打破障碍：确保有效医疗运营的5项合作策略

Breakingbarriers:5collaborativestrategiestoensureeffectivehealthcareoperations1 Breakingbarriers: 5collaborativestrategiestoensureeffectivehealthcareoperations Inbrief: 01Dismantlingbarriersbetweenpayers,providers,thirdpartyvendorsandgovernmententitiesenhancespatient-centric,value-basedcareanddrivesinnovation. 02Effectivecollaborationiscrucialfordrivinginnovation,meetingregulatoryrequirements,andaddressingmarketandcustomerdemandsefficiently. 03Payersareoneofthekeyfacilitatorsofcollaborationacrossallstakeholders. Today’sfast-pacedhealthcareenvironmentrequirespayerstoquicklyacclimatetonewrulesandregulations,whetherfinancial,complianceorcommunicationrelated—andoftenonshortnotice. Forexample,thelatestWhiteHouseexecutiveordersmandatethathospitalsandinsurersdisclosetreatmentpricestopatientsanddelayingtheselectionofsmallmoleculedrugsforMedicaredrugpricenegotiation. Theseandothernewexecutiveordersmayimpactexistingpayerandprovideroperationsandwillrequiretimelycommunicationtomemberstoachievecompliance. Moresweepingmandateslikethesearelikelyonthehorizon,andcurrentadministrationwillexpectswiftcompliancefrompayers,healthcaresystems,providersandvendors. Inthisfast-actingpoliticallandscape,successfuldigitaltransformationandeffectivecollaborationbetweenpayersandprovidersiscriticaltothequickandsuccessful implementationofnewmandatesandsimultaneousdeliveryofvalue-basedhealthcareservices. Payerandprovidercollaborationisnotonlyapriorityforoptimalpatientcareandoutcomes,butalsonowamandate.TheCMSInteroperabilityandPriorAuthorizationFinal Ruleaimstoimprovepatientaccesstocarethroughmore efficientandexpeditedpriorauthorizationprocessesandexchangeofhealthinformation.PayersandprovidersmustcomplywiththenewPriorAuthorizationAPIrequirementsbyJanuary2027.Inaddition,beginningin2026,payersmustprovideaspecificreasonforadeniedpriorauthorizationrequesttobothprovidersandpatients. Asthedeadlineapproaches,payersandproviderswithoutdatedhealthcaresystemsandinefficientprocessesmustreassesstheirstrategiestoenhanceoperationalefficienciesandmodernizetheirtechnologytobettermeetfederalregulations.Improvingthepatientandmemberexperienceisessential,andformany,achievingcompliancewhilefosteringacollaborativeenvironmentamongproviders,payers,andmemberswillhingeonsuccessfuldigitaltransformation. Payerswhoarestrategizingandworkingtowardsdigitaltransformationwillbewellpositionedtocomplywithregulatoryrequirements,elevatevalue-basedpatientoutcomes,reducecosts,improvediagnosticaccuracy,streamlinecaredeliveryandempowerpatientstotakeamoreactiveroleinmanagingtheirhealth. Howpayerscanpropelstakeholderstowardseffectivecollaboration Whenincollaboration,payersandgovernmentagenciesareuniquelypositionedtoenhancetransparencyandencourageallstakeholderstoworktogethertowardcommongoalsthatimprovememberoutcomes,optimizecostsanddriveinnovationinhealthcaredelivery. Belowisaguideforpayersandstakeholderswithinhealthcareorganizationstoimprovecollaborationacrossthehealthcaresystem: Streamlinedata-sharingframeworksacrosssystemsandstakeholders. Agingindividuals,particularlythoselivingalone,needreal-timeprotection.Connecteddevices,suchassmartsmokedetectors,watersensorsandmedicalalertsystems,canenableearlyintervention.Forbusinesses,agingworkforcesintroducenewrisksthatdemandenvironmentalmonitoringandadaptivesafetyprotocols. Utilizeadvancedtechnologiestosimplifyandautomateprocesses. Thetraditionalauthorizationprocess,whereinmedicalprovidersmustobtainapprovalfrominsurersforaspecificlistofproceduresbeforeadministeringcareormedicationhasbeenidentifiedasasignificantsourceofdelaysandadministrativeburdensthatnegativelyimpactpatientoutcomes.ArecentsurveybytheAmericanMedicalAssociationfoundthat24%ofdoctorsreportedseriousadverseeventsduetopriorauthorizationdelays.Payerscancanimprovecollaborationandenhancecaredeliveryby: •Simplifyingpriorauthorizationwithdigitalsubmissionprocesses •Givingprovidersaccesstodedicatedsupportteamsandimprovingtransparencyofprior-authorizationstatus •Allowingproviderstosubmitmissingoradditionalinformationusingdigitalchannels Emergingtechnologieslikeartificialintelligence(AI)serveascatalystsforcollaborationbystreamliningoperations,enhancingdata- drivendecision-makingandfosteringgreaterinteroperabilityamongstakeholders.Byleveragingthesetechnologyadvancements,payerscan improvecarecoordination,optimizecostsandsupportvalue-basedmodelsmoreeffectively. Forexample,AImodelsarebeingusedtoautomaticallyprocessandtriageclaims,flaganomaliesandreduceadministrativeburden,resultinginfasteradjudication,reducedmanualinterventionandfewererrors.Thisnotonlyimprovesproviderrelationshipsbutalsoenablesmoreefficientcollaborationacrossbillingandcareteams.PayersarealsodeployingAI-driventoolstoidentifyhigh-riskmembersforearlyinterventionprograms,casemanagementandremotemonitoring,helpingprovidersprioritizecareandimproveoutcomes. Withouteffectivecollaboration,though,theseinitiativesmayfaceresistanceorfailtoaddressreal-worldchallengeseffectively.SuccessfulAIimplementationrequiresactiveparticipati