The Payer-Provider Divide: Finding Common Ground Among Frenemies - Cover

The Payer-Provider Divide: Finding Common Ground Among Frenemies

KLAS recently hosted the third annual K2 Collaborative summit for the initiative to foster communication and coordination between healthcare providers and payers. While these relationships have traditionally been fraught, the efforts of those in attendance at the K2 summit should inspire hope. They indicate that there are many in the industry who would like to move on from their status as frenemies into more cooperative relationships between payers and health systems. 

Setting the Stage

The opening keynote message was offered as an olive branch to those in attendance and helped to set the stage for a two-day exploratory mission into the root causes of the payer-provider friction. James Murray, VP of clinical informatics for CVS, opened with a discussion around the vision for CVS’ growth and future. According to James, 85% of the US population is within 10 miles of a CVS location. 

Along with the growth of CVS’ actual footprint, James talked through the company’s vision post-acquisition of Aetna. He readily admitted that while he is both employed by and insured through CVS (Aetna), it has not always been the easiest bureaucracy to navigate from the patient perspective. This difficulty, he acknowledged, extends to the relationship between providers and their payer counterparts; both sides question what the other is going to do with their data.

And while everyone involved—patients, payers, and providers—can all point to valid reasons for that distrust, James reminded the K2 group that healthcare only works when everyone is at the table. To that end, he encouraged the group to spend the next two days focused on finding the joint wins.

That was the theme that Boyd Stewart and Aurene Wilford (KLAS’ dynamic duo of all things payer-provider research) built the K2 summit on. As an aside, both Aurene and Boyd deserve to be commended for stepping into the cross fire that sometimes flies between providers and their payer counterparts. That is hardly an easy task, but it is certainly a worthy one. 

The Sherpas of Healthcare

For those who are unfamiliar, K2 is the second-highest mountain in the world. While Mount Everest often draws more attention due to its unparalleled height, K2 presents its own unique set of challenges, often considered more difficult by many seasoned mountaineers. In a similar vein, while much attention is given to policy frameworks and overarching healthcare strategies, the intricacies of crafting symbiotic relationships between payers and providers can be just as daunting and receive comparatively less focus. In this delicate balance, providers seek fair compensation for their services while payers endeavor to manage costs, all the while ensuring that patients receive quality care.

Much like the indispensable role of Sherpas in guiding climbers safely up mountains, payers and providers that have successfully forged beneficial partnerships can serve as beacons for the larger healthcare industry. Sherpas, with their deep understanding of the terrain, weather patterns, and physical demands, are crucial for the success of an expedition to K2. Similarly, when providers and payers collaborate efficiently and draw from shared experiences, they can lead the way in demonstrating how to optimize patient outcomes without compromising financial sustainability. Their collective successes can light a path for others in the industry, showcasing that even in the face of considerable challenges, the summit is attainable through cooperation, mutual understanding, and a shared vision.

That process starts with listening. As one provider attendee of the summit put it, “I want my payers to call and then just listen, not to come prepared with things they want to say but to actually just listen to our concerns and then respond.” And beyond a simple platitude, this simple change can produce amazing results.

Points of Light Presentations

The balance of the summit was taken by various Points of Light presentations, wherein various case studies were presented on how collaboration results in long-term wins for all parties involved. To read through all of them, see KLAS’ white paper on the event.

As an example, UC Davis Health, InterSystems, and Centene health insurance presented on their successful adoption of HL7’s Da Vinci guides, which streamlined the process of their prior authorizations. Their effort and success underscore not only the utility in using the tools already available to the industry but, more significantly, the value of collaboration across the payer-provider divide. 

By working together with InterSystems, UC Davis Health and Centene have achieved a more efficient and clear exchange of information by creating an automated, in-workflow authorization process. The pilot use cases have been successful and have achieved improved efficiency, reduced costs, and—most critically—more timely care and improved patient outcomes.

An Achievable Vision

The future of healthcare rests on better teamwork between payers and providers. Recent advancements and patient needs urge both sides to work together more closely. The stories from the K2 Collaborative summit show that seamless communication and mutual trust are achievable. 

To every healthcare IT professional, vendor executive, or payer leader reading this, the challenge laid before us is clear; it's time we recommit to fostering cross-sector dialogues, leveraging technology effectively, and prioritizing the patient at every juncture. The K2 summit's lessons are profound, but their real power lies in our collective action. Let's embark on this expedition together to ensure that the next summit not only highlights successes but defines a new norm for the industry.


The first K2 Collaborative Forum will be held online on October 11, 2023, at 2 pm MT. Keep an eye on KLAS’ LinkedIn for more information.