After putting in their 10,000 steps a day at HIMSS15, anyone can tell you how much blame there is to go around in the complex dysfunction of U.S. healthcare. Rapturous vendor claims aside, how do we get to the interoperable learning system described in The Office of the National Coordinator of Healthcare Information Technology's Interoperability Roadmap?
In my blog post on the Roadmap (Will Today’s Payer Have the Role they Want Tomorrow?), I argued that we must include payers in the clinical connectivity movement to have a chance. My friend John Moore at Chilmark Research responded with an astute critique, “The relationship(s) between payers and providers is typically not one built on a whole lot of trust. I have not seen vast and growing evidence that this is occurring—yet.”
Of course John is correct—payer-provider antagonism is deeply rooted. But imagining that we can deliver reform without addressing pervasive industry distrust is an illusion.
The truth is, trust is in short supply across the healthcare ecosystem. Doctors don’t trust lawyers or even the regulators whose regulations the lawyers enforce. Specialists often don’t trust their hospital employers to be transparent on financial productivity. EMR vendors don’t trust their competitors. Clinicians don’t trust big data systems to provide pristine “evidence-based guidance,” while big data vendors don’t trust clinicians to tell the whole truth in the clinical record. Consumers don’t trust the healthcare “research” flooding the Internet—but they’re not too sure about the healthcare establishment either.
So how do we grow trust in healthcare? It may be that the payer-provider relationship, strange as it seems, is the best place to build a new foundation.
One scholar who has devoted much of his career to the study of societal trust is Professor Roy Lewicki, a pioneer in conflict management. He points out that trust and distrust are not true opposites: “contrary to traditional, normative views that trust is good and distrust is bad… both trust and distrust have a valid role in managing complex relationships… trust is valuable insofar as it is appropriate to the context, and a healthy amount of distrust can protect against the risk of exploitation” (Lewicki & Wiethoff, Trust, Trust Development and Trust Repair, 2000).
Lewicki’s insights support the idea that the payer-provider relationship, while historically difficult, may offer the indispensable ingredients to grow trust. Given the centrality of the payer-provider relationship to the core concept of reform (increase quality while reducing cost), this could be key to our national success.
Lewicki suggests the best way for organizations to increase trust is to use a contractual framework to demonstrate competence, consistency, predictability, empathy, and sharing of control—repeatedly, and over time. The VBR contracts proliferating between payers and providers, underlying new risk-sharing agreements, present an excellent platform for the development of mutual trust along these dimensions. Successful VBR contracts require competent performance by payer and provider, detail the sharing of control in key areas such as Medical Management, and specify the metrics and methods by which performance will be judged. The sheer number of such contracts across multiple payers and insurance products provides health systems with unparalleled opportunity to evaluate the trustworthiness of each payer as partner across multiple contract cycles.
Lewicki goes on to suggest that it is equally important to decrease distrust –which certainly rings true in healthcare. Once again, he focuses on the central role of formal contract agreements to enable clear specification of each party’s obligations. The contract can then specify how each party’s actions can be monitored and verified, under the protection of legal recourse and supported by the existence of third party arbitrators.
Compared with the payer-provider relationship, no other “axis of distrust” in healthcare offers such rich, powerful, or frequent contract mechanisms that can establish the repeated demonstration of trustworthiness. What’s more, the government’s growing role as the ultimate payer means that critically important standards of behavior and objective third-party regulation are increasingly transparent and available.
We at NaviNet are seeing the trust-building process play out at an accelerated rate around the country. It may be more exciting to suggest that providers are suddenly going to become payers and put the dreaded insurer out of business, but it may be more accurate to focus on the mainstream of health systems who are experimenting carefully in sequential product-specific partnerships with selected payers to explore roles, responsibilities, risks and rewards in new collaborative contracts. This will be at least as true for the health system “payviders” who are trying to become insurers themselves, typically in close cooperation with a payer-based “value-based TPA” partner, as they develop internal payer functions such as Utilization Management for the first time.
The ONC and academic reformers could miss a golden opportunity by ignoring this trend. By the time clinical interoperability could possibly be accomplished by “provider-only” means, healthcare industry structure will have been changed utterly by virtue of the innovations spawned by cooperation between payers and providers in shared risk for Medicare Advantage, Managed Medicaid, Exchanges, and commercial ACOs. In Darwinian fashion, the healthcare entities who thrive in reform will have learned to build trust between payer and provider functions by proving to each other that they are competent, predictable, and trustworthy by means of repeated cycles of shared-risk success in VBR contracts.