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Within the health care system, payers and physicians have long operated at odds with one another. While both have a goal to improve patient and member health, their approaches often differ, creating friction. Physicians get frustrated when they have limited information about how data are collected and used to calculate patient attribution and payments. They may feel powerless to control factors for which they are held accountable, and payments are at risk, particularly when there are gaps in electronic health record (EHR) data for cost and quality, or they have limited insights into levers available to impact population health, driving higher costs or lower quality scores.
Payers, on the other hand, grapple with rising costs and the need to minimize premium hikes to remain competitive with members. They understand that most patients have much higher trust in their doctors than in their insurance companies and want to improve their relationship with providers. But they also have to balance protecting proprietary data and sharing only necessary information with physician and other clinician partners. Additionally, because of the structure of the insurance claims process, most of the data they work with have a significant lag — three to six months on average — limiting their ability to address cost and quality shortfalls within a single performance year.