Payers and providers are converging to create payviders. Here’s what this means for physician insurance jobs and other careers.

Jul 27, 2020

There’s recently been growth within the healthcare sector of companies known as ‘payviders.’ Some clinical doctors working for this type of organization see little difference when compared to working for a conventional hospital system. However, physician insurance jobs, administrative roles, nonclinical positions, and certain clinical jobs for a payvider have a few distinctions.

(Note that ‘provider’ in the context of this article is not an individual medical doctor or other practitioner. It is an organization that offers healthcare as its service, such as a hospital system.)

Here’s what to know as a physician or other medical professional if you’re considering joining a payvider organization.

Healthcare payer + healthcare provider = Payvider

In the context of healthcare organizations, a provider is an organization that administers healthcare services, while a payer is a company that pays for the administered services. There are numerous variations on both of these business types that have emerged over the past several decades as companies try to differentiate themselves and improve their services or their bottom line. A payvider is one such variation that is rising in popularity.

A payvider is an organization that is responsible for both patient care and taking on the financial risk of that care. In a nutshell, it is a health system that has its own health insurance plan. You may have also heard their more formal name: provider-sponsored health plans.

The healthcare industry is seeing payviders come on to the scene when large, integrated health systems start to take on their own financial risk or when they are given risk by payers. Joint ventures, mergers, acquisitions, and strategic alliances ensue, ultimately resulting in the formation of a payvider.

There was a 10% increase per year in the number of providers that have created their own insurance plans from about 2014 to 2018. An estimated 36 million lives are covered by payvider insurance plans.

Why is this trend taking place? The main drivers have been the Affordable Care Act and a push toward value-based healthcare. Organizations from both the payer side and the provider side are looking for ways to:Reduce the administrative cost of care

  • Lower the overall cost of healthcare
  • Improve coordination of care
  • Improve clinical quality measures
  • Improve the patient experience
  • Improve patient outcomes

It’s tough to completely separate the provider of care from the costs and payment associated with that care when considering how to accomplish these goals. Payviders are an attempt to overcome this.

Examples of payviders

In my own community of Birmingham, Alabama, VIVA Health is the prevailing payvider and has grown quickly over the past several years. VIVA is owned by the University of Alabama at Birmingham (UAB) Health System and provides coverage to many UAB employees and to Medicaid and Medicare members.

VIVA’s competitive advantage lies in its care management capabilities, such as utilization management.

A few other examples include:

  • Well Priority – a joint venture between Anthem Blue Cross and Aurora Health Care
  • Allina Health | Aetna – a joint venture between Aetna and Allina Health
  • Aspirus Arise – a joint venture between Wisconsin Physicians Services Insurance Company and Aspirus Health

There are also companies that are neither payers or providers, but who offer a product or service aimed at the payvider market. As one example, Vivify Health aims to bridge the gap between the populations of “patients” and health plan “members” through tech-assisted solutions to care transitions, chronic disease management, consumer engagement, and analytics tools.

Considerations for physician insurance jobs, administrative positions, and nonclinical roles with payviders

Like any part healthcare sector, there are nonclinical opportunities for physicians with payviders. These include high-level leadership positions, administrative roles that are either clinical jobs with an admin component or entirely nonclinical, and physician insurance jobs such as medical directorships and utilization management positions.

There are some potential benefits to working with a payvider over working for provider or payer as a physician. Here are some considerations.

It’s no longer “you against them”

One of the main challenges for doctors working in utilization management for health insurance companies is having to communicate to treating clinicians that a requested service is not medically necessary. Similarly, receiving payment denials or being unable to get prior authorizations from payers is a major frustration of doctors treating patients on the provider side.

This is mitigated to some extent with the payvider model. Physicians who are directly treating patients are working for the same company as those who are making decisions about coverage and benefits.

Any readers interested in utilization review or other physician insurance jobs who are turned off by the thought of having peer-to-peer calls may want to consider work with a payvider.

Payviders may be more likely to invest in technologies

It appears that payviders may be more likely to invest in different types of technologies to assist them in providing high quality services that are cost-effective, as compared to conventional healthcare providers.

These technologies include population health management, clinical documentation programs, and clinical decision-making tools, among many others.

This creates a need for humans to support the implementation and effective use of the technologies within the organization. Medical professionals are critical to this because they can:

  • Consider clinician workflows and patient needs when selecting technologies
  • Successfully educate their peers on how to use the tools
  • Efficiently communicate clinician needs to IT staff and developers
  • Put data and metrics into clinical context

Payviders present an opportunity for physicians interested in clinical informatics and data analytics to take on positions in these areas and to focus on using technologies to improve the experience of both patients and doctors.

Physicians can play a lead role in strategy that truly benefits patient wellbeing

Physician leaders in healthcare systems often have their hands tied to some extent when it comes to payment of services. The system can’t run without accepting insurance, but the insurance companies decide what is covered, for whom, and when. Conversely, it can be a challenge for medical leaders at insurance companies to ensure that the payer’s strategy is clinically sound and evidence-based.

Doctors in leadership positions with payviders are more likely to be able to balance care and cost considerations equally when developing and carrying out strategy.

Moreover, provider network management is a major area of focus for payviders. Physicians in leadership roles with payviders can assist with this by utilizing their clinical expertise and ability to understand the needs of fellow doctors and medical practices.

Options and comfort when transitioning to a nonclinical career

Many physicians interested in transitioning to a nonclinical career in the insurance industry feel very uncertain about taking a leap away from clinical medicine. Accepting a job with a payvider can ease this hesitation and feeling of insecurity. Your new role – though focused on healthcare from the payment side – is still with an organization that provides actual care to patients.

Employment with a payvider also opens up doors to continue to practice clinically while working in a job that is largely nonclinical.

New models in healthcare delivery and financing are an opportunity for physicians

The ever-changing structures and nuances of healthcare financing can seem overwhelming. Sometimes, though, new models in healthcare delivery and payment represent an opportunity for physicians. For some doctors, the growth of the payvider is one of these opportunities. This is especially true for anyone interested in physician insurance jobs.

The rise of the payvider will be met with its own challenges. Physicians can play an important role in ensuring that this healthcare model remains true to the ultimate goal of delivering appropriate medical care to patients.

1 Comment

  1. Kalpana Doshi

    I am physician who practiced in Anesthesia field for 25 yrs,. then diverted in Medical Acupuncture practice , Board certification in Anesthesiology as well as Medical Acupuncture. Any opportunity for me in this field of Payviders ?

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