Payers looking for other data sources to succeed with SDOH initiatives

Medicare Advantage plans appear to be at the forefront of pushing social determinants of health to aid in success under risk-based payment models, a new industry report contends.

However, these risk-based plans “can’t go it alone” and succeed without input from others, says RAM Technologies, a developer of enterprise software for Medicare Advantage health plans.

Providers are an essential link, not only between payers and patients, but between payers and community service organizations that help with SDOH, say the authors of RAM’s new report, entitled “Making the Most of Payer-Provider Partnerships.”

In the past, the relationship between payers and providers has sometimes been fraught with tension, and that may have been tolerable in a fee-for-service environment, but today’s risk-based payment models require flexibility and collaboration, the report contends.

“Parties that were once at cross purposes are realizing that the healthcare system cannot evolve, and patient outcomes will not improve, unless they work together,” say the authors of RAM’s new report. The report reviews success stories and highlights ways that payers and providers can work more closely together, align their interests and improve care.

"Partnerships are becoming more and more important as the Medicare Advantage program continues to evolve,” says Christopher Minton, executive vice president of RAM Technologies. “As value-based reimbursement models move to the forefront and organizations are granted greater flexibility to address social determinants of health, it is becoming increasingly important for strategic collaboration between payers and providers, to manage spending and—more importantly—to drive better health outcomes.”

Physicians in today’s risk-based market face the daunting and immediate task of learning how to use new health information technologies, data analysis and business management, while payers face growing competition and tighter margins, the report says. But the good news is, they can help each other.

“Many physicians are willing but struggling to adapt to the evolving healthcare landscape, and collaborative partnerships with payers may be the incentive they need,” the report says. Meanwhile, “payers have access to vital claims and demographic data that they can share with providers and may have expertise in business and IT that providers lack.”

Collaborative arrangements between payers and providers don’t have to be extensive. Payers can partner with specific hospitals on surgical bundles, centers of excellence on cancer care and individual providers on primary care, RAM suggests.

“Regardless of the form, all value-based models rely on communication, data sharing and advanced analytics,” the report says. “Goals and metrics should be established at the outset of any payer-provider partnership, and adequate incentives must be developed.”

More information can be found in the RAM report, which can be accessed here.