What picture comes to mind when you think of the relationship between providers and payers?
Perhaps it’s conflict you think of, the unending struggle between utilization and cost. Perhaps you think of an uneasy alliance, united against injury, illness and mortality. Or perhaps you see separate worlds, morphing and adapting to the forces of regulation, innovation and transformation. As Becker’s reported earlier this year, “the insurer-hospital relationship has eroded dramatically over the last five years as insurers increasingly compete with health systems.”
I propose reframing this mindset. Today, healthcare leaders stand at a crossroads: the path of least resistance continues straight, characterized by waste and inertia. However, an alternative route offers fresh opportunity.
This path allows us to be efficient, balanced arbiters of healthcare spend, allocating resources effectively and identifying the areas of opportunity or improvement which lead to better outcomes. This path is made possible through the advances in computing technology and data analysis that allow an unbiased and objective framework for using healthcare data. It will only become a reality if tools and solutions are built to align the interests of payers and providers around outcomes, not opposition.
While determining medical necessity, inconsistency has become all too common. Standards are only effective if they are accepted and fully adhered to by all parties. Without a common framework that is intuitive to clinical staff and informed by clinical decision-making, reimbursement and care remain misaligned. However, data-driven analytics and predictive capabilities have adopted the role of neutral third party to bridge the divide between provider and payer.
By using analytics to aid clinicians and nurses in overcoming operational hurdles, hospitals understand and undertake their care and compliance continuum more fully, while payers lessen their administrative burden and costly adjudication efforts. When both parties begin collaborating with the same tools within a common framework, transparency grows, outcomes improve and innovation flourishes.
A majority of those who work in healthcare – whether clinicians, caregivers, nurses, vendors or ancillary staff – see their work as part of a larger purpose: my own entrepreneurial activities were undertaken because I knew I could make healthcare operations more effective, improving a sector that impacts us all. This motivation is a common bond, and one that we should strengthen through meaningful collaboration, standardized frameworks and unbiased analysis.
To reframe insurer-hospital relations, small steps will lead to better healthcare for all.
Joan Butters is CEO and cofounder of Nashville-based XSOLIS, the organization rethinking healthcare operations through cognitive computing and predictive analytics.