Resurgence of the Payvider

// By Lindsay R. Resnick //

A consumer-centric swimlane unites payers and providers around shared objectives.

In a health sector bombarded with labels such as InsurTech, HlthTech, FemTech, and AgeTech, it’s no surprise that confusion and mis-categorization run rampant. And now there’s another category being promoted by consumer-centric health companies bringing a tightly integrated financial and clinical health care experience to consumers. They call themselves “Payviders.”

Payvider isn’t a new category, but by no means is it mainstream in the health ecosystem. Defining a category has strategic significance — not only for brand differentiation in a sea of sameness, but category definers and leaders usually experience faster growth and receive higher valuations than companies bringing only incremental innovation to market. But there’s a downside — failure to deliver has consequences.

Successfully defining a category typically involves either a breakthrough product or business model. The latter is the case for Payviders. Done right, it takes a mix of laser-focused strategic vision, consistent brand messaging, and cross-functional and cross-organizational buy-in. For a Payvider it means bringing together payer and provider “frenemies,” often bound only by the aftermath of contentious network participation contract negotiations.

Convergence, Control, and Collaboration

Whether a fully integrated consortium such as Kaiser Permanente or Geisinger Health System, an Accountable Care Organization, or a payer/provider joint venture, a Payvider isn’t necessarily born out of ownership. Nor does it come out of legislation or regulation, vertical or horizontal delineation, and certainly not from PR hype or arbitrary labeling.

For Payviders it’s about convergence. It’s about control. It’s about collaboration. Most important, it’s about a holistic approach to patient well-being — delivering better value through integrated care resulting in superior experiences, lower costs, and improved health outcomes.

Payviders began to truly take off when outcomes or value-based payment schemes began to catch on, bolstered by the Affordable Care Act and Medicare’s Shared Savings Program. Pay-for-performance reimbursement, from basic risk sharing to episode of care and bundled payments, is rapidly transforming health care away from fee-for-service toward an outcomes-based financing system — incentives and disincentives based on quality of care delivered and tangible improvement in a patient’s health.

In the evolving volume to value environment, it quickly became apparent that by joining forces across the patient lifecycle, payers and providers working together could improve the traditional managed care model, where they find themselves one step removed, either clinically or financially, from the care patients receive.

The Payvider model relies on continuous, real-time visibility into the patient journey, from prevention and wellness to acute and ambulatory to post-acute and in-home, taking the payer and provider relationship to new heights.

Caring Is Sharing

Payviders are created when payers and providers go beyond collaboration to achieve a unified, hand-in-glove relationship aligned around an interdependent set of shared objectives:

• Manage and reduce financial risk
• Provide high-quality clinical care
• Deliver superior patient experiences
• Optimize disease prevention and health outcomes
• Improve efficiencies and stakeholder profitability

Achieving these objectives requires complete alignment between health and care, technology and people, and between risk management and reimbursement.

The Payvider operating philosophy is designed to overcome flaws plaguing traditional fee-for-service health delivery: absence of care coordination, little information transparency, misaligned incentives, and fragmented, unwieldy patient journeys.

Here are five core Payvider principles and best practices:

1. Relevant Experiences: Payviders are built on a foundation of data-driven customer insights and brand experiences that drive trusted relationships. The payoff is high satisfaction ratings, patient loyalty, and increased customer lifetime value.
2. Personalized Care: Proactive care coordination and interdisciplinary care management backed by data and technology allow Payviders to effectively (and efficiently) manage risk, provide better clinical outcomes, and improve patient experiences.
3. Partnership Driven: A cohesive yet flexible operating model to support and empower providers is critical to bring together financial goals, patient service, and optimized outcomes. This approach to local market care delivery allows for rapid growth and scalability.
4. Value-Based Alignment: Patient care takes a “member-first” orientation for medical and social needs across all components of a patient’s care team and support community. It encapsulates all phases of the care continuum: wellness, prevention, primary, acute, chronic, and end-of-life care.
5. Innovation vs. Tradition: Traditional health companies are often burdened by legacy technology and a lack of individual customer focus. Payviders embrace a vision of data-driven continuous improvement, disruptive technology, personalized customer experiences, and clinical excellence.

Unity and Common Destiny

Health systems and physician organizations continue their move into the risk-taking business with well over 100 provider-owned health plans across the country. At the same time, payers are getting more aggressive acquiring providers, from primary care physicians to urgent care and retail clinics to home care companies.

The lines are blurred and getting blurrier. Add to the mix continued erosion of fee-for-service reimbursement that has no link to quality or value, and owning a position in the Payvider category becomes even more important.

Forward to the Past

Payviders are carving out their own place in the health landscape. In some regard, they harken back to the earliest health care delivery and finance models founded in the coming together of community payers and providers (back in the day, one represented by a cross and the other by a shield).

It was a framework built on local physicians and hospitals working to deliver better-quality care financed through affordable insurance. It stood on the ideologies that: health care is uniquely personal; physicians hold the key point of influence over care delivery; while fraught with uncertainty, health risk can be managed, reduced, or avoided; and quality of care is driven by the art and science of medicine but for the patient it’s measured by its availability when needed and the resulting quality of life. It was the foundation for a system of care centered around a sense of unity and common destiny. It’s today’s Payvider.

Lindsay Resnick is executive vice president of Wunderman Thompson Health, responsible for strategic health initiatives, client growth, and business development. Email him at lindsay.resnick@wundermanthompson.com