Jul 02 2024

4 Digital Keys to Unlock the Potential of the Payer-Provider Model

A SAP leader shares his perspective on how “payvider” organizations can take advantage of their transformative model through digital capabilities.

Earlier this year, Blue Cross and Blue Shield of North Carolina announced it had acquired the North Carolina locations of FastMed, a national chain of urgent care clinics. Another insurer, Elevance Health, had closed on a deal to buy Paragon Healthcare and its network of 40 infusion centers across eight states. And Humana also was pushing further into the provider world via a partnership with primary care provider Patina Health.

The deals are indeed coming fast and furious in the healthcare industry, collapsing traditional lines of business to create a class of entities known as “payviders” that assume the dual roles of payer and provider. Looming large over all the recent merger, acquisition and partnering activity among companies staking their future on this new, blended business model is an overarching question: Can they deliver on the promises of a seamless, higher-value patient experience and improved patient outcomes, delivered profitably?

To answer that question in the affirmative, payvider companies will need to lean heavily on digital technology; in particular, capabilities that enable them to provide a superior patient experience (PX), while at the same time integrating core processes, systems and data to connect the payer side of the business with the clinical care delivery side. The goal is to do so within a single digital environment in order to streamline operations across the enterprise (finance, HR, procurement/supply chain, workforce management, facility/operations, sustainability) so they can get a clear picture of total cost of care.

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Focus Areas for Payviders to Guide Their Transformations

Based on my experience supporting payers, providers and other healthcare organizations in their digital transformation journeys, I see four areas where payvider organizations should focus their technology resources.

1. Elevating PX: As fraught as the healthcare patient experience has been with friction and frustration, payviders promise to provide a simplified, holistic patient journey, from insurance underwriting to provision of care, claims processing and beyond — a smooth, rich, single-login experience like those we’re accustomed to from the best online retailers. Across channels, patients must be able to interact with the enterprise through their preferred modes of communication, via a single portal through which they can view and manage their entire care journey. Likewise, the people who interact with patients must have access to every aspect of each patient’s journey, including all recent and relevant patient data, so they’re fully informed and better prepared to meet the patient’s needs.

To enhance the PX, payviders must also have the means to create and align incentives across the care continuum, giving patients digital tools and resources for better preventive care and for monitoring, reporting on and managing their conditions effectively.

And because it’s difficult to improve on what you don’t measure, it’s critical that payviders have tools to map and measure the quality of the patient journey and experience.

2. Creating a fully integrated, enterprisewide digital environment: To fulfill the promise of the payvider model, business systems, workflows and processes have to be tightly integrated, intelligent and efficient on the back end. That requires having a single digital platform in which the payer side of the business and the clinical side are connected. Within this environment, payers and clinicians can work with and share trusted data (more on that below), including electronic health records and analytics-generated intelligence to better manage costs, improve processes and make better enterprise-level decisions.

From this platform, the payer side of the business can access the information it needs for underwriting, claims, business planning and the like, while the provider side can do likewise for managing patient care, supply chain and billing, all within a standardized environment — no jumping from system to system. Such a setup could reduce the mounting administrative burden placed on providers by payers, while also improving overall management of spending and revenue, as well as simplifying the process of developing, launching, refining and supporting new services and revenue streams.

3. Ensuring that current, trustworthy data flows unimpeded and transparently across the entire enterprise: Data interoperability is also critical to making the payvider model work. Having a centralized view of data (patient, financial, operational) improves decision-making, operational performance, risk management and compliance. It also supports a better PX.

4. Improving workforce management capabilities to better control labor costs without compromising quality of care and PX: In 2024, higher labor costs are the biggest driver of margin pressure for health systems, according to a CFO survey conducted by the Healthcare Financial Management Association. Using intelligent workforce management tools powered by AI, payviders can more effectively tap and manage various labor pools for the entire enterprise, including the clinical workforce, where labor is particularly scarce and costly.

By 2026, according to a 2023 analysis from IDC, 55 percent of worldwide private health insurance companies and 75 percent of U.S. health systems will evolve into payviders. As competitive as that space likely will be in coming years, those that arm themselves with a strong digital foundation are bound to have an edge over those that don’t.

UP NEXT: How does clinical workflow optimization create better patient outcomes?

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