Authors: Dr Vishal Anand, Sr Business Healthcare Analyst, CitiusTech and Prafull Mathur, Sr. Business Healthcare Analyst, CitiusTech
With the ever-changing regulatory environment and the accelerating shift towards value-based care, it becomes critical for payvider organizations to have exceptional and germane performance management strategies and solutions that would enable them to achieve business and market goals.
In the previous blog of our payvider value chain series, we discussed different aspects of data curation and management. This blog addresses various aspects of payvider performance management like industry trends, key challenges, and solution considerations.
Payvider Performance Management Trends
Operational & financial performance
Performance Management Challenges for Payviders
Numerous data sources are leading to unprecedented levels of data. Aggregation followed by data standardization to develop a coherent model to drive outcomes and cost utilization holistically is a big challenge owing to the disparate data sources and the data quality issues. It also impacts data to decision life cycle as data strategies are not aligned to deliver insights aligned with priorities and speed of business. Our previous blog on data management provides additional details on data management challenges.
There are a lot of regulatory pressures, with the regulations getting stricter now and then. The volume of enrollees increasing has also added to the pressure to achieve HEDIS compliance. Also, the limitations in terms of the frequency of HEDIS reporting (monthly) and custom reports have caused many problems for payviders.
COVID-19 not only has shaken the entire world with its devastating effects but has led to gaps in care, as observed by many. It proves a challenge for payviders that deal with high-risk populations. Also, existing tools limit payviders to monthly or semi-weekly compliance runs, and they can’t address care gaps effectively, which directly impacts their outcomes and scores.
Population health management for precision medicine and care coordination can have a massive positive impact on patient outcomes. It can save a great deal of money for both payviders and patients as experimentation with different treatment modules and procedures can be avoided. It also supports faster diagnosis, which can lead to faster treatment. However, payviders need to make sure that they manage care coordination with all stakeholders in the ecosystem, including providers and patients to manage the patient population effectively and seamlessly.
Many times clinical and operational leaders are not aware of what is needed to take advantage of value-based opportunities in existing programs as they tend to work independently. Also, a lack of coordination and transparency between contracting and operational leaders leads to misalignment of contract, program incentives and operational priorities. Typically, each payvider has numerous benchmarks and methodologies for its VBC arrangements, often with variations between lines of business. In some cases, the same facility tracks more than 200 metrics connected to incentive payments for its commercial contracts alone.
Solution Considerations for Payviders
The payvider need is clear: drive foundational and transformation data and analytics strategies to achieve the three goals - reliable data, timely access, and interoperability. Figure 2 depicts where these three goals sit within foundational, intelligent, and transformational initiatives..
Figure 2: Achieving three payvider goals within foundational, intelligent, and transformational initiatives.
Analytics play a significant role in revolutionizing the payvider market. Rescaling analytics requires anchor within and establishing the appropriate initiatives across the healthcare continuum while promoting culture shifts, and managing the portfolio to maximize quality and financial health. Figure 3 represents those required considerations to scale enterprise analytics.
Figure 3: Requirements for scaling enterprise analytics for payviders.
Here are six considerations for payviders to stay focused on competitive forces and enhance overall business and market performance.
Steamline regulatory reporting through powerful solution features like chase execution, campaign management, chart abstraction, and submission to NCQA/CMS. HEDIS reporting capabilities must also be further enhanced with daily compliance runs, comprehensive rules management, NCQA compliant validations and reports, as well as powerful analytics that align with current near-term needs.
Payviders need to focus on both member acquisition and retention. This is where consumer analytics plays a vital role, enabling insights into how members purchase their health plans and supporting decisions and marketing, sales strategies that attract more members and achieve economies of scale.
Payviders need to Seek out world-class tools and solutions to ensure that redundant tasks are automated while greatly improving overall efficiency. Automating workflows not only saves time and labor, it reduces errors caused by manual, human interventions.
Pursuing gap closure via a value-based care approach gives payviders an opportunity to review their standards, processes, and operations. Which functions and actions have the best impact on care, health, and experience -- administrative and care processes, payments, coding, quality metrics, and communications. This can make certain that provider workflows support payment models, including fee-for-service and value-based payments, while still delivering individualized care. Coordination with charting, coding, and finance also are needed to ensure gaps are closed, and credit is correctly attributed. Organizations should target select stakeholders instead of creating an entire care management organization or burdening providers with significant additional work that interferes with their ability to engage patients.
Appropriate revenue optimization via risk adjustment will enable payviders to compensate for taking on high-risk populations. Improper data integration practices hamper this process, ultimately affecting financials. A proper FHIR-enabled data platform supports data integration with disparate sources and enables analytics, allowing informed decisions about premium pricing, membership expansion, bid rate calculation, and other critical business and market choices.
Look for a centralized mechanism to implement and manage provider performance, goals, incentives, and oversight with advanced analytics to guide performance feedback. A highly configurable, end-to-end solution will empower health plans and provider groups to monitor and enhance provider performance. A solution should include pre-built KPIs and analytics across clinical quality, financial, operational, and utilization measures, giving users a unified view of all programs, processes, and performance measures. Other features to look for include artificial intelligence capabilities, various models that leverage data science to aid in decision-making for value-based programs with recommended benchmarks, targets, and compensation. Lastly, any solution should allow providers to manage their gaps and metrics independently via self-service interfaces and on-the-fly report building.
Performance management is one of the most critical areas to achieve Payvider value chain targets. Advances in technology, elevated healthcare standards, and increasing regulations make it imperative for payviders to adopt and create a more streamlined and efficient ecosystem.