When people interact with the healthcare system, it’s typically a connected experience where one encounter leads to another: a doctor’s visit, a trip to the pharmacy, a course of physical therapy, a hospital stay. Yet today, the care itself is sometimes separated from payment for that care in ways that can be confusing for consumers.
The partnership between care providers and payers (payers can be a health plan or a self-insured employer) in healthcare isn’t always obvious to people who are receiving care, but that collaboration is a key part of the system that keeps us healthy and addresses our pressing healthcare needs. When we work together toward a common goal — healthier outcomes for everyone — we start to remake the system with the consumer at the center of everything we do.
“One way the industry has accounted for this difference in understanding how care is experienced versus how it is consumed, is in the form of bundled payments,” said Kyle Weber, chief strategy officer for Elevance Health. “Paying a care provider once the ideal outcome is obtained — for example, when an individual can ride a bike again following a total knee replacement — means that care provider has the incentive to offer the highest quality care. Most hospitalization payments include the surgeon, the anesthesia, the recovery, the discharge planning, rehab, and follow-up visits.”
Payer and Care Provider Collaboration Makes the Healthcare System Stronger
The difference between payers and care providers in healthcare may seem obvious: One provides care to individuals, the other helps people navigate the healthcare system, works to ensure they are getting the support they need, and reimburses care providers for that care on behalf of its members. There are several types of payers in healthcare: commercial, private, and government — and even more options for health plans, ranging from Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and high-deductible plans. But whatever the type of plan, Weber said, consumers benefit when their payers and care providers join forces to make healthcare more effective, cost-efficient and easier to navigate.
Working Together for Transparency and Ease of Use
Elevance Health has prioritized efforts to make pricing and quality data transparent, understandable, and actionable for consumers, working to connect that data to their health plan, their deductible, and their conditions and needs. Going a step further to share that data with care providers can help them close gaps in care, identify contraindications, and improve overall health outcomes.
The idea is to support consumers to take more control of their health — and help care providers deliver the best care possible. “Consumers tell us to make it simple for them,” Weber said. “I don't think they care too much about the intricacies of ‘this is where a payer’s function starts and where a care provider’s function starts.’” People want the healthcare system to be simple, not only for themselves, but for their family members and for their care providers.
“Part of our role as payers in healthcare is recognizing that we have the privilege to help guide our members through the system,” Weber said. “But, ultimately, it’s their primary care physicians, their specialists, their nurses who are going to really help them with their healthcare. We need to make it easier for consumers to navigate the system and make it easier for our provider partners to deliver individualized and efficient care.”
Working Together to Create a Seamless Healthcare System
The safe and secure exchange of health data is key to improving the member experience and ensuring that vital health information is getting properly communicated among payers and providers while protecting individual privacy. It’s about harnessing data to serve the whole health of each individual member. However, as Weber pointed out, “it’s incumbent on us and others in the healthcare system to take that data and responsibly make use of it.”
That’s the inspiration behind Health OS, a comprehensive digital platform created by Elevance Health that takes health data out of silos and puts it into the hands of payers and care providers, maintaining privacy and security while enabling more informed, personalized, and proactive care decisions.
Elevance Health is also working with electronic medical records organizations, such as Epic, to facilitate more seamless exchange of health information between care providers and affiliated health plans. Increasing and improving this communication aims to better leverage data-driven insights in care decisions, simplify healthcare, and ultimately improve health outcomes. Creating secure, seamless data exchange between providers and health plans makes it easier for patients to receive more timely access to appropriate care. It gives clinicians more time to focus on delivering care and improving quality for consumers, because it helps streamline administrative processes such as prior authorizations. In addition, it enhances care management, giving clinicians near real-time access to secure consumer health data, which helps address care gaps.
Successful interoperability can benefit the entire healthcare system by improving efficiencies, reducing redundant administrative processes, and ultimately making healthcare more affordable. It can assist care providers as they help their patients manage chronic diseases — with context and in a way that gives clinicians valuable insights about treating those diseases while protecting individual privacy. “As healthcare professionals, it’s time we look at data interoperability as the means to creating truly proactive, predictive, personalized care for all,” said Rajeev Ronanki, Elevance Health president of digital platforms. “While there is still work to be done, creating a frictionless exchange of health data will be the path toward a truly value-based healthcare system.”
Driving Innovative, Collaborative Healthcare Models
In recent years, value-based care contracts have started to take the place of traditional fee-for-service models. These payment models incentivize quality over quantity, tying reimbursements to the effectiveness of treatment, and they have the potential to improve quality of care while driving down healthcare costs. These contracts are successful when payers work closely with care providers to make sure they have the options they need, Weber said.
Value-based arrangements accounted for more than 60 percent of Elevance Health’s medical expense in 2021, and they have shown impressive results. Value-based provider partners conducted 12% more annual well visits, on average, and delivered lower overall costs, with 19% fewer emergency cases per 1,000 for those in value-based arrangements and 15% lower inpatient admissions.
“Value-based care rewards providers for quality, rewards them for experience, and ultimately keeps costs down,” Weber said. “As those relationships evolve and we get into even deeper value-based care relationships, we will be partners in sharing both the savings and the risks. If they're going to take that outside risk, we need to give them the tools and empower them to actually do well in those types of arrangements.”
Successful payer and care provider collaboration can help reimagine the health system as one that is focused on the whole health of each consumer to improve outcomes and experiences. “Our care providers are very clearly our partners,” Weber said. “And we are always looking to deepen those partnerships as together we work to improve care for consumers.”