Humana CMO: Trust is No. 1 challenge for the payer-provider relationship

As hospitals and health systems work to cut costs and keep patients out of hospitals during the transition to value-based care, payers and providers must continue to strengthen their relationship to tackle the numerous challenges care delivery presents today.

At Becker's Hospital Review 4th Annual Health IT + Revenue Cycle Conference Sept. 19 in Chicago, a panel of healthcare experts weighed in on the biggest challenges and opportunities affecting the payer and provider relationship today. The panel included:

  • Roy Beveridge, MD, CMO of Humana
  • Aneesh Krishna, partner at McKinsey & Co., health insurance segment
  • David Gallegos, senior vice president of consulting services for healthcare technology company Change Healthcare

In reflecting on the top challenge payers and providers face in transitioning from fee-for-service to value-based care, Dr. Beveridge said one of the most significant changes is providers are becoming more accountable for their care. From the provider's perspective, this shift makes the payer's role more important, particularly from an IT and data standpoint.

"When I started practicing, everything was fee-for-service, and the bad guys were the payers," Dr. Beveridge said. "In a fee-for-service system, it's a 'mother may I' process that involves getting permission from someone else to do something. This is always going to result in disharmony no matter how good the relationship is."

Now, as providers shift away from the fee-for-service model, the key to eliminating that disharmony lies in developing a strong sense of trust, Dr. Beveridge said.

"Around the value-based world, the biggest challenge affecting the payer and provider is trust," Dr. Beveridge said. "We're moving into a world where we have aligned incentives, and in that case, the challenge is to develop that trust."

Mr. Krishna built on this, discussing how successful value-based models must align provider and payer goals.

"The whole notion of misaligned incentives has plagued the healthcare space for a long time," Mr. Krishna said. "Building trust between payers and providers becomes less of a zero-sum game and more of a collaborative approach to drive down costs. The more payers and providers come at this challenge together and create win-win programs, the more we make progress in healthcare."

To help eliminate fragments in the healthcare system, consolidation processes that bring larger data systems together and allow for a greater exchange of information can help payers and providers in tracking high quality care, Dr. Beveridge said.

"As we move into value-based care, do patients really know how good a doctor or hospital is? The answer is we probably don't," Dr. Beveridge said, "but bringing data together will allow us to have common systems that can look at quality measures, cost measures and give us needed transparency."

Payers and providers also will have to continue to manage different patient populations while keeping care costs down, Mr. Krishna said, reflecting on his experience serving national and regional health plans and systems.

"Most providers I work with have struggled with how to tailor the experiences of patients with same condition," he said.

In this way, as providers focus on population health, they have a broader responsibility to not only consider the patients in front of them, but also manage patients who are not in the office, Dr. Beveridge added.

However, in focusing on population health, payers and providers must be careful not to lose sight of patients as consumers who want data relevant to them, Mr. Gallegos said.

"Consumers don't want big data; they want small data that is relevant to them. Amazon, for example, doesn't tell me what everyone's buying. It tells me what I would want to buy. I think healthcare needs to do the same thing and send patients precise information tailored to them."

For payers and providers moving to value-based care, perhaps the most significant challenge will be recognizing that a successful system goes beyond merely ensuring patients are free from disease, Mr. Gallegos said.

"We're beginning to realize healthcare is more than just the absence of disease," Mr. Gallegos said. "It's about creating an environment of well-being, and that's going to be the magic bullet to reduce costs and keep people out of hospitals."  

More articles on payer issues:
Key payer issues in 2018 — 4 thoughts
10 states with the least competitive health insurance markets
Meet Cigna-Express Scripts' executive team: 3 things to know

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