations.
Keys to a successful VBR implementation:
- The most effective plans will take time to segment the providers they work with and establish a provider-support framework.
- Provider organizations must lead the way in managing the medical expenses for which they are at risk, with plans as their partners.
- The most successful providers will take advantage of the infrastructure created by benefit plans to use clinical information and new care models effectively.
The winners in this convergence process will be the payers and providers who figure out how to collaborate, how to share information and how to use technology to enable higher quality and lower costs.
To learn more about the role of IT in VBR payer-provider relationships, download our article, “IT strengthens payer–provider partnerships as VBR arrangements take hold.”
About the authors
Dean Farley, PhD, MPA, Vice President of Provider Reimbursement, Optum Payer Consulting
Dr. Farley is a health economist with more than 30 years of experience managing and conducting research on health care financing and reimbursement. He currently manages a consulting practice focusing on payment reform and payment analytics within our Networks and Population Health business.
David Chennisi, Vice President, System Integration, Optum Payer Consulting
Chennisi has more than 30 years of experience in the health care industry and is a key leader in the Optum Payer Consulting Practice. His teams are responsible for successful systems implementation and integration projects spanning core administrative claims adjudication, medical management, business intelligence/data warehouse and customer relationship management applications. Prior to Optum, Mr. Chennisi served as CIO at Texas Children’s Health Plan.