By using this site, you agree to the Privacy Policy and Terms of Use.
Accept
Health Works CollectiveHealth Works CollectiveHealth Works Collective
  • Health
    • Mental Health
    Health
    Healthcare organizations are operating on slimmer profit margins than ever. One report in August showed that they are even lower than the beginning of the…
    Show More
    Top News
    benefits of using protein powder to build muscles
    Protein Powder for Muscle Mass: Everything You Need to Know
    December 12, 2021
    changes brought on by blockchain in healthcare
    Technology In The Healthcare Industry
    March 28, 2022
    What Does Core Body Temperature Say About Health?
    August 17, 2022
    Latest News
    Medicare Helps Seniors, and People with Disabilities & ESRD
    November 27, 2023
    The Link Between Allergies and Sinusitis & Strategies for Relief
    November 27, 2023
    What Health Complications Can a Sunburn Cause?
    November 22, 2023
    From Mountains to Metropolis: A Guide to First Aid Approaches
    November 20, 2023
  • Policy and Law
    • Global Healthcare
    • Medical Ethics
    Policy and Law
    Get the latest updates about Insurance policies and Laws in the Healthcare industry for different geographical locations.
    Show More
    Top News
    medical attention
    The Importance of Seeking Immediate Medical Attention after a Health-Related Accident
    August 7, 2023
    Image
    Health Insurance Monopoly
    September 9, 2017
    How Obama Would Cut Medicare and Medicaid
    September 13, 2017
    Latest News
    Automation in Pharmacovigilance: A Double-Edged Sword
    November 15, 2023
    What Does Science Say About Modern Health Practices?
    November 12, 2023
    Harnessing the Power of Email Marketing in Healthcare
    October 26, 2023
    10 Proven Strategies to Level Up Your Health Business
    October 25, 2023
  • Medical Innovations
  • News
  • Wellness
  • Tech
Search
© 2023 HealthWorks Collective. All Rights Reserved.
Reading: Forming Alliances to Mitigate Risk: Payer Provider Perspective
Share
Sign In
Notification Show More
Font ResizerAa
Health Works CollectiveHealth Works Collective
Font ResizerAa
Search
Have an existing account? Sign In
Follow US
  • About
  • Contact
  • Privacy
© 2023 HealthWorks Collective. All Rights Reserved.
Health Works Collective > Business > Finance > Forming Alliances to Mitigate Risk: Payer Provider Perspective
BusinessFinanceHealth ReformHospital Administration

Forming Alliances to Mitigate Risk: Payer Provider Perspective

Abby Norman
Last updated: 2014/12/15 at 9:11 AM
Abby Norman
Share
6 Min Read
Mitigate Risk
SHARE

Mitigate RiskReaching Across The Aisle – in Healthcare?

We hear a lot about bi-partisanship in politics – but what about healthcare?

Contents
Reaching Across The Aisle – in Healthcare? Reaching Across The Aisle – in Healthcare? Agreement in Process Between Providers & PayersWhat Does Transparency Really Mean? Bundled Payments, DRGs and RiskChronic, Progressive Conditions Complicate Bundled CareProviders Shouldering More of the Risk Under ACA

Mitigate RiskReaching Across The Aisle – in Healthcare?

We hear a lot about bi-partisanship in politics – but what about healthcare? Sometimes it seems like the payers and the providers, the administrative and the clinical, are across the aisle from one another in more ways than one, and it brings to mind the challenges faced by politicians who just can’t see from the other side’s perspective.

While politics shoulders many competing agendas, when it comes to healthcare the bottom line is the same no matter where you are: good health for the best price. This is even true of the patient’s themselves, who are becoming more and more concerned with the cost of the services they receive – and using the internet to find out if there’s a better “bargain” on care somewhere else.

Agreement in Process Between Providers & Payers

For payers and providers, there has to be not just an agreement in ideals, but an agreement in process. This can be difficult to fathom when you remember that while the bottom line might be the same for everyone, the specific needs of providers, who work in a largely clinical (though, increasingly administrative) setting, are often at odds with what’s needed by those in the financial sector.

There’s a lot of talk between these two groups, but not much true communication or collaboration. Not unlike the awkward first-date, neither side knows what to do, exactly, but they aren’t totally shying away from the interaction either! To address this impasse, key stakeholders in electronic medical records are hustling to please both parties, in hopes that through the use of EMRs they’ll be well on their way to a solution.

EMRs will help to aid transparency between healthcare professionals and patients, too, which is the major buzzword of the minute when we’re talking about healthcare reform.

What Does Transparency Really Mean?

What does it mean to be transparent? For payors and providers, it means being clear and consistent about goals, needs and expectations. It also means everyone involved has to own up and take charge when something’s not working and be willing to come together to find a solution – without placing blame. For payers to understand what needs to be done, they need to understand the clinical challenges providers face. Likewise, providers need to understand what expectations are upon those in the payment sector. It requires transparency on both sides, because providers need to be open about what goals they aren’t meeting regarding their patients, and payers need to remain open about compensation and coverage, especially when it comes to Medicare/Medicaid.

In the same manner that physicians have all the clinical data, payers have the ability to provide longitudinal analytics regarding financial data and costs, and examining these ratios will give providers keen insight into performance.

Bundled Payments, DRGs and Risk

The concept of bundled payments has contributed to important risk shift within the industry with the help of DRGs (diagnosis related groups). Bundling services originally began with acute inpatient care – where the risk moved from the payer (Medicare) to the hospitals themselves. Accountable care grew from this seed of – well, accountability – within the healthcare industry.

Chronic, Progressive Conditions Complicate Bundled Care

It would be the easiest on everyone if each patient could just stick to having one condition, but as we know that isn’t usually how it pans out. Many patients not only have chronic conditions, they have multiple co-morbid chronic conditions. Since a single patient may need various bundled services over time, depending on where within an illness or condition they are on a spectrum of care needs, the burden of organizing is left mostly up to the providers – and then the payers will compensate accordingly (or, if they’ve decided not to cover certain services, they may not).

The way services are bundled isn’t always in relation to the patient’s condition, but sometimes has more to do with the setting which is required for services, or the timing or chronology of services that need to take place. When the latter is used, it can be difficult (with conditions that are chronic and progressive) to determine cost efficiency when the treatment can be, essentially, indefinite.

Providers Shouldering More of the Risk Under ACA

Just as physicians consider risk when they make treatment decisions with their patients, payers too need to consider risk adjustment as well. Understanding the relationship between the nuances in care delivery and cost, they can project out how costs will rise and prepare accordingly.

Providers are taking on more risk than they’ve had in the past when it comes to quality, cost and efficiency of care, the basis of the Affordable Care Act. But they can’t do it alone, and while healthcare organizations may be looking to shift risk, they’ve got to be mindful to not also shift blame.

Sign Up For Daily Newsletter

Be keep up! Get the latest breaking news delivered straight to your inbox.
By signing up, you agree to our Terms of Use and acknowledge the data practices in our Privacy Policy. You may unsubscribe at any time.
Abby Norman December 15, 2014 December 15, 2014
Share This Article
Facebook Twitter Copy Link Print
Share
By Abby Norman
My name is Abby Norman and I am a healthcare blogger. With over 10 years of experience in the medical field, I have developed a passion for helping others understand the complexities of healthcare.
Previous Article Add Interactivity to Your YouTube Channel: Annotate!
Next Article Navigating Cancer Faster

Stay Connected

1.5k Followers Like
4.5k Followers Follow
2.8k Followers Pin
136k Subscribers Subscribe

Latest News

Unlocking a Healthier You: Shedding Unwanted Pounds
Weight Loss November 29, 2023
hearing aids
Navigating the World of Hearing Aids with Confidence
Wellness November 29, 2023
find affordable hearing aids
Finding Quality Affordable Hearing Aids That Fit Your Lifestyle
Wellness November 29, 2023
Rhinoplasty
Rhinoplasty 101: 6 Factors To Consider Before Going Under The Knife
Surgery November 29, 2023

You Might also Like

healthcare business tips
BusinessHealth care

10 Proven Strategies to Level Up Your Health Business

October 25, 2023
medical billing training
Medicare

Navigating Through the Essentials: Medical Billing Training for Beginners

September 12, 2023
healthcare providers
Hospital Administration

How Revenue Lifecycle Management Helps Healthcare Providers to Optimize Business Operations

September 6, 2023
conducting Clinical Trial
Global Healthcare

5 Tips for Conducting a Clinical Trial

July 26, 2023
Subscribe

Subscribe to our newsletter to get our newest articles instantly!

Follow US
© 2008-2023 HealthWorks Collective. All Rights Reserved.
  • About
  • Contact
  • Privacy
Welcome Back!

Sign in to your account

Lost your password?