Payer-provider collaborations: The key to improved patient outcomes [Special Report]

One of the defining features of the new healthcare landscape is the rise of payer-provider partnerships. As providers increasingly move toward value-based care models, they must work with their counterparts in the payer sector to coordinate care and prevent readmissions.

But the transition is proving bumpy in some cases due in part to the historic mistrust between payers and providers. In a survey by Numerof & Associates, less than 60 percent of healthcare executives polled said payers were more than "somewhat willing" to commit to agreements. This distrust goes back to how each industry has historically viewed the other, according to Numerof & Associates Founder Rita Numerof, Ph.D. (pictured).

"Payers are frequently looked at as being focused on 'how many different ways can we say no to a particular claim,'" Numerof told FierceHealthcare in an exclusive interview. "There's pressure in terms of reimbursement, and part of that has been driven, quite frankly, by cost-shifting on the part of providers, where they're essentially dissatisfied with the amount of reimbursement they get for either Medicaid or Medicare and as a result, have been in position over the years to be able to charge more in negotiation with commercial payers. Blame needs to be put squarely on the shoulders of both parties in this dance."

For payers and providers to form relationships that genuinely transform outcomes, they must recognize that "there is more to gain than there is to game," Numerof told FierceHealthcare--in other words, finding a mutually beneficial path forward has far more potential than each side trying to take advantage of the system. "What will happen is, the expectation for doing things differently will begin unfolding in each of the respective organizations," she said.

The implication of the recent shifts in both the healthcare business and between payers and providers in general, she said, is that the industry needs a "fundamentally different payment model," as well as evidence of improvements in both care quality and cost on both sides of the equation.

Despite these potential hurdles, numerous payer-provider collaborations already serve as success stories for care quality improvement. In this special report, FierceHealthcare takes a look at two successful partnerships among providers and payers that have led to improved patient outcomes and patient engagement.

Innovation Health: Collaboration leads to improved patient outcomes

When managed care giant Aetna and Virginia's 1,700-bed Inova Health formed Innovation Health, the two organizations were able to bridge many of the historic problems between the sectors, according to Amy Turner, (pictured right), Innovation's executive director.

"Innovation was created to bring both of these parties together," Turner told FierceHealthcare in an exclusive interview. "We started selling our plans in October of 2013. We've grown pretty well not only in terms of membership, but our programs as well."

Innovation has also improved outcomes. For example, under Innovation's Enhanced Care Coordinator Program, nurses from both entities meet daily to review data on Innovation members who are either hospitalized or received emergency treatment the day before. The two compare data on the patients in question, with Aetna sharing claims-based historical data while Inova and two of its affiliate hospitals provide clinical-based information gleaned from electronic medical records.

"They meet and review each and every member that either is in the hospital or has been in the emergency room the day before and they develop a unique care plan for each individual," she said, after which nurses reach out to the patients and work to activate them and involve them in their own care process. It runs a similar program for transitional care. Since implementing these programs, engagement rates have climbed from 20 percent to nearly 70 percent, Turner said.

"They're a lot more receptive and engaged with their care from a longitudinal perspective, versus if we wait seven days out or wait until the claim hits," she added. Moreover, she added, 30-day readmissions are down 28 percent.

The participants, she added, had the advantage of being on friendlier terms than the typical provider-payer pairing due to an existing relationship. "Both parent companies took the time and had the discussion before the launch to make sure that those parties understood the rules of the road and how they were going to work together going forward," she said. "Taking the prudent time to go through those discussions … is why we've been able to be successful in the marketplace."

Medicare and Medicaid collaborates with Trinity Health on patient engagement

For Trinity Health, a national, not-for-profit Catholic health system operating 86 hospitals in 21 states, one of the major advantages of payer-provider cooperation has been collaborating with federal payers such as Medicare and Medicaid, according to Linda Keenan, the system's vice president for population health management.

"They look to Trinity because we have a large footprint [and] they look to us to see what we are doing in the way of patient management," Keenan told FierceHealthcare in an exclusive interview. In contrast to the often-stormy payer-provider relationship, she added, the Centers for Medicare & Medicaid Services have welcomed the chance to take pointers from Trinity on patient engagement and care coordination, which has given the provider's efforts to improve care outcomes a major boost.

"Patients are not being admitted to the acute hospital arena, because they were able to manage their care better through the education," she said. "That level of engagement is what is creating this success."

Payer collaboration has, over the years, helped Trinity overcome one of its major barriers, giving clinicians access to the data they need to improve care, according to Stuart Kilpinen, Trinity's senior vice president for managed care. The system, he said, has collaborated with payers extensively to share information in real-time. These partnerships work, he said, because the system makes transparency a prerequisite for any payer seeking to collaborate with them.

"I think we've been able to establish that relationship and continue that spirit of transparency," he said.

Read more on