Accountable Care – The Payer-Provider Conundrum

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The majority of payers and providers continue to see clinician adoption, alignment and leadership as the top three barriers to building a successful Accountable Care Organization (ACO). Adding to these barriers is a history in which payers and providers have not always viewed each other as equal partners in the same system. In an age where market and regulatory forces are demanding more efficient care through an integrated model of finance and care delivery, it is clear that the barriers to collaboration must be breached – and the two entities must work together.

ACOs are not a set of tools and techniques that any organization can adopt; it’s a business model that changes how your organization functions collectively. Undoubtedly, ACOs are a highly beneficial improvement strategy for healthcare systems, but ACOs cannot be successful within the existing culture and structure between payers and providers. In order for payers and providers to successfully execute the ACO business and care model, three foundational elements must be achieved:

1.  Establish governance. As healthcare leaders, our first role should be to lead the people and second to manage the process. If we are consistent and effective in the first, the people will support the second. Organizations that have embraced this paradigm are proving successful in embracing the ACO model.   

Transparency is required for payers and providers to build an ACO together. To do so, payers and providers should adopt a common purpose and mission and agree upon what constitutes clinical transformation – how healthcare happens. Establishing a good governance model requires forming a legal and functional structure, forming an accountability system, defining financial and operational commitments and communication expectations, and aligning motivators.

2.  Payer-Provider Collaboration. For ACOs to be successful, payers and providers must be aware of their interdependencies and committed to supporting one another. They must seek a mutually beneficial relationship in all interactions and think in terms of opportunity rather than adversarial competition. To that end, it is helpful to have partnership agreements which clearly detail working relationships and interdependencies with respect to managing financial, clinical, operational and actuarial risk. 

In the broader definition, they must make their core competencies – administrative and population health management capability from payers and clinical delivery capability from providers – available to the other.  Underlying this collaboration will be the use and sharing of data and merging clinical and utilization claims data.  A common understanding of what defines success is required.

3.  Innovate to Improve Care. The first two points are required just to form and keep an ACO running. To sustain quality improvement and efficiency requires clinicians to be actively involved in using data to create processes that result in improved health and lower cost. Common motivators drive clinician engagement: autonomy, mastery and purpose. Although a good technology infrastructure, an EHR system and analytics provide tools for improvement, clinicians – together with individual patients – must determine the best courses of care to sustain the best results. Developing a strategy that gives them functional access to enterprise data, population data and individual patient and clinician performance data engages them in the continuous quality improvement culture.

There has never been a better time to create accountable care that integrates payer and provider expertise for the benefit of better health for all. Overcoming historical barriers and achieving a lasting foundation is the first step to achieving sustainable success.  

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