Fierce Exclusive: Payer and provider executives talk about breaking down the historical barriers to collaboration

FierceHealthcare gathered a group of more than 20 health industry executives to talk about payer-provider collaboration. (Getty/Martin Barraud)

Editor's note: This is the first in a three-part series. In this article, provider and health plan executives share their thoughts on payer-provider collaboration to lower costs and to improve member experience and care. Part two focuses on partnerships with physicians and nontraditional provider relationships; part 3 will cover technology, including collaborative data-sharing to improve outcomes.

From large, risk-sharing financial arrangements to small pilot programs to improve the patient experience, payers and providers are increasingly collaborating to improve care, lower costs and engage patients.

But payer-provider collaboration is also a fairly new concept (at least in the slow-to-adopt world of the healthcare industry). Us-versus-them attitudes built sturdy walls between payers and providers long before value-based payment models and other market forces made collaboration an essential part of doing business.  

FierceHealthcare gathered a group of some 20 payer and provider executives to talk about the ways they're partnering to deliver better care to their members and patients. In the free-ranging dinner discussion, they asked each other for advice, shared their challenges and frustrations and talked about their strategies and success stories.

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To encourage our guests to speak freely, we aren't publishing their names or the names of their organizations. But the comments below come directly from the CEOs, chief information officers, chief operation officers, chief medical officers and directors of business development, payer relations and strategy who attended the event. The participants represent organizations ranging from small to midsized practices to regional health plans to large health systems to national health insurance companies.

The event was held earlier this month during the annual meeting of America's Health Insurance Plans in Austin. FierceHealthcare Editor-in-Chief Gienna Shaw led the discussion.  

Payer-provider collaboration to improve the member experience

"One pain point our members keep echoing is the referral process," one attendee, a payer executive, said. "They don’t want to be their own secretary, trying to coordinate their own care … We have insight into the group’s authorization system, so that when they call our member services, we can [help them]."

As members go from one health plan to another, they want to make sure their physician is in the network. When a patient comes into a new plan, the provider they’re already seeing knows a lot about them, especially when it comes to their medications.

"We want to improve their experience by getting that information from the physician’s office, so we can get them set up on the pharmacy side," she said. "Those are the gaps that we’re trying to bridge through provider integration."

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Her organization gives each medical group information, such as how adherent their patients are to their medication regimen. "We focus on those with chronic conditions—diabetes, hypertension, cholesterol," she continued. 

That means giving providers weekly pharmacy claims data to identify patients that need extra attention.

"We guide them on the quick hits. We also stratify the membership to identify patients who need a more in-depth conversation. We help them to understand the barriers and help them over those barriers. We have some in-house programs that we do, as well, to help outreach to our members regarding medications."

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Payers can monitor patients’ adherence rate by how often they fill their medications. But just because the patient fills a prescription doesn’t mean they'll take it.

"That’s where your care management programs help to fill in the gaps," one attendee said. "Collaboration is about how you create the right incentives so everyone is moving in the right direction. It’s easy to agree to in theory—it’s hard to do."

Teaming with other organizations to improve care coordination

Seniors, in particular, like their relationship with their retail pharmacist, the group agreed.

And retailers like CVS and Walgreens can handle detailed system requests. "They can identify down to the health plan level," one attendee said. "They can implement an intervention system-wide or they can customize it to the health plan."

For example, the pharmacist can see that a member has just started a statin and counsel that patient, then follow up a week or so later to ask whether the member is experiencing any side effects.

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Retail health partnerships are a two-way street. When payers or providers refer patients in get counseling, but they’re also buying nonpharmacy products.

"They’re trying to create more stickiness with the customer that walks into their pharmacy, and leveraging the pharmacist is one of the key ways,” one attendee noted. "We’re working with the pharmacists on quality incentives. … They have to put dollars at risk and show performance on these quality measures." 

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Studies have shown that patients often form stronger bonds with their pharmacists than with their physician. One payer executive said their data show members go to their doctor three to four times a year. But they go to their pharmacist 18 times a year.

Partnering with dental providers to add preventative care 

Dentists can take blood pressure, screen for diabetes or provide a health assessment that not only helps the dentist provide better care but also helps identify conditions early on that might need treatment by the medical provider, noted another attendee.

Meanwhile, providers have information, such as whether a patient is undergoing chemotherapy, that makes it imperative for them to get dental care, one attendee said.

"Dental is a prerequisite to other conditions and health risks not taken into consideration," he said. "And there are people who go for cleanings and a checkup twice a year religiously and never go to a physical. [Dentists can] identify chronic conditions that might otherwise go untreated."

Changing patient-provider relationships to improve member experience

The relationship between payers and their members is starting to evolve as consumers pay more attention to the political landscape and as plan design shifts more cost to patients. 

"It's changing because the climate of our country is changing. We are all bombarded day in and day out by the media. And healthcare has become the hot buzzword among every consumer," one attendee said. "Our customer service reps and care managers are having conversations with our members [that are] much more sophisticated than they’re used to, because consumers are being bombarded with the news."

There's also confusion between commercial and marketplace products, she continued. And folks in Medicaid states were calling during "that whole debacle earlier in the year." 

That's led to an uptick in calls asking about what will become of their coverage if the Affordable Care Act is repealed, some attendees reported. 

"We've become part of the education process in their healthcare experience," said one.

Payers have a bigger stake in patient care now, our group of experts agreed, because of value-based propositions.

Added one payer executive: "We have to be clued into the clinical performance of our network of providers."