Given the risk that nonpayers—from technology giants to pharmaceutical companies—could make powerful moves to establish themselves in central positions of digital health ecosystems, the pressure to act now is increasing. John Poziemski In today’s evolving healthcare environment, providers and payers alike are exploring competitive strategies. These monitors are usually used to … As an HMO, we had a referral process so we helped members navigate their benefits. This is the only way to properly manage the health of its consumer base, as primary care doctors would benefit from having data showing whether their patients were seen at an emergency room or were admitted to a hospital. “Being willing to be flexible is also important,” he added. Regardless of the specific role, digital health ecosystems must be a core part of any payer strategy in the future. These capabilities should utilize data from multiple sources, media, and timeframes (including real time). “All of those savings that we realize, we pay those forward, keeping premiums low, and improving benefits. These strategies all require an initial investment of time, money, executive leadership attenti… The power of aligned payer-provider incentives is generally underestimated. All Rights Reserved. The payer imperative is to find the sweet spot where investment in prevention and high-quality care balances out financially with the cost avoided through better health and lower utilization of high cost services. First, payers operating in new value-based care models will need to ensure greater transparency with their provider network. © 2020 Arlington Healthcare Group. Being late to support new approaches can result in serious erosion of market share. Emerging care and payment models, incentive realignment, rapid advances in digital technologies—whatever new challenges may arise, those payers that thrive will transform their business to meet the shifting demands of the healthcare market. In fact, GlobalHealth’s strategy to implement data analytics tools and follow quality metrics among their provider network was able to keep this HMO from increasing premium costs among their members in recent years. Providers must decisively define a forward-looking strategy that identifies and plans for a payer contracting “reboot” that includes restructuring their payer contracts and reimbursement models in the post-pandemic landscape. While other payers have had a rise in premiums since the Affordable Care Act took effect, GlobalHealth has kept their costs down, saved on spending, and passed those savings forward to their consumers. Existing business models have created growth for many sectors in our industry, with healthcare now making up 18 percentof the U.S. gross domestic product (GDP). “What we’ve done is we’ve developed internally predicted modeling tools, care management applications, and built a care coordination team. This will ensure that payer and provider incentives are aligned. “We engaged with a predictive modeling partner called Vitreous Health and we sought out to not only be great at what we’re already good at, which is managing care at the point of care, but become great at preventing avoidable admissions, unnecessary medical services, and improving population health outcomes.”. Payers of all types – employers, commercial insurers, government or individuals – can’t indefinitely sustain cost trends higher than overall economic growth. In doing so, you can prevent expensive episodes, reduce redundant services, improve patient safety, and achieve better healthcare outcomes at lower total cost for a stable population over time. To learn more about how Arlington Healthcare Group can help you define and execute your organization’s strategic plan for transition to Value Based Care & Reimbursement, contact us today. “Understanding exactly what motivates the provider and exactly what motivates the health plan and coming up with metrics and measurement of the success of those programs [is vital],” Thompson continued. The growing rate of change driven by new technologies and regulatory demands puts more pressure on payers to manage their core business better: winning and retaining customers, managing provider networks more effectively, and processing claims more efficiently. The reimbursement costs and reasons for claim denials must be very clear from early on. Organization: Accenture Strategy – Health Payer Strategy ManagerLocation: NegotiableTravel: 80% to…See this and similar jobs on LinkedIn. This type of medical data exchange is critical for the payer-provider relationship to succeed in a value-based care reimbursement model. Often, having reimbursement tied to quality care benchmarks helps incentivize providers to improve any gaps in care. Healthcare Musings For 29 November 2019. by Dr. Gene Lindsey | Nov 29, 2019 | 2020 Presidential Debates, Adaptive Change, Elizabeth Warren's Medicare for All Plan, Featured Post, healthcare for the rural and urban poor, Healthcare Quality, Medicare For All, Medicare For All Who Want It, Single payer, the difficulties of change, The Triple Aim. “Over the years, we’ve continued to improve our relationship with our providers.