Payer strategies for quality improvement now include providers

Payer organizations are on the hook for the care provided to health plan enrollees but need and depend upon clinicians within their network to deliver care and drive quality.

Convincing, collaborating with or enabling clinicians are their options. Payers work hard to convince busy providers how important it is to address gaps in care but collaborating with providers to improve quality is ultimately much more effective. Enabling providers to drive quality at scale across their patient population is the ultimate goal.

Recent highlights from the 2018 J.P. Morgan Healthcare Conference pinpointed 12 distinct strategies providers are embracing to deliver greater value in healthcare. Payers are quickly adopting similar approaches and supporting resources that help answer the call for cost management, scalability, physician engagement and analytics-driven action. As payers and providers acclimate to pay-for-performance reimbursement models influenced by patient ratings and clinical outcomes, alignment on data-driven care management and patient engagement is vital.

Driving Better Care Through Provider Enablement
To meet quality goals, payers are increasingly empowering clinicians with technologies that inform clinical intervention and support engagement strategies that help move patients from awareness to action. Shared resources drive collaboration on population health management and other value-based care initiatives between payers, providers and patients alike. The key is to find resources that offer scalable, cost-conscious solutions that:

● Unify disparate data sets: claims data, lab results, immunization and screening data, prescription data, social determinants of health, retail preference data and more.
● Offer centralized insight into care gaps across the patient population to facilitate the greatest improvements to care quality.
● Include mechanisms for customized patient engagement programs that help patients more easily navigate the complex world of healthcare.

To drive sustainable improvements, healthcare organizations must think beyond initial risk-assessment to the full patient journey. By arming network providers with advanced analytics tools, payers can support clinicians’ patient risk assessment efforts, illuminate at-risk patient populations and then help close identified care gaps among hard-to-reach patient members by offering health interventions that align to patient preference and convenience.

Courting Healthcare Consumers on Their Care Journey

Many payers are exploring ways to help clinicians influence patient behaviors and transform health plan members into more active participants in their own health. Using patient data to deliver a more personalized healthcare experience is one way stakeholders are working to better appeal to patients.

Overburdened provider organizations have been cautious to jump on the digital engagement bandwagon with patients. The recent rise of consumerism in healthcare, however, is necessitating a fresh approach to engagement as patient expectations evolve. As a primary point of patient contact, payer organizations are well positioned to aid their physician networks’ patient engagement efforts. Using the same analytics resources that support care gap analysis, payers can help facilitate tailored, provider co-branded outreach built to appeal to different patient personas.

Getting patient attention is step one in the care journey. Getting a patient to navigate a series of activities is what fundamentally creates value in healthcare. How are healthcare stakeholders most likely to close a gap in patient care? At home, at a retail pharmacy or during a worksite event? The more that healthcare organizations tailor outreach and engagement opportunities to create convenience for the patient, the greater the probability of patient follow-through.

Navigating the complexity of the U.S. healthcare system is a challenge. Engineering rigor is required to configure and manage a more sophisticated engagement ecosystem. Digital engagement tools are a necessary part of an effective patient user experience. Payers can empower provider networks—who often lack the necessary bandwidth and resources—with engagement solutions that offer:

● Multi-modal patient communication, including mobile and email options.
● Online, centralized access to patient-specific scheduling options, health results and health education materials.
● A simplified user experience that is easy to navigate and features real-time access to data to motivate patient action.
● Care interventions that extend beyond the walls of traditional care settings, including retail care, home visits and direct-to-consumer offerings.

By enabling providers with resources that marry behavioral science with intuitive user design, payers can make a measurable difference in patient activation.

Working together, insurers and network providers can take positive steps to boost clinical performance and patient ratings. Patients benefit from a personalized patient experience more akin to what they’ve come to expect from other industries. Healthcare organizations benefit from better outcomes, improved payer-provider collaboration, increased patient loyalty, long-term savings and immediate incentives related to care gap closure.

About the Author

Justin Bellante is CEO at healthcare technology company BioIQ.

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