Collaboration is key To achieve quality clinical and financial goals, physicians participating in MA plans need access to patients’ medical information from across the continuum, which is typically not included in an individual provider’s EHR. With a more complete medical record, the delivery of care can be safer and more effective, and costly duplications in service can be minimized.
However, physicians don’t always have ready access to comprehensive records from other providers — though payers do. With MA and other risk-based plans, payers and providers must collaborate so that physicians have access to critical medical information and are empowered to drive quality outcomes.
Providers also control access to payers, which is another reason payers should be motivated to collaborate with providers. However, in regions where a provider holds a large percentage of the market, the provider may be less inclined to cooperate with payers or participate in an MA plan. Instead, the provider may prefer to leverage the health system’s volume and hold onto their historical fee-for-service strategy, thus preventing collaboration with payers. A provider with a larger market share also has more power, which is one reason health systems continue to consolidate in many regions.
Compare that situation to the position of smaller second- and third-tier health systems with smaller market shares. These organizations are facing more pressure to move into value-based arrangements and are more likely to move forward and embrace models that require payer-provider collaboration. Smaller providers are at greater risk of seeing their margins erode because CMS reimbursements aren’t rising as fast as inflation and they do not have the market share to negotiate a higher rate from payers. They recognize that they are better-positioned for success if they enter the MA market in partnership with a strong collaborative payer that puts the patient first, is committed to the elimination of waste, and strives to deliver quality patient outcomes.
The pace of change is accelerating Changing long-established routines and behaviors takes hard work and requires time. Payers and providers have been slow to collaborate, both fearing that a closer alliance could in some way jeopardize their success, based on their historic adversarial relationship.
But the pace of change is escalating. CMS continues to introduce initiatives that promote MA and other value-based programs. Outside investors and venture capitalists are becoming more interested in value-based opportunities and infusing new money into the market. Technology is also advancing and making it easy to liberate patient and population data from multiple sources.
