Creating "members for life" is the ultimate goal of any payer's customer loyalty effort. Competitive rates are one strategy to enhance loyalty, but in today's landscape of consumers who expect more engaging and cost-effective care, the proof is often in better health.
While cost is important to consumers, it's not always the determining factor for choosing a health plan. Consumers also consider options that promote more convenient and effective care, especially for those with chronic conditions who have long faced the frustrations of a fragmented health system -- namely, uncoordinated care and high costs. Simply put, the best way to attract and retain customers is to facilitate innovative partnerships which promote and support strong care delivery environments that allow people to preserve or regain their health.
Payers who understand the shift occurring within new risk-bearing care delivery models realize that population health management is not just a provider responsibility. While the preventive PHM "action" to better engage patients in their care does occur at the provider level, getting these initiatives off the ground successfully will require a collaborative effort between providers and payers.
Transparency is the name of the game, and payers will need to show how providers in their plans are helping consumers actively manage their health, increasing the efficiency and effectiveness of care. Moreover, consumers increasingly will demand care on their terms -- not just at the convenience of their providers. Those in the industry willing to respond will come out on top.
Improving payer-provider collaboration
The opportunity for cooperation between providers and payers exists on numerous levels. Moving from a fee-for-service mindset to one that places quality at the forefront requires a willingness on the part of payers to become more transparent with patient data, provide incentives to decrease utilization and partner with providers to implement PHM initiatives.
Consider a Medicare plan, for example, where payers have the opportunity earn bonuses by achieving quality metrics through active disease management. In order to do this, they must get providers to build PHM programs that can support quality-driven care delivery. In other words, relationship-building must occur between providers and payers in a way that aligns PHM goals at the negotiating table. Providers will be much more willing to move from a fee-for-service model if reimbursement evolves to positively impact the bottom lines of those who decrease utilization.
All of this means that although payers and providers have been hesitant to share patient data in the past, they will need to share real-time, comprehensive data going forward, including historic claims information. Critical to PHM will be the tools necessary to promote active, open relationships with providers, as well as similar tools to engage consumers. Payers can help equip providers with these tools by partnering to sponsor infrastructures that open the lines of communication and meet consumers wherever they are in their healthcare journeys.
Getting collaborative initiatives off the ground
Consider a not-so-uncommon scenario within the current fragmented healthcare system: A patient is referred to a regional medical center specializing in high-risk pregnancies. After waiting two hours for a scheduled appointment, the patient is seen by a physician who has no background information on the patient's condition and no clear understanding why she has been referred.
These kinds of frustrating, time-consuming scenarios must be eliminated in order for payers and providers to both retain customers and function in the risk-bearing environment. When an advanced technology infrastructure exists that can deliver real-time, comprehensive patient data between payers and providers, care delivery becomes more proactive and effective--and thus patient experiences are enhanced. If such data was readily available, patient care would become that much more targeted with informed decision-making and collaboration between payers and providers for improved outcomes.
Healthcare organizations must be equipped with the capability to glean key patient data from all disparate systems and present it in a meaningful way to care management teams. Workflows and change management are equally important and cannot be overlooked. Payers and providers should approach these strategically by considering such factors as the patient populations served, the potential outcomes of risk arrangements, and the skills and tools needed to perform optimally.
When PHM initiatives are organized as a true payer-provider partnership, effective shared savings plans can be built and deployed in a sustainable, innovative way. By developing a robust infrastructure, shared decision-making, trusted patient-provider relationships and a variety self-management tools offered across mobile networks, PHM programs will be poised for success.
Ultimately, the future of successful population health management rests on stakeholder alignment and collaboration. Payers and providers must align their ideologies and priorities around the health of their consumers in order or effectively provide top-notch healthcare while remaining successful in the business arena. This alignment is a must in order to succeed in population health management and empower payers, providers and consumers to actively participate in patient-centric care models. Payers must proactively increase their momentum to align with physicians and consumers to create true value.
Drew Kraisinger is the vice president of strategy and innovation at Medecision.