Guest Column | October 1, 2015

Why Payers & Providers Are Collaborating More Than Ever – And Why Pharma Should Care

Why Payers & Providers Are Collaborating More Than Ever – And Why Pharma Should Care

By Faisal Mushtaq, president, Allscripts Payer/Life Sciences Business Unit

The U.S. healthcare industry is in the midst of evolving to outcomes-based payment models, shifting away from fee-for-service models toward value-based care. The payer-provider relationship is evolving in response. It’s a new era of collaboration among payers and providers, with the ultimate goal of closing traditional gaps in healthcare delivery.  It’s about time that pharmaceutical organizations be included in this collaboration. This article highlights what is already happening in the payer-provider relationship, and how it may help pharma engage and benefit from the collaboration.

Payers and providers have had a complex relationship. Stereotypes suggest payers want to cut expenses, while providers want high quality care (regardless of cost). Conventional wisdom says these parties have treated each other with suspicion in the past.  The same could be said for pharma-payer relationships.

But as providers become more responsible for cost in value-based-care payment models, payers are willing to offer information and expertise. Additionally, better connection of providers and their ability to share insights about practicing medicine can enrich payers’ ability to assess the quality ROI of a treatment over time.

Both sides are increasingly sharing the goals of improving quality and reduced expense. There is a more collaborative approach among payers and providers in the U.S. healthcare industry today than ever before — a trend which will likely accelerate.  Pharmaceutical companies need to be part of this discussion.  They are developing the treatments that will improve quality of life and the improvement of outcomes, potentially reducing costs to the patient and the payer.  Increased connectivity of health IT with these organizations can help bring them into the collaborative effort. 

How Health IT Enables More Complete Collaboration

For the new healthcare paradigm to be successful, this collaboration must extend beyond the payer and provider to the patient as well, primarily since the patient is starting to play a very active role in managing health outcomes and costs.

Meaningful Use has driven significantly wider adoption of health IT by providers. With such a robust community of providers, health IT can help foster innovation and connection, and not just among providers and payers, but to also include patients. Health IT can bring together parties that are traditionally on the fringes of the payer-provider relationship, such as pharmaceutical companies, research organizations and pharmacy benefit managers.  For pharmaceutical companies in particular, health IT can assist these organizations throughout their development process  by helping them optimize the selection process and automate and streamline recruiting. During an active clinical trial, health IT can automate the monitoring of participants, ensure accurate data collection, and implement alerts that could help reduce participant dropout rates.  These are all expensive endeavors, and streamlining these activities can potentially reduce development costs, duration of a study, and a new drug’s time to market.

Ultimately, strengthening these connections improves quality of care and cuts costs for everyone along the continuum. For example, it helps the industry use big data to speed outcomes-based research. As electronic health records (EHRs) mature, more organizations realize the value of the data that a connected community can capture. Solutions that can aggregate and “anonymize” data can give clinical and financial insights to providers, pharmaceutical companies, and payers. For example, pharmaceutical companies could more effectively screen provider sites against study criteria which would lead to a more optimized site selection methodology and an accelerated screening process.  Using the data for analytics, research, clinical trial management, and other purposes helps lower costs overall.

Health IT can also help with day-to-day transactions to improve clinical outcomes. From prior authorization to clinical decision support, these tools help clinicians. For example, patient education and adherence programs can help with compliance and improve results.

Technology can also help payers and providers automate manual processes. It can reduce burden and expense by creating a secure connection between them for chart audits. Accelerating the transfer of chart information can reduce administrative burden and speed payment. If it can help improve claims management and billing systems, both payers and providers appreciate more accurate, timely claims. This same technology can potentially benefit pharma organizations by providing them the ability to automatically access participant records in a secure fashion. 

Last but not least, health IT enables patients to be more engaged in their health care. An integrated set of patient engagement solutions enable improved patient education, patient adherence, and office visit payments.

By connecting all the players in the value chain, health IT can bring more innovation to the market. The industry must continue to think BIG in this space. Because the stronger these relationships are, the more opportunities we have to improve health care.

5 Gaps Health Care Can Close With Collaboration

Value-based-care models seek to minimize gaps in care, one of the key steps in better managing population health and improving patient outcomes. Add health IT to the mix, and the payer-provider collaboration is better equipped to meet challenges like these:

#1 – Are clinicians identifying enough patients who need clinical intervention? Best-in-class treatment guidelines need to be available as point-of-care alerts. Sponsored by life sciences companies, health IT can help educate providers and practices about how to use alerts to close gaps in care for patients. Gaps in care occur simply because providers cannot keep up with all the current guidelines.  It’s not intentional – they’re simply overwhelmed.  Many guidelines reflect new treatments that provide for better outcomes.  Automating these guidelines and presenting recommendations helps to raise awareness with the provider population of these new protocols. Programs can address everything from rheumatoid arthritis to diabetes to vaccines and beyond. These programs will increase awareness of potential gaps in care so that the clinician can work efficiently to improve patient outcomes.

#2 – Do patients take their scripts to the pharmacy? About 30 percent of new prescriptions go unfilled. Clinicians can provide patients with patient-appropriate medication education at the point of prescribing. This education has the added benefit of serving as a reminder for patients to pick up their medications and helps physicians achieve credit for the Meaningful Use patient education measure, in addition to driving medication first-fill compliance.  Improved compliance with treatment means that pharmaceutical companies’ products are being purchased – and better outcomes are being realized for patients. 

#3 – Can patients afford their prescriptions? Clinicians can receive an alert at the point of care if there are any coupon programs available for the medication they just prescribed. Clinicians can pass those savings along to the patient, which also increases the likelihood of first-fill compliance and adherence.  As with improved knowledge, offering financial assistance helps to drive improved compliance – the medications are being purchased and helping to fund future research for the pharmaceutical realm.

#4 – Will prior authorization (PA) delay access to medications for patients? Today’s authorization process for certain high-cost medications is often a lengthy, manual back-and-forth process among the doctor, payer, pharmacy, and patient. According to Frost and Sullivan, about 70 percent of patients who encounter a manual paper-based PA do not receive the original prescription, and patients abandon about 40 percent of manual PAs. Health IT partnerships with payers and life sciences companies can enable physicians to obtain PA electronically, leading to faster patient access to medications and reduced rates of prescription abandonment.  As with the previous two prescription points, it’s all about driving compliance.  If the patient doesn’t comply with their treatment plan, outcomes are negatively impacted and funding for future research by pharmaceutical organizations is reduced.

#5 – Does the provider have relevant patient care information from other providers? Inclusion of the Payers Health Profile in the EHR will enable and expand the longitudinal view of a patient’s health record based on claims and other data aggregated by the payer from multiple providers. In the future, this view may be offered as part of clinical trial arrangements to assist pharmaceutical companies in improving the automation of their research and monitoring efforts. 

It’s important that all stakeholders collaborate – patients, providers, life sciences, payers, and health IT companies – because that’s how we’ll succeed with value-based care. Working with all stakeholders enables clinicians to access the knowledge they need to transform health care for the better. The success in efficiencies and transparency will lead to improved outcomes, better health, and reduction in costs across the health care continuum.