From left to right: Josh Berlin, CEO of rule of three, LLC; Sunita Koshy-Nesbitt, chief quality officer for the hospital channel at Texas Health Resources; Steven Stepp, chief data officer at Blue Cross and Blue Shield of Kansas; and Samantha Roushan, senior vice president of clinical transformation at Cohere Health
The relationship between providers and payers has been historically contentious. After all, the nature of this relationship inherently puts both parties at odds — providers desire to get paid for all the care they deliver, and payers want to keep their costs down as much as they can. In recent years, the chasm between providers and payers has grown even wider, due largely to administrative burden.
During a panel discussion held Thursday at MedCity News’ INVEST Digital Health conference in Dallas, three executives representing a provider, a payer and a technology vendor shared their thoughts on how to heal the rocky relationship between hospitals and health plans. Below are three key lessons they offered to the audience.
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Don’t be afraid to relinquish some control
Both payers and providers want the prior authorization process to be more streamlined, but in order to achieve that, they both have to “give up a little bit of control,” said Samantha Roushan, senior vice president of clinical transformation at Cohere Health, a startup offering a platform to simplify prior authorization.
“One of the key elements of our technology is that we’re able to auto-authorize the vast majority of prior authorization requests. When I talk about control, that means that you know those cases are not being reviewed in detail. We’re applying our AI technology responsibly to solve this problem,” she explained.
With this kind of automation software, payers and providers can reduce friction in their relationship simply by decreasing the frequency with which they need to talk to one another, Roushan added.
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Adopt tech that aligns with both parties’ goals
In its ACO, Texas Health Resources has taken on the full risk for readmissions, said Sunita Koshy-Nesbitt, the organization’s chief quality officer for its hospital channel. She noted that the technology platform Texas Health Resources has implemented to reduce avoidable readmissions in the ACO does a good job of helping keep costs down because it has the best interest of the provider, payer and patient in mind.
“From a tech standpoint, what was really helpful was that the technology aligned to both parties,” she declared. “If I saw a patient in my hospital a week ago, and then my computer pings and my MA sees that my patient literally just hit the emergency room 10 seconds ago, I can intervene at that point. If I just saw the patient a week ago, I’d like to call the ED and say, ‘No, don’t admit this patient — we’ll see that person tomorrow at three o’clock,’” Koshy-Nesbitt said.
Having a system in place to prevent unnecessary, costly emergency department visits helps both providers and payers reduce costs, she explained.
Build comprehensive risk models
The relationship between payers and providers is often plagued by information asymmetry, meaning one party possesses more information than the other, pointed out Steven Stepp, chief data officer at Blue Cross and Blue Shield of Kansas. “A lot of folks” underestimate how much friction and inefficiency this causes, he said.
“How do we solve that information asymmetry? We’re not going to tell the providers to stop generating data or tell the payers to stop accumulating data. I think the boundary object is around risk. One of the things that we bring to the table, as far as payers are concerned, is that we wouldn’t be in existence without determining risk,” Stepp declared.
Payers and providers need to get on the same page when it comes to calculating risk for the specific populations they serve, he noted. Using a shared, comprehensive risk model will lead the two parties toward information symmetry and make their relationship less antagonistic, Stepp argued.
