The need for tighter payor-provider partnerships has never been greater.
Health plans with a 4+ Star Rating dropped from 51% to 42% between 2023 and 2024. Member experience in the provider’s office is directly linked to 70% of all CAHPS survey measures. And in 2023, JD Power reported that health plan satisfaction fell by 13 points. Even member retention rates are hovering at 86%.
Providers face their own challenges with increased competition from new care channels like retail, pressures to adopt value-based care, an aging population with more chronic diseases, and shortages causing burnout.
While payors and providers have unique challenges and objectives, they also have one common goal—to activate greater member engagement. This goal is foundational to many of the issues that healthcare organizations face today.
Different priorities but one common goal
Both health plans and providers have made engagement a top priority. This is because healthcare leaders see how critical active member participation is to health, quality, and financial outcomes.
Engaged members are more likely to pursue information to help them make better treatment decisions, preventive measures, and lifestyle changes. Also, employer research shows that active member engagement and decision support can lower medical costs by 5.3% and reduce hospitalizations by 12.5%.
Engagement is thought to build greater trust, a critical goal for payors.
A national survey found that only 35% of members trust their health plan. This seems to primarily stem from a belief that a payor’s interests are at odds with the member’s, reinforcing the idea that the plan’s top priority is only to keep costs down.
A consumer survey found that actively engaging members creates a more positive view of their health plan, leading to members following plan recommendations for in-network providers or sites of care.
For providers, active engagement helps keep the organization competitive. Consider that the average member splits their care among four to five different provider networks each year. Providers can leverage engagement to raise their profile with members who have greater choice in where they receive their care, such as an urgent care center, pharmacy or retail clinic, a specialist, or a telehealth app.
As Figure 1 highlights, payors and providers have common and unique objectives. However, active member engagement is essential to all of them.
Understanding these distinct goals is key to achieving greater engagement.
Health plans vs. providers: Synergize unique strengths
Similar to how payors and providers have common and distinct goals, they also have shared and unique capabilities to contribute to a synergistic partnership.
Figure 2 summarizes key strengths that contribute to the success of a payor-provider collaboration.
Where providers have deep clinical experience and a more personal connection to members, health plans have invaluable claims data and analytics. And while health plans have been involved in care management for years, providers are gaining traction through Medicare programs.
When these strengths are combined as part of a payor-enabled, provider-delivered care management program, the alliance can build greater trust and value for the member while increasing their active engagement. This is where payors and providers see the most yield across health, quality, and financial outcomes.
Partnerships can deliver what consumers want
In 2023, the Advisory Board conducted a consumer study of more than 3,000 health plan members. They uncovered insights into what members expect from payors and providers to support them.
Figure 3 highlights this research, showing key opportunities for payors and providers to benefit from collaboration.
Insight #1: Members prefer certain activities from payors versus providers
Members want their health plan to answer financial questions, such as, “Where am I in my deductible or out-of-pocket maximum?” or “How much will my care cost?”
Members prefer their providers answer clinical questions, such as, “Which specialist should I see?” or “Why should I have an annual physical and other preventive screenings?”
Insight #2: Members are open to payors having an expanded role
For example, members are open to care navigation services, such as helping members find a new primary care physician. But, it’s important to engage new members for such care-related decisions in the first 12 months before the novelty wears off.
Insight #3: Members with chronic conditions trust health plans more
Because of having greater trust, members with chronic physical conditions are open to payors providing more care navigation or coordination support. This was not true, however, for members with behavioral health conditions.
Considering these research results, health plans and provider organizations can leverage their strengths, care management standards, and technology to expand their roles and deepen member engagement.
Care management partnerships support engagement
Research has demonstrated the quantifiable value of care management:
- Coordinated care trials found that actively engaged patients with chronic disease had significantly fewer deaths compared to a control group who only took appropriate medications.
- Studies of complex care programs have found that participants had lower total medical expenditures, fewer inpatient days, and less emergency room utilization than those enrolled in standard care.
- One care management case study achieved $1.9 million in cost savings.
- According to the CDC, a growing body of evidence shows that patients with higher patient activation—knowledge, skills, and confidence—have better health outcomes.
Payor-provider collaboration amplifies care management value
Payor-enabled, provider-delivered care management leverages each partner’s strengths to create a more seamless, cost-efficient, medically effective, and member-empowering experience. Through this partnership, members are actively engaged, resulting in synergistic benefits:
- Members take greater responsibility for making changes needed to improve their health
- Customized care and guidance reduce fragmentation and optimize outcomes
- Members improve their health literacy and self-management capabilities
- Members receive interventions, preventing escalating risk and costly exacerbations
- Members understand the value of preventive care, helping avoid future disease
By building greater trust and influence, payors can attain a more significant role with members and have a more timely understanding of their needs. Providers can share the load of engagement and care management, leveraging cost and population data to support decision-making.
Shared responsibility can help avoid conflicting care plans, duplicate tests, medication interactions, increased costs, and poor health and safety outcomes. Payors and providers need each other to be successful.
ThoroughCare bridges the payor-provider gap
ThoroughCare's care coordination platform can be shared between health plans and provider networks to enhance communication, support preventative measures, and deliver the most personalized member experience.
Through single or combined programs, payor-provider teams can maximize member engagement, lower costs, and provide a more cohesive and complete experience.
Whether a health plan wants to focus on members with one or more chronic conditions, transitions of care, behavioral health, or through Remote Patient Monitoring, ThoroughCare provides all the evidence-based structure, workflow, analytics, and reporting needed for a successful collaboration.
ThoroughCare's payor pilot program can:
- Enhance care for high-risk members
- Focus on specific member populations to improve outcomes
- Benchmark existing care management performance
- Increase member enrollment within six months