Payers Join the Healthcare Team

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Back when I was in medical training a decade ago, patient rounds were usually conducted by a group of physicians. We’d walk down the ward, visiting patients and scribbling notes as we went. If we were feeling particularly inclusive, we might bring nurses along. But that was as diverse as the care team got. Even the concept of a “care team” was only just starting to take hold on wards where highly complex patients were being cared for.

These days, the picture looks quite different. Now, in addition to doctors and nurses, we have pharmacists, social workers, therapists, nutritionists, and case managers joining us on rounds.

The care team concept has fully taken hold, and going back to the old way of doing things seems inconceivable now. The complexity of modern healthcare demands a multifunctional, multidisciplinary team that can help patients navigate not just their illness, but also the dizzying medical systems that patients face after leaving acute care.

As the cast of characters under the care team umbrella grows, there is one particular actor – heretofore almost unrecognized – that I think is poised to make a big splash on the care team stage: the payer.

“But wait!” you ask. “Surely you’re mistaken! How can a payer be a part of a care team?”

I’ll admit it raised my eyebrow, too, at first. But the more I learned, the more it made sense.

Like many docs, I often spend time after hours taking care of billing. I’ve spent many a late evening shaking my little fist at insurance companies, the government, and anyone else who might be responsible for the arcane, hopelessly complex system of codes and rules we call medical billing. I’ve also spent far too much time calling or writing to insurance companies, asking for coverage on behalf of a patient.

While I’ve always been polite in these exchanges, I’ve had some choice words when out of earshot. My relationship with payers could be most politely described as oppositional.

Imagine my skepticism, then, when I heard about a client of ours, a payer named Healthfirst, trying to collaborate with hospital physicians. They were using their claims data to provide accurate, timely medication lists to admitting inpatient physicians to facilitate medication reconciliation. Med rec is difficult and time-consuming at best, so being able to reference a single claims-based list from a payer sounded very appealing.

Healthfirst’s efforts didn’t end there, though. They also planned to provide participating providers an aggregated, consolidated view of patients’ clinical and claims data, and they’ll be sharing internally analyzed gaps-in-care information to help their providers navigate quality improvement and population health efforts.

And it’s just early days; I’m very hopeful for what’s around the corner.

So color me optimistic. While payers don’t have a direct seat at the care team table (yet), the data they can provide can give care team members a real edge at improving the quality and cost of care. Welcome aboard, I say. We need all the help we can get.

ED CHUNG, MD is a clinical advisor to InterSystems

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1 reply »

  1. Be sure to read about the principal-agent problem. You want to retain boundaries so that each side has no conflict of interest. The patient does not want to see you altering your therapy or diagnostic efforts to help the payer. The doc and patient expect fiscal tension from the real world but they shouln’t be on the payer’s side. And the payer, also, has obligations to his Boards and investors. Don’t mix the two. Your job on rounds is patient beneficence only, not trying to assuage the payer’s fiscal worries. I think it is ok to do this as long as the group doesn’t get too chummy and that you occassionally make the payer frustrated. Then you will know you are a true agent.