The whole healthcare continuum benefits when payers and clinicians collaborate

By Carley Thornell | January 19, 2022


Putting the decision-making and economic purchasing power in the hands of patients used to mean that the health industry focused more on simple, consumer-friendly technology solutions. But that’s changing. In a recent survey of provider, health plan, and life sciences executives, more than 9 out of 10 said improving the clinician experience was among their top priorities, according to PricewaterhouseCooper’s Health Research Institute (HRI). Clinician satisfaction is especially important as the nation’s battle with COVID-19 continues – and exacerbates physician burnout in many instances.

But the pandemic may have opened up opportunities, not just challenges. Seventy-three percent of executives surveyed by HRI said they were starting to or have plans to collaborate with other care providers and payers as a result of the pandemic. Such collaboration will ultimately benefit the whole healthcare continuum, yielding healthier consumers, more informed clinicians, and cost savings.

Information about costs is “critical” at point of care, say clinicians

The cost of medical care and transparency surrounding it is top of mind for Dr. Paul Carlan, president of Valley Medical Group in Massachusetts. He recently shared his insights as part of an athenahealth symposium centered on the future of payer-provider collaboration. “Information about cost of care is critical to have at the point of care,” he said. “When we refer a patient to a specialist, or when we send someone for an imaging study, we don’t know what that costs. And our patients are extraordinarily sensitive to that.”

Physicians like Carlan have seen progress recently when it comes to estimating out-of-pocket medication costs. Medication abandonment contributes to nearly $300 billion in avoidable healthcare costs and 125,000 potentially avoidable deaths; one of the main reasons patients abandon treatment is the out-of-pocket price tag on medications. Digital partnerships across the healthcare continuum like real-time benefits checks for patient-specific prescription pricing information promote better adherence — and better experiences for patient and provider alike. The downstream effect is a reduction in administrative tasks that contribute to burnout, like pharmacy callbacks and prior authorization approvals. Clinicians can keep encounters focused on patients’ clinical wellbeing instead of their financial health.

Michael Palantoni, athenahealth vice president of platform services

New regulatory requirements that go into effect soon could offer even more traction when it comes to increasing cost transparency and reducing friction across the healthcare continuum. Requirements of payers in the Transparency in Coverage Final Rule include disclosing to the public in-network provider negotiated rates and historical out-of-network allowed amounts. They also require disclosure of cost-sharing information including an estimate of a participant’s cost-sharing liability for covered items via an online tool and on paper, or by telephone. The former goes into effect mid-year and the latter requirement will be phased in by specific items and services starting in January 2023.

The Rule follows the Hospital Price Transparency final rule, which requires hospitals to make public a variety of pricing information. Organizations like Hollywood, Fla.-based Memorial Healthcare System rolled out patient-facing price estimation capabilities in 2014, which provides out-of-pocket cost information for 300-plus outpatient procedures, diagnostic services and physician visits (and what’s included in the quote). Matt Muhart, Memorial's executive vice president and chief strategy officer, says an analysis of 300 quotes yielded $1.5 million in revenue. While that can’t be fully attributed to the tool, Muhart believes the functionality engaged patients and provided a better consumer experience — and may have even brought in patients who otherwise would not have considered MHS.

Technology will help create a more informed, curated experience

Michael Palantoni, a symposium presenter and vice president of platform services at athenahealth, believes the clinician experience is intrinsically linked to that of the healthcare consumer. “If you really think about how 50 percent of the downstream cost of care comes from the primary care physician, arguably the most important shopper for care is the primary care physician,” he said, citing McKinsey research. Palantoni says that enhancing clinicians’ experiences to pull in costs, quality, and network guidance – especially within native workflows — needs to be a priority.

Transitioning from data dumps to the proper balance of transparency and information curation were among clinicians' top goals shared with athenahealth and payers. Rick Foerster, senior vice president for value-based operations at Privia Health, says that clinicians can lack a complete picture as to where they are sending their patients. “That information is really not easily available, and it’s hard to get to, even sometimes as a patient,” he said. “We're trying to create a more informed experience, where that doctor, when they're making their referral, they understand that network status, quality, and cost status. For doctors, that better experience resonates with them a lot.”

Taking the onus of that homework off clinicians so they can focus on visits ultimately makes for a better encounter, whether someone sits on or beside the exam room table. HRI finds that 73 percent of provider executives and their organizations are working on improving the clinician experience by automating administrative tasks. They are not alone. The think tank expects more investment by payers in process automation, citing automated provider contracting and/or credentialing. Enhanced portals will give clinicians insight into claim processing, or straight-through processing to automate handoffs between different systems, they write.

As for now, the pandemic has accelerated some payers’ efforts to reduce administrative burden. Louisville, Kentucky-based Humana has prioritized easing up on prior authorizations (an initiative the company was already working on). They also made claims processing “easier and faster” for providers to get paid more speedily. Administrative burden among the company’s employees is a focus as well, and Humana uses artificial intelligence and automation so that bots can help associates serve members more quickly and easily.

It’s clear that no matter what one’s role is in the healthcare continuum, everybody wins when the pace of innovation matches the speed of need to so rightfully right the ship, and make the clinician-patient relationship a top priority.