Reflections from AHIP 2023

Healthcare Evolution: Journey Towards Payor and Provider Alignment

When it comes to gatherings of healthcare industry thought leaders, the AHIP annual conference is as close to a household name as it gets. Year after year, leaders across the entire healthcare spectrum convene to discuss policy changes, and stack hands on the important work that still needs to be done to best support the health care consumers that they serve. ?

However, this year there was a clear evolution in the tone of the conversation, moving beyond the traditional concentration of AHIP on "payors only". A fresh perspective has emerged as the focal point of discussions: the redefinition of the relationship among payors, providers, and patients appears to be well underway. A paradigm shift that shows a great deal of promise to benefit how patients consume and experience care.

For Payors and Providers, The Time for Better Partnership Is Now

Witnessing this paradigm shift – the collaboration between payors and providers – on full display at AHIP 2023, evoked memories of my time as a graduate student in a healthcare administration program in the late 1990s. Back then, there was much speculation that vertical integration and alignment between payors and providers were the elusive keys to managing skyrocketing costs and enhancing quality of care. The caveat being that if such a model were to succeed, it had to be based on a true partnership between the payors and providers, with incentive alignment on serving the needs of the healthcare recipient and not the “bottom-line” needs of one organization versus the other.

Now, nearly 25 years later, the industry is shifting, realizing that the “elusive” keys to success, are tangible, possible, and necessary. The converging forces of economics, regulation, and technology have finally blurred traditional boundaries, reshaping the contours of the healthcare system. Traditionally distinct roles between payors and providers are beginning to overlap, with payors extending their influence well beyond financing to a more active role in patient care.

As payors and providers continue to partner and collaborate, challenges across the health system will inevitably be broken down, and solutions will be more apparent. So long as these partners remain rooted on the mission and the processes that lean into patient centricity, data, and measured outcomes, the entire industry stands to see improvement.

Health Care Is Moving in The Right Direction

As a long-time healthcare professional, I have collaborated with payors, suppliers, and stakeholders across the industry. Yet, my perspective has always been largely anchored in the care provider viewpoint. It was eye-opening to witness how the AHIP conference content and focus areas mirrored what I would have expected at a provider-oriented trade show, emphasizing care personalization, the patient care experience, clinical outcome optimization, and best practices for managing specific chronic health conditions. Discussions encompassing social determinants of health, whole-person care, breaking down barriers in care, closing care gaps, and the ever-present topics of population and value-based care seemed to permeate just about every session.

I have long advocated for and have been applauding the trends in the direction that I observed at AHIP 2023. It appears we have entered an era where value-based reimbursement, favoring customer-centric models of care, has motivated payors to diversify their focus and embrace their responsibility to bolster the patients' overall care experience. This transformation echoes a deliberate design shaped by regulatory and incentive changes that foster a shift from reactive care to proactive, preventative, whole-person care. In response, we are witnessing in real-time as payors are charting new care management strategies to better support member health, often facilitated by innovative digital tools and data analytics capabilities.

This alignment between payors and providers can and, in many cases, is already bringing forth tangible benefits. I was encouraged by the impact and results shared in sessions where payor organizations conveyed impactful stories and data driven outcomes of how they proactively identify high risk individuals and deliver personalized services, expanded access to mental health services, employed telehealth for specialty care in communities that traditional had to go without, and in general treated the member as a recipient of care to proactively manage health conditions, improve health outcomes, and reduce the overall cost of care – work that used to be exclusively the domain of the provider, but no longer. This strategic shift has profound implications for the future of healthcare, promising improved patient experiences, better health outcomes, and a more sustainable healthcare system.

Advanced Analytics – Next Level of Excellence in Health Care

Based on what I heard at AHIP, it was clear that the essential next step for the industry to continue on this journey towards alignment was a robust and interoperable analytics infrastructure that supports a common language and a common data model between providers and payors. Almost without fail, no matter the topic of discussion, this ended up being a critical need for realizing cost savings, achieving the benefits associated with value-based care, and promoting health equity initiatives.

Any successful consumer facing initiative depends on data-driven decisions that further align strategic objectives, meet the personalized needs of each individual, measure ROI, all with the aim of advancing societal health. Data interoperability serves as the cornerstone in this transformation towards cooperative, integrated cared. While patient data sharing between these parties is not novel, the modern reinterpretation of this exchange, fueled by technology and data analytics, offers the potential to achieve unprecedented value.

Analytics Challenges to Overcome – And Why

With a wealth of health data at their disposal, payors and providers can gain a deeper understanding of patient health trends, forecast potential health risks, and deliver personalized health interventions. However, the transition to a unified data model, despite its promise, comes with its share of challenges.

One notable hurdle is achieving semantic interoperability – the capacity to not only exchange information, but also ensure the interpreted meaning is uniform across all stakeholders. Given the diversity of terminologies, data taxonomy, and the constant need for clarification and updates, semantic interoperability within the healthcare system is a complex objective to attain.

It's critical that we tackle these remaining challenges head-on and pave the way towards a comprehensive, mutual understanding of data between payors and providers. Achieving this will facilitate efficient coordination and integration of care, leading to enhanced patient experiences and ongoing improvement in health outcomes. The future is very exciting and its increasingly feeling like the future is now!