Payer/Provider Summit 2022 White Paper
Bringing New Energy and Direction to Payer/Provider Collaboration

The purpose of the event was threefold:

This white paper covers three different sections, listed below. Click the links to jump directly to each section’s insights:

1. Findings from the summit discussions and poll

2. The goal, scope, and key findings of KLAS’ payer/provider measurement

3. An overview of the payer/provider/HIT vendor partnerships that received a 2022 Points of Light award for their efforts to collaboratively reduce friction between payers and providers

Evolving into a Collaborative

Forming the KLAS’ Payer/Provider Initiative was KLAS’ first step toward bringing payers, providers, and HIT vendors together to address the billions of dollars wasted each year in avoidable healthcare administrative costs. However, after hosting two successful summits, publishing the first Points of Light report, and distributing the first Points of Light awards, KLAS believes this initiative must evolve to reflect the collaboration necessary to solve mountainous insurance issues and improve the patient experience.

Why K2?

K2, a mountain located in the Karakoram mountain range in Asia, is one of the most difficult and dangerous mountains in the world for climbers to summit. Second only to Mount Everest in elevation, K2 has been summited only 377 times (as of February 2021), a mere fraction of the thousands of times Everest has been summited. More people have been to outer space than have reached K2’s peak.

Like the mountain, the friction and financial waste among payers and providers may feel insurmountable; however, KLAS (the “K”) and payers and providers (the “2”) can work together to summit these immense challenges. And the payoff will be worth the climb.

What about HIT Vendors & Other Organizations?

The success of the K2 Collaborative will ultimately be driven by payers and providers. However, just as climbers need the right equipment and guides to summit a mountain, these two parties also need help from HIT vendor partners and other organizations, who provide tools and experts that streamline the journey. For more about how vendors and other organizations are partnering with payers and providers today, read the Points of Light case studies at the end of this white paper.

Summit Discussion: Removing Hurdles Surrounding Value-Based Care

Summit participants were asked to discuss the following issues regarding the healthcare industry’s shift to VBC:

This data shows the following:

• VBC is viewed as the preferred environment for payer/provider collaboration. Since the 2019 summit, an increased number of attendees agree that moving to VBC can do more to improve payer/provider cooperation than anything else. However, a majority of attendees believe that successful collaboration is still possible in a fee-for-service world. Provider attendees are the most optimistic about this possibility, followed closely by payer attendees and then more distantly by HIT vendor attendees.
• Similar to 2019 results, most 2022 attendees agree that in 10 years, VBC will be the main care-delivery and financial model. However, they don’t believe VBC will be a silver bullet to solving payer/provider friction—all 2022 attendees agree that payer/provider relationships can still break down in the VBC world.
• Across parties, confidence remains high that HIT vendors can play a key role in building alignment. Interestingly, among payer and provider respondents, agreement is lower than it was in 2019. Payers and provider organizations often tell KLAS that leveraging HIT vendors is difficult when there is a lack of trust and relationship between the payer and the provider organization.

Key Question: How Do We Remove Hurdles and Accomplish the Quadruple Aim?

To answer this question, summit attendees brainstormed during tabletop discussions. To move toward VBC and accomplish the Quadruple Aim, attendees suggested the following:

Standardize: Standardize tools, definitions, shareable data, data formats, rules of engagement, and transactions.

Align: Work toward better alignment around incentives, goals, measurable clinical outcomes, services rendered, the payment of services, and the definition of risk.

Build trust: Start small and solve individual problems. There is more risk in the VBC world, so transparent communication and policies are critical.

Share data: Explore ways to share data, including integrating claims with clinical data, using a bidirectional exchange, and determining how to implement more relevant and timely payer data into providers’ workflows.

Get patient buy-in: Measure patient satisfaction and provide more education support services and incentives for patients.

During the discussion, one group of attendees shared the following insight: “We are trying to redesign a fragmented system that was built with competing incentives. If we were building from scratch, we could figure things out more easily, and prior authentication likely wouldn’t have existed. Fee-for-service and value-based care are so fundamentally different. We are trying to build value-based care in a fee-for-service structure. We have to build with the patient at the center. We are trying to determine how to tear things apart and put them back together. We are solving micro problems, but we want to make sure things are scalable. The fee-for-service and value-based care models will have to live side by side for a while.”

What Are KLAS’ Next Steps?

1. Increase number of Points of Light award recipients: We will continue to highlight the provider organizations, payers, and technology vendors who have found success via partnership and collaboration. We will be looking at innovation, creativity, and scalability to determine how these collaborations are improving the patient experience and reducing friction. To submit your story, please email us at POLCollaboration@klasresearch.com.

2. Encourage regional collaboration: We will work closely with region-specific provider organizations and payers to identify how to increase partnership and reduce friction in their respective regions. This will include regional summits as well as qualitative and quantitative measurement.

3. Continue with the payer/provider measurement: We will continue to refine the payer/provider measurement and include region-specific findings with our national benchmarking data.

Payer/Provider Measurement: Creating Visibility and Transparency

As part of KLAS’ K2 Collaborative, provider organizations are invited to participate in the payer/provider measurement by anonymously measuring each of the top commercial payers their organization uses. KLAS will collect, aggregate, and analyze the data and then report the results back to the industry. In March 2022, KLAS completed a pilot study for our first payer/provider measurement. At the summit, we shared initial findings, and summit attendees were asked to provide feedback on the existing scope and quantitative and qualitative metrics to help fine-tune the measurement. The following sections outline the goal of the measurement, the current scope and metrics, initial key findings, and attendee feedback.

Current Scope of Payer/Provider Measurement

• Data is from March 2021–March 2022
• Participating organizations are located across the US but are mostly in the Midwest and Eastern regions; no particular region was a focus for this study
• 11 participating provider organizations (KLAS will gather payer perspectives in future phases of the measurement)
• 7 health systems with acute care and ambulatory care data
• 2 health systems with only acute care data
• 2 large ambulatory practices
• 32 participating payer organizations (74 unique payer/provider partnerships measured)
• All payers are commercial organizations

Quantitative Metrics and Definitions

Qualitative Questions about Payer Relationship

In addition to providing the quantitative metrics above, respondents were asked the following supplementary questions about their relationship with their payer partner.

1. For each of your top commercial payers, how would you rate the following (on a 1–9 scale)?

• Proactivity in working to build trust
• Transparency and understandability of rules or policies
• Ability to share data bidirectionally
• Efforts to reduce laborious manual processes or human errors (e.g., developing new technology, partnering with technology provider)
• Ability to update their governance structures and processes to support innovation in a timely fashion
• Timeliness of communication

2. What is the most impactful thing your payer has done to reduce friction and improve efficiency?

3. What is your payer’s biggest missed opportunity in terms of reducing friction and improving efficiency?

No national payer organizations are leading the way with provider organizations, though provider-owned health plans stand out. Of the five payers with above average metrics, three are provider-owned health plans. All three payers report they had to go through a long process to establish mutual trust.

“Our payer definitely has a cool story. Two or three years ago, they used to be our worst payer, but they have come a long way. I think that is because of the approach we have taken with our payer; we have shifted to a risk agreement with a shared responsibility to care for patients and be a good steward of their healthcare costs. Removing administrative burdens, complexities, and waste on both sides should be top of mind for both payers and providers. If we can’t operate more efficiently, we aren’t going to make it.” —Senior director of financial services at a health system

The percentage of A/R over 90 days is higher than average for most of the payers who partner with multiple provider organizations. This is often due to payers requesting more information from provider organizations and then taking time to respond. Provider organizations do not speculate about why there are delays, but they mention the payers seem to be experiencing staffing shortages and backlogs.

Of the payers who partner with multiple provider organizations, Payers 5 and 29 are mostly in line with or better than the average. Initial findings indicate that the provider organizations who partner with Payer 29 and report better-than-average metrics also perform well across all the payers they work with. These provider organizations report their success is being driven largely by their internal efforts—reported best practices include regularly communicating with payers, allocating the right number of resources to tasks, and retaining a payer consultant when needed.

“We have allocated appropriate resources around developing relationships, and we maintain constant communication with the payers. We make sure there are checks and balances and that the payers are applying the correct fee schedules and policies. It is great to have extra individuals who are working on these things, but at the same time, there is an added FTE expense for the extra layers we have built in.” —Executive director, patient financial services

KLAS learned from the qualitative interviews that both healthcare providers and payers recognize that it will take time to resolve existing issues; however, they believe working toward a solution is well worth the effort and investment in the long run.

“We had conversations around how much time things were taking and how many data sharing and administrative burdens there were. People believed that was the status quo. We looked at how many times provider organizations were moving people into offices and chart rooms and how often they were moving someone away from patient care and assigning them to payer administration. We hope to help reallocate staff back to overseeing patient care and not administrative burdens.” —Director of a large payer organization

Feedback and Next Steps

After KLAS presented the scope and metrics of the payer/provider measurement at the summit, attendees were asked to provide feedback on the scope, suggest additional VBC-based metrics, and refine the definitions of the current metrics. KLAS recommended that any newly proposed or updated metrics should be:

Actionable: Both parties should be able to use the data to have meaningful conversations and start making changes.

Digestible: There should be no information overload.

Standardized: Organizations should be able to pull the metrics with clearly defined definitions and no ambiguity.

Easy to pull: Provider organizations should be able to pull the same data regardless of their technology/services partners.

Summit attendees provided a lot of helpful feedback, and the most mentioned suggestions are listed below. KLAS intends to finalize next steps and begin broader data collection based on the updated metrics and scope.

Use data from standardized measurements of patient satisfaction (e.g., NPS, CMS Star ratings, HCAHPS)

Pull patient experience data (e.g., estimated costs, patient access to care, no-show rates, quality of care)

Measure administration efficiency, especially prior authorization timeliness and turnaround (e.g., time from authorization to approval, percent of authorization denials overturned, delays in treatment due to payment/prior authorization reasons)

2022 Points of Light Awards

As part of the K2 Collaborative, the annual Points of Light awards celebrate success stories—or “points of light”—from payers, providers, and vendors who have partnered to reduce costs and inefficiencies and improve the patient experience. Fifteen such collaborations were awarded a 2022 Points of Light award, and overviews of their strategies and outcomes are shared below to illustrate the art of the possible. Additionally, each collaboration includes a review from KLAS’ payer/provider advisory board, which consists of five well-respected experts in the industry: Glenn Raley (Director of Provider Interoperability Product Management at Humana), Neil Kulkarni (VP of Customer & Clinician Experience Solutions at Highmark Health), Rachel Verville (Chief Revenue Cycle Officer at Allegheny Health Network), Todd Craghead (VP of Revenue Cycle at Intermountain Healthcare), and Victoria Losinki (VP of Quality & Risk Adjustment at Blue Cross and Blue Shield of Minnesota). Each review from this group—dubbed “The Fab 5”—details the uniqueness of the case study and the organizations’ impact on the industry. See the Points of Light 2022 report for in-depth case studies of each collaboration.

Executive Summary: Seeking to provide a simplified billing experience for patients and reduce administrative costs, Payer Organization 1 and Healthcare Organization 1 teamed up with Cedar to create a unified patient bill that combines the health system’s billing with the payer’s explanation of benefits. The payer and healthcare organizations also integrated their customer service. By working collaboratively and leveraging Cedar’s patient financial experience technology, the organizations were able to achieve improved member/patient satisfaction, higher collection rates, and reduced costs. The participants emphasized the importance of building trust and letting go of past narratives that didn’t serve the common goal.

Fab 5 Review: The uniqueness of this case study is the payer’s and provider organization’s commitment to come together to collaboratively craft an approach that puts the patient/member needs at the center of the solution. As the case study mentions, it is often difficult for these stakeholders to put aside biases based on past experiences or assumptions. The ability to eliminate biases and build trust was essential to ensuring that the crafted solutions truly did support patient/member needs. The confusing billing experience described in the problem statement is a long-standing, extraordinarily frustrating dynamic that has long created distrust and confusion for patients/members. The healthcare industry must come together to eliminate this unnecessary point of friction that negatively impacts patients/members, often when they are in the middle of a stressful health crisis. This approach is a winner.

Executive Summary: Spectrum Health partnered with Priority Health to tackle two areas of inefficiency that were causing employee frustration and reducing productivity: the credentialing turnaround time and the denials process. A workgroup that included representatives from both stakeholder organizations was formed to identify areas of friction in these processes and to implement solutions. The results include improved member/patient satisfaction, increased staff productivity, and reduced denials. The collaborators note that success came as they were willing to fully commit to the project and work amicably on a shared objective.

Fab 5 Review: Most notable in this case study is the demonstrated willingness by both the payer and provider organization to engage in active conversation in order to solve a problem. The process of credentialing a new provider involves several handoffs which are dependent upon each other. Provider organizations are eager for new providers to begin offering care soon after the onboarding process. There is increased friction on both the payer and provider side when this process breaks down. This case study demonstrates that when effective collaboration exists between the payer and provider organization, positive outcomes can be achieved, which will increase overall patient/member satisfaction.

Executive Summary: In response to a growing volume of clinical-data requests, the collaborators in this case study worked together to streamline and automate the chart-retrieval process. Using a 100% digital chart-retrieval solution from Moxe, Payer Organization 3 is able to access complete, accurate clinical data from Novant Health and Healthcare Organization 3. By bringing all stakeholders to the table and creating relationships of trust, the collaborators have been able to improve satisfaction among members/patients, reduce frustration and manual work for the healthcare organizations, and improve ROI for the payer.

Fab 5 Review: It is unique that the payer and provider organization worked together to evaluate, select, and implement a technology vendor partner to support chart retrieval and transfer protocols. This approach ensured that the technology solution met the needs of both sides, that the data would be normalized appropriately as part of the exchange, and that all payer and provider stakeholders negotiated accountability and responsibility. The largest impact on the industry is the reduced effect of administrative burdens on patient care. As noted in the summary, increased time, effort, energy, and cost focused on administration detracts from investments in care. Minimizing the burden of data exchange will allow payers and provider organizations to focus on the value in value-based arrangements, thus improving quality and patient health outcomes.

Executive Summary: Administrative costs in healthcare are now in the trillions. Hoping to reduce these costs, the three stakeholders in this case study worked together to incorporate UnitedHealthcare’s payment rules into the University of Iowa Hospitals & Clinics’ billing solution. This allows the health system to catch errors before claims are submitted, reducing rework and saving on administrative costs. The collaborators emphasize the importance of continued collaboration to make sure the suggested edits continue to be refined and expanded.

Fab 5 Review: Allowing Optum to work with UnitedHealthcare to build payment rules inside of the provider organization’s system is somewhat unique. While many provider organizations work to model payment rules in their systems, they are often challenged due to complicated plan designs. Running the claims against payer rules provides insights into deficiencies that could delay processing and increase the likelihood of denials. The biggest impact this case study will have on the industry is helping others accelerate claims adjudication and reduce administrative burden.

Executive Summary: Seeking to reduce the manual effort required to obtain prior authorization, the collaborators in this case study worked together to create a SMART on FHIR link between Conway Medical Center’s EMR and the software used by Palmetto GBA. The link simplifies the process for both the payer and healthcare organizations and frees up resources to work on critical pandemic-related tasks. The stakeholders are now working to expand the automation to additional procedures and healthcare organizations.

Fab 5 Review: I believe this study is unique because of the way the groups worked collaboratively as equals to achieve mutually beneficial outcomes. This builds trust between payers and provider organizations, and that trust is often overlooked. Reducing the administrative burden and integrating that into the provider workflow has a real impact on the industry’s bottom line.

Executive Summary: To better serve individuals experiencing homelessness—who are often super-utilizers of The Queen’s Health System’s inpatient and emergency department (ED) services—the stakeholders in this case study worked together to enable the healthcare organization to first identify these individuals and then provide community health workers to help connect them with available community resources. The resulting program has been extremely successful for all parties involved—first and foremost for the patients and the clinicians who serve them.

Fab 5 Review: The payer’s willingness to (1) offer funding to a provider organization for the initial program without being part of a risk-sharing agreement and (2) provide needed information directly to the provider organization is a unique approach. Additionally, the provider organization’s ability to engage other payer partners and make similar arrangements without the initial payer organization having any restrictions is an open, beneficial approach that other organizations can model as they move forward (not everything needs to be propriety or competitive). Additionally, given that the provider organization was outside of a value-based agreement, they could have seen this concept as destructive to their ED and refused to move forward with the model. Yet they didn’t, and their commitment to patients and their community outcomes should truly be commended. The provider organization maintained a personal connection between the navigator (i.e., community health worker) and the patient while maintaining a small caseload for each navigator, and the patient could be comfortable and build proficiency; this differentiated approach is extremely valuable. If the organizations determine that the model is truly scalable across other locations, lines of business, and diagnoses while maintaining the high-touch model with low caseloads for the navigators, that could change the way payers and provider organizations think about what is truly scalable.

Executive Summary: The technology in this case study is used by Essentia Health and GuideWell to automate the prior authorization process and thus reduce manual processes and delays in care. This case study is unique in that the highlighted healthcare and payer organizations pursued their prior authorization automation independently of each other. Their perspectives demonstrate how the technology is able to reduce friction for both the provider and payer markets without direct collaboration or contracting.

Fab 5 Review: When the organizations used automation and focused on improving documentation quality, patients benefited from faster decisions on prior authorizations and fewer denials, and physicians saw greater efficiency.

Executive Summary: In order to provide better care and build trust between their payer and provider divisions, Community Health Plan of Washington (a provider-owned health plan) worked with Arcadia.io to build a 360-degree patient view based on both claims and clinical data. They then used the data to create a pay-for-performance program that rewards providers for value-based behaviors. The program has led to both quality and financial improvements.

Fab 5 Review: Though standards exist for data types, they cause additional expenses in the healthcare industry, and emerging efforts to create new standards won’t be effective for a long while. In this case study, there was an intentional focus on data quality and on creating shared normalized data that improves each party’s trust in the data. It is very interesting to see the approach of utilizing SDOH data for risk programs. As the industry shifts to focus on health equity, this approach would become a significant enabler.

Executive Summary: With the costs for maternity care rising, Metro Nashville Public Schools partnered directly with Vanderbilt Health to create a bundled payment program for their maternity population. Technology from Cedar Gate Technologies enables the smooth, efficient administration of the program, resulting in high satisfaction for all stakeholders, including the patients themselves.

Fab 5 Review: Layering a value-based reimbursement component on top of an existing fee-for-service model is an interesting opportunity and a way to help employers, payers, and provider organizations continue their journey toward broader value-based reimbursement agreements. Additionally, the way the bundles were designed to simplify and change other administrative processes (such as prior authorizations) empowers physicians and nurses to operate at the top of their license. The organization’s ability to build provider buy-in and engagement in the model and their willingness to be held accountable for outcomes sets a foundation for accelerating the shift to value-based reimbursement across their system. This type of model may work for an employer that is primarily located in a certain geographic location and can allow them to work with a provider organization focused in that geographic location. However, it also poses challenges in how scalable this approach is. The health systems’ ability to drive provider engagement and buy-in is something that can be further evaluated and replicated for other systems looking to embark on that transition.

Executive Summary: UVA Health realized that the government-mandated clinical decision support they used when placing imaging orders for Medicare patients could potentially be leveraged to expedite the prior authorization process while also improving providers’ imaging order patterns. As a result, the organization partnered with Change Healthcare and one of their commercial payers to leverage the clinical decision support mechanism for non-Medicare patients and expedite the prior authorization process, leading to significant benefits for patients, ordering providers, and the payer organization.

Fab 5 Review: I believe the unique aspect of this study is the acknowledgement that the entire health system needs to be willing to participate. These solutions are proving valuable, but they will only bring about true change with scale and broad adoption. Agreeing to repay for unnecessary imaging so that there is shared risk is crucial. As the lessons learned indicates, these relationships help to increase trust across provider organizations and payers, and the long-term result is the industry will be better focused on outcomes and reducing the overall cost of care.

Executive Summary: As the industry shifts to value-based reimbursement, everything revolves around quality of care. And providing a high quality of care requires increased collaboration and data exchange between payer and provider organizations. In this case study, SC House Calls’ EMR vendor used FHIR APIs to create and automate a closed-loop exchange of clinical data between the organization and Humana. Outcomes of this collaboration include reduced administrative burden, improved clinical outcomes, and improved provider satisfaction.

Fab 5 Review: The intent of value-based payment models is to align incentives to ensure clinical quality in support of optimal patient outcomes. Sadly, current mechanisms used to gather data to support quality and outcomes often obscure that goal, and the health and care needs of patients/members are pushed to the background. This solution supports the needs of both payers and provider organizations and is built around ensuring that both payers and provider organizations can adequately understand the patient/member population. Creating more streamlined, comprehensive, and bidirectional data sharing between the two parties allowed for appropriate risk stratification, intervention, and quality care management. This is a significant need across the industry. A care gap that is not closed, or a chronic condition that is not tightly managed, could result in a serious health issue for a person, triggering a negative contractual result. Putting patient/member needs first will lead to overall improvement in financial outcomes. And leveraging technology to improve workflows, assist providers, and allow for more visibility by payers is fantastic.

Executive Summary: Lack of patient-level insurance coverage data at the point of care can add to the administrative burden for provider organizations, pharmacy benefit managers, and payers and lead to high prescription costs for patients. The technology in this case study helps reduce these issues by confirming whether prior authorization is needed and embedding patient-specific formulary information into the prescriber’s workflow. The results have been a win for all stakeholders involved.

Fab 5 Review: Embedding the Rx authorization process within the EMR workflow provides a unique approach to managing and improving this process. Human error is reduced by leveraging technology to determine whether an authorization is required or to help manage the process of determining what alternatives should be considered based upon the health plan in play. The biggest impact this case study has on the industry will be accelerated turnaround times for required authorizations, which improves overall outcomes and reduces costs.

Executive Summary: To combat a prior authorization process that was burdensome to patients, providers, and payers, the stakeholders in this case study worked together to provide a more automated process and incorporate suggested care plans into the provider workflow. The stakeholders kept the patient as the center of their focus, and the collaboration has not only led to faster access to care for patients but also reduced the administrative burden for the payer and provider organizations.

Fab 5 Review: This work demonstrates that trust, partnership, and technology can improve patients’ timely access to care while creating medical savings and decreasing administrative burden and workload associated with prior authorization.

Executive Summary: The stakeholders in this case study collaborated to bring together clinical and claims data in one holistic view of the patient. This data is used to identify high-cost or high-risk members covered by capitated contracts so that these individuals can be referred to Baton Rouge General Medical Center’s comprehensive care clinic. The care management provided by the clinic is designed to optimize health outcomes and reduce costs.

Fab 5 Review: This approach is very interesting and unique because the payer and provider organization were willing to collaborate and work together in a different way, use the same external solution, and share and bring together payer and provider data at scale. Additionally, the clearly defined accountabilities and the level of communication and coordination across the case managers and care coordinators enabled the successful outcomes. This case study is an example of how organizations can take steps to build trust and work toward value-based reimbursement arrangements. This is a model that other payers and provider organizations can use to start building new capabilities and establishing a path toward value-based reimbursements and population health management.

Executive Summary: When prior authorizations and claims are being processed, requests for additional clinical information creates administrative burden for payers and provider organizations and delays patient care. In this case study, the collaborators leveraged Epic’s clinical data exchange system, Payer Platform, to share timely clinical information about shared patients/members. This connection has given BCBSMN direct access to medical records, allowing them to find needed clinical information rather than requesting medical records from Mayo Clinic. There are now decreased denials, and both organizations have experienced positive administrative impacts.

† This Points of Light case study was presented at the 2022 payer/provider summit; thus, it has not yet been published by KLAS or reviewed by KLAS’ advisory board. The case study will be published in KLAS’ 2023 Points of Light report.

Summit Attendees