Achieving Value-Based Care Through the Payvider Model

An increasing number of health systems are adopting the “payvider” model, in which they provide both healthcare services and health insurance, spurred by the continued move from fee-for-service payments to value-based care and the need to stand out in a competitive market.

“The idea is to support value-based care, where there is better-coordinated care, which should drive improved health outcomes and lower overall costs,” says Matt Pomrink, industry executive adviser for U.S. healthcare at SAP.

Payviders are often at the forefront of digital transformation in healthcare because they have to provide a seamless, integrated experience for their customers.

“The more that payviders can use technology to do transactions and coordinate care efficiently, the more it benefits their organization and patients through cost savings and seamless service,” says Richard Gundling, senior vice president at Healthcare Financial Management Association.

Sentara Health’s Enterprise Data Platform Integrates Operations

At Sentara Health, data used to be siloed, but the organization’s cloud migration has enabled Skeen and his team to build an EDP that unifies care and insurance data, and serves as the foundation for the large provider’s efforts to integrate the two sides of its business and improve customer service, he says.

“The cloud was the right place to start to make data interoperable and help data flow across our platforms and connect,” Skeen says. “It’s a lot simpler and more cost-effective to do it in a cloud environment.”

The EDP, built largely on the Azure Databricks Data Lakehouse platform, has enabled many projects, including new customer relationship management software. CRM will allow call center staff at Sentara Health’s clinical access center to get a complete view of patients and members so they can provide more personalized services, he says.

Three years ago, Sentara Health standardized on Salesforce Health Cloud for patient communication and outreach. To beef up its CRM capabilities, in the past year the health system has adopted Epic’s Cheers CRM software and is integrating data from Salesforce, health records from Epic and insurance data from its payer applications. 

It's a multiphased project that will see the Cheers CRM enabling Sentara Health’s clinical access center to view all of the patient information in one dashboard, including scheduled appointments, bills and claims, and previous communications, Skeen says. Through advanced analytics, the software will also alert call center staff to make suggestions on preventive care.

“With that complete picture, we can help you with anything you need or direct you to the right place,” he says.

Sentara Health is also working to speed the prior-authorization process by building an electronic workflow between its payer and provider systems. Today, prior authorization is bogged down by manual and paper processes that can take days, Skeen says.

The new solution will enable requests, documentation and approvals to be accessed and completed electronically.

Sentara Health plans to automate authorization of common services that don’t require human review, Skeen adds. Today, 90% of requests are approved. Only 10% need staff review because they are expensive or complex services.

“I’m not saying we will automatically approve 90%. I’m saying let’s take advantage of automation, so our staff is focused on higher-value activities,” Skeen says.

Geisinger Builds Customer Portal to Integrate Platforms

In Danville, Pa., Geisinger is launching a new portal page that provides customers with single sign-on access to healthcare services and insurance. Previously, members logged in to separate patient and health insurance portals with different usernames and passwords.

For customers who use Geisinger for only one of those services, nothing will change. But for those who use Geisinger for both healthcare and insurance, a new landing page will provide seamless access to both, says Sarah Sommer, Geisinger’s vice president of digital engagement.

“When people are both a patient and health plan member, it’s confusing when the digital experience is fragmented,” she says. “Upon login, we will point them to a unified landing page that brings them a singular experience for their care and benefit information and make it easier for them.”

RELATED: Get the most out of your electronic health record through integration.

A cross-functional team that includes staff from IT, the health plan and the clinical enterprise have collaborated on the two-year project, says Amanda Jones, Geisinger’s senior director of digital engagement. The team also sought customer feedback to learn about their pain points.

When the landing page goes live in fall 2024, it will recognize when people are both patients and health plan members, prompting them to choose one username and password, Jones says.

To enable single sign-on, Geisinger used its existing identity and access management platform with additional identity verification processes, says Geisinger IT Director Mike Trelease. The power behind the new portal experience is a customer data hub that integrates patients’ health and insurance data, he says.

Banner|Aetna’s Frictionless Billing System

Banner|Aetna, a joint venture between Phoenix-based provider Banner Health and payer Aetna, continually invests in new technology to better integrate the payer-provider sides for an improved customer experience. 

“Our strategy is to improve every interaction with customers,” says Banner|Aetna COO Joanne Mizell. “We want them to get the same experience, whether they are a patient or a member. And the best way to do that is by having better connectivity between the various company assets.”

In 2022, the organization introduced a frictionless billing system that combines Aetna’s insurance information with billing details from Banner’s physicians and hospitals into one easy-to-understand statement, Mizell says. 

A big complaint across healthcare is that billing is confusing, she adds. Many customers have trouble reconciling their insurance company’s explanation-of-benefits statements with bills from their healthcare provider.

So, Banner|Aetna simplified the process by building a frictionless billing solution. Executives and IT staff from both organizations collaborated, creating new electronic workflows and integrating data between Banner Health’s revenue cycle management software and Aetna’s insurance apps.

As a result, patients today get an all-in-one statement that shows all of the billing details: what they’ve paid, what insurance covered and what they still owe, Mizell says.

“The member gets a bill that says, this is your single source of truth,” she says, adding that frictionless billing has increased member satisfaction scores.

More recently, Banner|Aetna has implemented new cloud-based case management and utilization management software, which unifies disparate data from patients’ health records and insurance information to give staff a holistic view of customers.

“When a nurse is talking to members or a hospital is trying to get authorization for services, everything is connected, so they don’t have to go to multiple sources,” Mizell says.

Through algorithms and data analytics, the software can also identify high-risk or high-cost members. Now, a nurse case manager can call those members and provide better assistance.

“There’s a deeper understanding of what their needs might be,” she says. “Rather than asking, ‘how can I help you?,’ they can provide more precise suggestions to help that member.”