Availity Blog

RISE Observations


4.04.2018 By Susan Bellile, Principal, Health Plan Risk & Quality


The RISE conference in Nashville was a great opportunity to learn about new approaches to analytics and member engagement, as well as to hear about many of the creative initiatives health plans are implementing to improve quality scores and meet the complex web of risk adjustment requirements for Medicare Advantage, ACA, and Medicaid.

But no matter how creative a health plan’s initiatives are, their success ultimately depends on how well they communicate with their provider networks, who are responsible for assessing and documenting member conditions and delivering appropriate care. There were a few providers in attendance, and many suggestions offered on ways health plans can improve provider relationships. These included segmenting provider groups and customizing outreach accordingly, aligning incentives, and spending more time and effort on education, training, and in-person contact.

These are all good recommendations, but given the number of EHRs and unique implementations, multiple health plan systems, and the fact that each provider is interacting with as many as 15 different health plans, there are still many “failures to communicate.” Here’s why I think this is still the case.

Health plans and providers are aligned. Technology isn’t.

We hear a lot about health plan and provider incentives not being aligned, but from my perspective, providers and payers do have the same fundamental objectives: providing quality care in a manner that is financially viable for the member/patient and the healthcare system. Where we lack shared incentives is the technology infrastructure that supports the exchange of clinical information. There are good reasons for a health plan to share their comprehensive set of information about a member with that member’s provider, and good reasons for a provider to share with the health plan the information they have documented about that member’s care.

What is lacking is an efficient and effective (i.e. electronic) way for health plans and providers to share this member information. There are three key reasons for this:

EHRs are provider centric. Despite Meaningful Use and multiple attempts to develop standards, there is still no common approach to capturing quality metrics in an EHR and routinely disseminating the information to the appropriate health plan.

Legacy health plan information systems. Many health plan information systems are still transaction based, not member-centric. They are designed to provide eligibility information at a point in time or to adjudicate an individual claim—not to present a comprehensive view of the member’s conditions or care across all providers.

Cost. Obviously, making any substantive changes to technology infrastructure requires significant capital investment. When the benefit is better communication, it is not always clear which party(s) should cover the cost.

Availity is moving forward

As a leader in provider engagement, Availity is working to address the challenge of clinical information sharing, from both ends of the technology spectrum:

  • Convert paper and manual processes to a multi-payer platform, leveraging the Availity Provider Engagement Portal where providers and health plans already exchange millions of administrative, clinical, and financial transactions.
  • Consolidate “one-off” direct connections. Health plans and providers invest a lot of time and resources developing and maintaining connections between one provider’s EHR implementation and one health plan. By connecting directly with Availity, a provider can share appropriate member data with multiple health plans, and health plans can receive clinical data in a consistent manner from multiple providers.

There is still a lot of work to do, but at next year’s RISE conference I hope to see more examples of how efficient sharing of information between payers and providers drives high-quality, cost-effective care.

Learn more about Availity’s risk and quality solutions.


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