The healthcare landscape is undergoing a transformative shift towards the payvider model, driven by the imperative for enhanced care coordination, cost efficiency, and improved patient outcomes. Although the concept of payviders is not new, recent advancements in technology and a heightened focus on value-based care have sparked a resurgence in this integrated approach.

Unlike the traditional healthcare model, which often pits payers against providers in a bid to control costs, the payvider model merges these roles to provide more insights to direct care providers. This integration fosters a more patient-centered approach, aligning incentives across the care continuum and leveraging comprehensive data to deliver seamless, high-quality care.

So, who are payviders?

A payvider is an integrated healthcare entity that combines the role of a healthcare payer (often a health insurance company) and a provider (usually a healthcare delivery system).

In the traditional healthcare model, there is often a disconnect between payers and providers. This separation can create conflicting incentives, where payers aim to minimize costs while providers focus on the delivery of care, sometimes leading to adversarial relationships that are not in the best interest of patients. The lack of integrated insights can result in fragmented care, inefficiencies, and a less patient-centered approach.

Why become a payvider?

Being a payvider allows an organization to not only access but also own and control clinical, operational, and payment data. This control makes real-time access to this data much easier, enabling healthcare providers to make smarter decisions, offer personalized care, and manage health proactively. With comprehensive data control, payviders can easily and rapidly identify trends, improve forecasting, and swiftly adjust processes and policies. This integration leads to better patient outcomes, reduced costs, and more efficient, coordinated care. Embracing the payvider model positions healthcare organizations at the forefront of the evolving healthcare landscape, aligning perfectly with the shift towards value-based care, which prioritizes quality and efficiency in healthcare delivery.

Evidence and drivers of payvider growth

Pioneer payviders like Kaiser Permanente, Geisinger Health System (now part of Kaiser Permanente subsidiary, Risant Health), and Intermountain Health have seen significant growth, each increasing their membership by over 33% in the past decade. Newer entrants, such as UPMC and Providence, have experienced even more impressive growth, with over 70% growth in the last 10 years.

Strategic acquisitions highlight the growth of the payvider model. UnitedHealth Group, Elevance Health (formerly Anthem), Humana, and Cigna have been acquiring providers and systems to expand their integrated care networks. These acquisitions aim to enhance their ability to deliver coordinated, value-based care by integrating primary and specialty care, as well as other factors such as social determinants of health (SDOH), with insurance services.

Other organizations are entering the market and evolving towards the payvider model. The CVS Health acquisition of Aetna has integrated its insurance operations with its extensive network of retail pharmacies and healthcare services, including MinuteClinics and HealthHUBs.

Another significant driver is the expansion of Medicare Advantage (MA) plans. The Medicare Advantage market is rapidly growing, driven by the aging population and preference for integrated care options. More than 10,000 people age into Medicare every day, and the number of MA enrollees continues to rise. By integrating care delivery with the payment side of the equation, leveraging financial incentives to manage risk, focusing on value-based care, and tapping into a growing market with strong regulatory support, payviders can achieve improvements in care coordination, cost efficiency, and patient outcomes.

Delivering healthcare is hard

The promise of patient-centered care delivering better health outcomes while simultaneously reducing costs is a goal that the healthcare industry has long strived to achieve. Value-based care models have been around for decades, but delivering on that promise has been challenging.

Non-payer organizations made attempts to enter the market but have struggled to find success. Walmart announced their goal of opening 30 Walmart Health centers by the end of 2024, but has decided to close all 51 health centers across five states. Amazon, with its OneMedical offering, has recently experienced some leadership changes and layoffs despite its partnerships with some of the largest health systems in the country.

Healthcare organizations face numerous obstacles, from integrating complex data systems to managing financial risk and ensuring compliance with ever-evolving regulations. The transition from a fee-for-service model to a value-based care approach requires significant changes in how care is delivered, coordinated, and reimbursed.

  1. Complex data integration: Seamlessly integrating data from various sources, such as electronic health records (EHRs), claims data, SDOH, and patient-reported outcomes is a monumental task. Disparate systems and varying data standards make it difficult to create a unified view of patient health, which is essential for delivering coordinated, personalized care.
  2. Financial risks and sustainability: Managing financial risk is a significant challenge for payviders. The shift to value-based care involves taking on more fiscal responsibility for patient outcomes, which requires accurate cost predictions, robust financial reserves, and effective risk management strategies. Balancing these financial pressures while investing in quality care initiatives can be difficult.
  3. Regulatory compliance: Navigating the complex regulatory environment in healthcare is a continual challenge. Ensuring compliance with regulations such as HIPAA and HITRUST, and staying updated with changes in healthcare policies, requires dedicated resources and expertise. Non-compliance can result in significant penalties and damage to reputation.
  4. Care coordination: Coordinating care across multiple providers and care settings is essential for achieving better health outcomes, but it is also challenging. Effective care coordination requires seamless communication and data exchange between primary care providers, specialists, hospitals, caregivers and other healthcare and non-healthcare entities.
  5. Patient engagement: Engaging patients in their care is critical for improving adherence to treatment plans and achieving positive health outcomes. However, motivating and enabling patients to take an active role in their health can be difficult. Healthcare providers need to leverage technology and personalized communication strategies to enhance patient engagement.

Payviders’ guide to success

The payvider model offers a promising approach to healthcare by integrating payer and provider roles. To be successful, payviders must excel in several key areas, with effective data management playing a critical role.

  1. Integrated care delivery and coordination: Successful payviders ensure seamless coordination between various healthcare services, from primary care to specialty and post-acute care. This integration reduces fragmentation, improves patient outcomes, and enhances the overall patient experience.
  2. Value-based care: Emphasizing value-based care is crucial. This means focusing on the quality of care rather than the quantity of services provided. Payviders are incentivized to improve patient outcomes while controlling costs, aligning their financial goals with the health needs of their patients.
  3. Patient-centered approach: A patient-centered approach is at the heart of the payvider model. This involves understanding patient needs, preferences and health goals, and tailoring care plans accordingly. Engaging patients in their care journey leads to better adherence to treatment plans and improved health outcomes.
  4. Robust financial management: Managing financial risk effectively is essential. Payviders need sophisticated risk management strategies, including accurate cost predictions, appropriate premium setting, and financial reserves. This ensures sustainability and the ability to invest in quality care initiatives.
  5. Regulatory compliance: Staying compliant with healthcare regulations is non-negotiable. Payviders must navigate complex regulatory landscapes, ensuring they meet all requirements related to patient privacy, data security and reporting standards.

Role of data management in successful payviders

At Neudesic, we understand the that access to the right data at the right time as a cornerstone of the payvider model, enabling the integration of care delivery and insurance functions, and supporting several key aspects:

  1. Comprehensive patient data integration: Data from various sources – such as electronic health records (EHRs), claims data and patient-reported outcomes – must be integrated to provide a 360-degree view of each patient. This holistic perspective enables more accurate diagnosis, personalized treatment plans, and better care coordination.
  2. Advanced analytics and predictive modeling: Advanced data analytics and predictive modeling allow payviders to identify at-risk patients, predict healthcare needs and allocate resources efficiently. By analyzing patterns and trends in patient data, payviders can implement preventive measures and early interventions, reducing healthcare costs and improving outcomes.
  3. Interoperability and data exchange: Seamless interoperability between different healthcare systems and EHRs is crucial. Payviders leverage standards like HL-7 FHIR to ensure efficient data exchange and coordination across various care settings. This interoperability enhances communication among providers, enabling the provider to access the right information at the right time, leading to better coordinated and timely care.
  4. Enhanced patient engagement: Data Management tools enable payviders to engage patients more effectively. Patient portals, mobile apps and other digital tools allow patients to access their health information, communicate with providers and participate actively in their care. This engagement is key to improving adherence to treatment plans and overall health outcomes.
  5. Regulatory and compliance reporting: Accurate and timely data management is essential for meeting regulatory and compliance requirements. Payviders must ensure that data is secure, accessible, and accurately reported to regulatory bodies. This involves implementing robust data security measures to protect patient information and ensure compliance with HIPAA, HITRUST, and other regulations.

Successful payviders put their members first with a focus on member enrollment, point of care transitions and payment coordination. To ensure that goals and interests align, communication between payers, providers and patients is key, and we offer solutions to enable your organization to meet their goals.

  1. NeuCare is a care management platform which provides a 360-degree view of all patient data and relationships, alongside transactional data, ensuring informed and personalized interactions. Our person-centered design and planning focus on meeting the unique needs of each patient, driving better health outcomes and satisfaction.
  2. Purpose-driven healthcare data solution: Our solution includes an Open Common Data Model and the Microsoft Cloud for Healthcare Common Data Model – HL7/FHIR to ensure seamless data integration, enhanced interoperability and accelerated digital transformation.
  3. Provider data management solution: This solution streamlines onboarding, credentialing, contracting and network operations. By optimizing these processes, we help you maintain compliance and operational efficiency.

All Neudesic solutions are designed to comply with regulatory requirements easily and efficiently, empowering your organization to scale and thrive in the rapidly evolving healthcare environment. Contact us today to learn how our solutions can transform your organization and help you achieve your goals. Together, we can create a more integrated, efficient, and patient-centered healthcare system.