Rethinking How Payers Collaborate with Providers through Clinical Workflow

11.22.21

by: Julian Malinak

Here at Moxe, we’re improving how the payer-provider relationship functions by focusing on clinical data exchange. We strive for a future where clinical data and insights flow freely between provider EHRs, payer systems, and patient apps. I often think of us as a “payer-provider collaboration” vendor, solving the thorny economic, clinical, and technological challenges inherent in that relationship.

Within the realm of clinical data, we primarily think of two large problem areas: moving data from providers to payers and moving data from payers to providers. The first problem involves moving data from provider systems of record (mainly EHRs) to payers. This continues to be a core business for Moxe: helping payers acquire clinical data quickly, at a low cost, and in formats structured to the specific use cases that matter. The familiar standbys of quality improvement (HEDIS/Stars) and risk adjustment are major focus areas, while we’re also excited to bring clinical data to payers for other initiatives like prior authorization and payment integrity.

Barriers that Impact Payer-Provider Clinical Workflow
The second problem is where I’ll focus the rest of this article: how clinical data and specifically actionable clinical tasks move from payers to providers. We are working to present payer data and insights to providers where they do their day-to-day work: their EHRs. To actually make this work, it is critical to address several long-standing barriers.

1. Aligned incentives and economic model. We’re talking about impacting clinical workflows, which typically means that payers are conveying information to providers and prompting them to take time to complete specific tasks. For instance, reconfirming conditions and addressing quality gaps in care to support risk adjustment. As this takes time and resources for providers, economic and incentive alignment is critical. A broad risk-sharing model is ideal here — one that creates upside for the provider without undue administrative burden and complexity. In the absence of such a value-based model, or in addition to it in some cases, “pay per completed workflow” approaches can also work to drive provider adoption.

2. Accuracy and utility of payer insights. The insights sent from the payer to the provider need to be accurate and useful. Inaccurate insights might be due to out-of-date information on the payer’s part (e.g., a risk adjustment reconfirmation that has already been addressed in a prior encounter) or due to analytic challenges (e.g., a quality notification that applies to patients with COPD is delivered for a patient without COPD). On the issue of clinical utility, I’ve heard many providers express skepticism that risk adjustment workflows are useful for anything but financial outcomes. While the financial element of risk adjustment is important (see above about aligning incentives), we have seen that when insights are delivered in the right fashion and incorporated into care management programs, there can be a positive impact on the quality of care delivered. The aim is that when payers and providers work together on new ways of using risk adjustment it helps both parties improve population health programs — and is elevated from being purely a financial activity.

3. Reduction of abrasion in how workflow is delivered and completed: The primary challenge here stems from the historical divide between payer and provider systems of records. Providers work in their specific EHRs; payers have their own systems for clinical data workflow and analytics. As a result, providers end up documenting a given workflow (e.g., depression screening) in both their EHR and some separate system for the payer, whether a portal or faxed form. This abrasive double documentation adds another clerical task and contributes to the administrative burden that providers cite as a major factor in burnout. To solve this problem, tools must enable a single documentation workflow to send data to the right places in both the EHR and the payer’s systems simultaneously. Additionally, it is critical that the workflow tools are designed to reduce time searching for information, clicking, and typing.

4. Efficient implementation with multi-payer utility: Providers deal with a range of payers who often use distinct workflow tools, adding complexity for both clinical teams and administrators. As much as possible, payers need to work with vendors and providers to reduce differences in how they deliver workflow and data to providers. Payers can and should have their own proprietary insights and incentive models for provider collaboration, but the method of how these are delivered should not be jarringly different across payers.

How We Think About Abrasion Reduction
At Moxe, our focus has historically been on addressing barriers (3) and (4) above: we implement a workflow tool that can be used across payers, which eliminates double documentation and increases efficiency. This means providers spend less time on paperwork and more time thinking about patient care, while payers realize improvements in workflow completion rates and timeliness. So far, we have seen a 300% decrease in workflow completion time (i.e., 12 minutes to 4 minutes on average for a set of risk adjustment and quality workflows) and an improvement in completion rates of 100%.

Our product is a SaaS web application that is embedded in the EHR and feels like a native tab / module to the EHR — no separate log-ins or application windows. Our aim is to combine the best of modern SaaS apps with an EHR-native experience: web applications can be continuously improved and customized in a much more nimble fashion than making changes to the base EHR, while EHR-native workflow is the experience providers want.

Critically, we do the work to integrate with the EHR to both read and write data, so when providers do work in our tool it not only sends that data to the payer, it also puts data back in the right places in the EHR. Even for relatively simple risk adjustment reconfirmation or suspect condition workflows, there are typically several places (e.g., diagnoses, notes) we need to write back to the EHR to truly eliminate double documentation. Quality workflows are more complex, since writing back to the EHR may involve order sets, prescriptions, and other clinical actions. This is challenging integration work that varies significantly by EHR vendor (e.g., Epic vs Cerner). It also varies by provider given different configurations and user preferences of their specific EHR instance.

Managing the complexity of EHR integrations and the nuances of workflow design to eliminate abrasion and improve efficiency has been and continues to be our primary focus. In terms of the accuracy of the workflows and data delivered, we are increasing our focus here. To further enhance the usefulness of payer-generated insights, we check against data in the EHR to suppress insights that have already been addressed by providers. Behind the scenes without any provider burden, we send the relevant data on those already-completed items to the payer. We work closely with payers and their analytics vendors to ensure a high quality data cycle: improved data exchange with provider EHRs enables richer analytics, which in turn improves the accuracy of workflow items payers are sending through our technology. We focus on being the best at EHR workflow and data exchange, so when it comes to the pure analytics we have the flexibility to plug into any vendor or platform preferred by our payer clients.

On the economic and incentives front, while we help payers think through and refine their value-based and pay-for-performance programs, our goal is to work within the context of the payer’s overarching programs rather than impose our own provider incentive model. With that said, real-time clinical data and true workflow integration within the EHR allows payers to design and implement more sophisticated analytics and incentive models – and we’re humbled to be an important piece of the puzzle as payers move toward the future of value-based payment models.

The Path Forward
We’ve seen the challenges on the ground with providers using separate tools for each payer they work with. Yet we regularly talk with payers who understandably view their workflow tools and analytics as a proprietary source of competitive differentiation. Our goal is to abstract away the actual exchange of data and workflow between payers and providers, creating a seamless communication layer that can be used by any provider and payer with minimal effort. It is admittedly a lofty goal that we believe will take time for us and the industry as a whole to achieve.

In that future state, we believe there could emerge a clarity where payers find differentiation in the provider collaboration arena. Even if a payer can seamlessly share data and insights with any provider, there will continue to be an enormous opportunity to generate novel insights that improve care and reduce costs — and to build relationships with providers in aligned payment models that improve outcomes. Our aim is to make it possible for payers to focus on these areas by not worrying about how they will deliver their insights or receive data from providers.

If you’re interested in finding out more about how we can help solve these clinical data exchange problems, we would be thrilled to talk. Contact us at info@MoxeHealth.com or 608-669-9176.

Join Our Network

Start connecting with millions of patients, health systems, and health plans.