The changing world of payer-provider collaboration

Michael Rose

Not so long ago, payer and provider alignment and close collaboration was not often spoken of in the same sentence.   In today’s healthcare environment, it is increasingly recognized that these two constituents need to work in synergy with each other.  Healthcare providers across the country are working to address the changes set in motion by government and private payers, including the Affordable Care Act, and the shift from volume-driven to value-based healthcare.

Value-based healthcare is a fundamental shift from the old “fee for service” model and focuses on improving outcomes, lowering cost and increasing access to care.  Value-based healthcare is intended to provide comparative performance information to providers.  The hope is that will be achieved by making meaningful and actionable information available to providers so they can improve the care they furnish, and moreover, by migrating to physician reimbursement that rewards value rather than volume.  In this environment, it is expected that providers will focus their attention on patients who have the highest healthcare utilization – ED visits, overutilization, non-compliance and high care variation.

Going forward, payers – who have real-time access to claims information (patient problems, medication prescriptions, test results), and, providers – who have access to the clinical information will collaborate, not compete.  The healthcare reform goal is that by bringing these two constituents together in collaboration, rather than in competition, this will ensure greater success with population health strategies that are contingent upon effective clinician decision-making at the point of care.


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