Data alignment starts internally
Payers looking to use their foundational data and clinical content to reduce abrasion would be wise to first consider internal alignment.
Allison Combs, lead of payer products at Wolters Kluwer’s Clinical Effectiveness division, points out that “Historically, medical and pharmacy has been pretty much siloed. So you have your pharmacy benefit team, your medical benefit team, and again, they all have different systems, different data, different code sets that they use.” This internal variance, especially in light of how newer specialty meds can straddle medical and pharmacy benefits, runs the risk of creating conflicting benefits and policies that will contribute to provider frustration.
“Whether it's the care management teams or the specialty pharmacy teams or the MTM medication therapy management teams at payers, it is really important to support that member,” Combs continues. “Making sure that they're all hearing the same thing and getting the same information at the same time is critical.”
As specialty medication and the speed of evidence continue to challenge traditional structures, payers should work to not only review their internal organization but make a concerted effort to align the inputs disparate teams are using to make decisions that impact members and providers.
Payers can prevent conflict
On the surface, many might assume that payers and providers have different goals, but fundamentally, both are aiming to drive the most appropriate care and best outcomes for patients and members. However, the businesses often operate at different altitudes. Providers are face to face with patients, often making decisions based on real-time evidence provided through clinical decision support (CDS) tools. Payers, on the other hand, are often setting policy and benefits in advance and considering a population level.
Combs explains the extra considerations payers work with: “While they’re both taking into account evidence, payers also have to consider whether something is covered or appropriate from a population level. So, while the payers have to weigh the financial costs as well the clinical benefits, they’re doing that up front, whereas many providers don’t tend to look at the financial pieces until closer to the end of that patient interaction or even after the patient has left the health system.”
These different perspectives, however, need not cause only friction. Payers investing in and utilizing the same drug and clinical information that providers use at the point of care are starting their decisions in a better position to work with providers.
Payer-provider alignment starts with trust
Fostering trust and transparency between payers and providers should be an overarching goal for payer leadership seeking to lessen abrasion. When these are prioritized with members at the center, decision-making improves, and new opportunities open in the member experience.
Teams setting policy, outlining benefits, and evaluating claims need access to the same consistent evidence-based content that clinicians know and trust. With medical knowledge doubling every 73 days and new FDA drug approvals hitting all-time highs, payer teams need confidence in their decisions. They need to know that the choices they make ultimately won’t impede provider decision-making or the member experience.
