The pandemic has brought many hospitals and insurers both closer together or farther apart depending on how the two responded and interacted during the first year of the crisis.
Providers and payers that expanded their cooperative efforts since COVID-19 struck are likely to continue on that path, and so are those who pulled back from each other in the past year.
That in turn is shaping how payers and providers approach upcoming contract negotiations, experts say. “The payers who really stepped up and were willing to help and form a partnership this past year will be included in ongoing discussions around how we best manage both longitudinal care and acute needs across the country and potentially around the world,” said Wesley Wolfe, senior director of payer contracting at Cleveland Clinic. “Those payers who were very transactional may have less influence,” he said.
As the landscape shifts between payers and providers, post-pandemic negotiations are almost guaranteed to be more focused on telehealth than they have in the past.
“Our hope and desire and expectation is that coverage for care delivered virtually will remain in place,” Wolfe said.
He added that payers have historically been concerned that virtual visits would be another access point that drives up overall healthcare utilization, “but now we have a really credible dataset to show it really is, in large part, just a replacement of in-person utilization.”
Some organizations are arguing for reimbursement rates for telehealth that are similar to in-person visits. However, Dr. Robert Berenson, a fellow at the Urban Institute, believes that is unlikely to happen. “If these visits are reimbursed at parity under a fee-for-service model, costs will go through the roof—it’s not sustainable,” Berenson said. If that were to happen, Berenson said he would expect to see a dramatic increase in the use of telehealth, because of patient preference and potentially lower overhead costs for physicians.
More broadly, relationships between payers and providers are expected to mostly be an extension of how the pandemic went. Some of Cleveland Clinic’s payers engaged in “robust conversations” during the pandemic, looking for ways to work together and ensure both chronic- and acute-care patients had their needs met, Wolfe said.
For example, some payers provided invaluable cash advances in the early stages of the pandemic. Others may look to see how a hospital responded to a loosening of administrative requirements like those mandating prior authorization of care, said Dr. Robert Lorenz, executive medical director of market and network services at Cleveland Clinic.
“There will be a postmortem on what transpired during the pandemic and I think payers are going to recognize that we didn’t run amok with their temporary relaxation of prior authorization requirements, and we stuck to appropriate utilization,” Lorenz said. “Nobody wins with overly intrusive requirements, particularly when we have a historical rate of over 90% approval.”