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Payer Executive Q&A: Navigating the Payer-Provider Relationship

By Tara Fragiacomo

As the healthcare industry continues the shift from fee-for-service to value-based care, it’s important that payers and providers work together to get the most out of their partnership. Both must adapt and innovate to meet members’ needs—this includes optimizing care delivery, leveraging reimbursement and payment mechanisms, and using every tool to their disposal, including telehealth and remote monitoring

We sat down with Helion’s Director of Network Management, Ken Burkholder, who provided insight around telehealth adoption, value based care contracts, and sharing member data with the provider. 


Factors Influencing the Use of Telehealth

Q: How can payers support a provider in using telehealth solutions to improve care and lower costs?

A: Payers are not in a position to deliver care, so they rely on providers and clinicians to treat their patients. 

Innovative payers have started to think not only about how to discourage unnecessary care, which often leads to higher consumer costs, but also about how to encourage care decisions that lead to lower costs and better outcomes.

One of the most effective ways payers do this is by shifting incentives from volume to value through payment and contract levers. Oftentimes, this comes with less prescription and more flexibility for the provider in return for taking the financial downside for outcomes. 

Download the eGuide: 6 Reasons Why Telehealth Makes Sense for Payers

Value-Based Care Contracts

Q: What are some of the reasons that providers are reluctant to value based care contracts? 

A: Although there has been an impressive level of adoption in the post-acute provider market, there are still a number of reasons providers may not want to sign value based contracts.

Some reasons include:

  • Lack of data: Information asymmetry is a huge challenge for the payer-provider partnership. If a provider doesn’t truly understand where their focus needs to be for success, it is highly unlikely that they will be comfortable with shifting incentives. Payers can help alleviate these concerns by striking the right balance between the amount of non-actionable and actionable data shared, with a strong preference toward the latter.

  • Uncertainty about readiness and maturity: A provider can simply feel as if they are not ready to move to a value based model. This can be due to a sense that adopting the model will be more challenging with a lower likelihood of financial success, require more administrative burdens for reporting, or that they will not have time to learn about the new initiative fully.

    Often, payers, including CMS, understand the need to pace innovation with market readiness to maximize adoption and create program roadmaps. Pacing innovation can start with upside-only models that move toward risk deals in later stages, or beginning more upstream with a period of data sharing without payment impacts. 

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  • Reimbursement challenges: Until a majority of a provider’s volume is reimbursed under a value based contract, it’s difficult, or often financially impractical, to make the sort of changes needed to maximize performance. With a broader shift to value based care, these challenges continue to decrease but still exist, especially in provider segments outside of primary care and hospitals.

    There are two ways to solve this: one, focusing priority deals where there is concentrated volume; and two, crafting programs that require less transformative changes to realize an incremental, but not overly substantial, financial upside. 

Sharing Member Data

Q: Between the payer and provider, do you think there is willingness to openly share member data?

A: It’s important to consider where there is strong alignment first—the member and patient. Whether an organization’s job is to deliver the care or manage the payment it’s highly likely this common ground exists. 

Health care is a unique industry where everyone can win. The payer wins through optimized utilization and lower premiums to spur growth. The providers win through higher revenue and more flexibility and time to deliver good patient care. The patient wins through higher quality outcomes and affordable healthcare. The idea of how the payer, provider, and patient can win is something everyone must believe in in order to achieve the transformation in healthcare that is needed.

Most payers want to share data that will lead to insights and action on the part of the provider, but understand that it must be done in a measured fashion. Some providers may be ready through their expertise, technology, and deployment mechanisms to absorb, digest, and take action from claims data.

The payer and providers must work together to decide which data elements are most valuable for the provider to identify the changes needed to optimize patient outcomes. By doing so, the payer and provider are both doing what they do best for the benefit of the patient.


Download the eGuide: 6 Reasons Why Telehealth Makes Sense for Payers

Tags: cost savings, reimbursement, Payer, Industry trends, Access to care

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