Effective collaboration between payers and providers can be challenging, particularly as more people receive care outside of the hospital and providers shift to reimbursement based on quality of care, rather than volume.
However, there are opportunities to boost collaboration by building a data-driven network, panelists concluded during a Sept. 15 webinar hosted by Becker's Hospital Review and sponsored by Xsolis.
The panelists — George Renaudin, senior vice president of Humana; Joan Butters, CEO of Xsolis; and Doug Ghertner, CEO of IVX Health — covered topics discussed the primary obstacles to payer-provider collaboration and how artificial intelligence can help overcome those barriers.
Four takeaways from the discussion:
1. Asymmetry and latency stand in the way of improving payer-provider collaboration through data. For example, payers and providers may not have the same information and datasets about a member or patient, noted panelists. Additionally, time delays can occur before data is transferred to a provider or payer, causing one to receive information sooner than the other.
2. Data inefficiency creates opportunity through technology, such as Xsolis' artificial intelligence platform, Cortex. Cortex specifically addresses operational challenges of managing utilization review, the process that helps hospitals determine appropriate care levels. Ms. Butters said Xsolis saw subjectivity in medical necessity determinations as well as waste related to the repetitive and duplicative efforts of payers and providers. However, "the application of data, AI, data-sharing helped us to formulate and focus on a data-driven network between payers and providers to do this process, to manage the UR process a little differently," she explained. Ms. Butters said Cortex interfaces in real-time with hospitals' EMRs — and processes and standardizes data — to create a clinical picture of the patient or member's condition.
3. The pandemic has created opportunity, in terms of payer-provider communication. Mr. Renaudin cited a recent example involving Humana and a health system in the Northeast. He said Humana was concerned with COVID-19 in the New York City area and wanted better idea of what members at the system were experiencing. Through Cortex, Humana was able to see where patients were being admitted and discharged. "Just as we have found COVID accelerated the move to telehealth, COVID changes the way you start thinking about things, and you can start thinking more broadly and deeply about how you can change the way you interact and the way you can drive better data and information," he said. "I think that communication layer and the ability to communicate in real time is going to open the door to all sorts of ways we can collaborate better between payers and providers."
4. Payers and providers should change the lens through which they're viewing technology decisions, according to Mr. Ghertner. He recommended thinking about technology in terms of whether it will spur better internal decisions and whether it can be pushed out to other healthcare partners to help them make better decisions. "I think the more we look at things with that mindset and the more collaborative we can be, I think the more successful we'll be, and I think that creates great opportunity and potential for the future," he said.
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