It’s no secret that payers and providers must work together to improve the quality and efficiency of care. Or, in other words, pay for care with care.
That has typically proved easier said than done. Until now.
Based on a recent case study from Zelis and HealthCorum, we now have a concrete step in the right direction — optimizing provider networks.
Facilitating a more harmonious relationship between payers and providers will never be without its challenges. Developing provider networks takes time and resources (both of which there never does seem to be enough). But it’s worth the effort. Here’s why.
The study
The challenge
NeuGen, a shared services organization based in Madison, WI, needed a data-driven solution. Moreover, that solution needed to allow for transparency into provider practice patterns at a granular level, along with network modeling and design capabilities to put that data into action.
Put plainly, NeuGen needed to shift utilization from low-value to high-value providers.
Shifting utilization of health services to the most efficient and highest-value providers presents an opportunity to reduce wasteful spending, freeing funds for additional high-value services to improve quality and member satisfaction.
But identifying the right providers to put at the center of networks is a difficult feat for any organization. How can you objectively determine who is delivering the greatest value when compared to peer providers? What steps can you take to shift utilization to those high performers?
The solution
NeuGen needed a vendor partner with a one-two punch.
Powered by physician-level analytics, NeuGen’s chosen vendor began optimizing their network by processing millions of lines of claims data. They then used this as the foundation to benchmark and score all providers in targeted specialties statewide.
Once the data output was created, it was fed into the partner vendor’s platform, allowing NeuGen to seamlessly use the scores for narrow network design and network modeling. The resulting information was also leveraged in collaboration with primary care providers to prioritize referrals towards high-value specialists.
And the projected impact seems promising.
When just 5% of utilization is adjusted toward high-value providers, NeuGen and their members will conservatively realize over $2.9M in savings annually.
What to look for in a vendor partner
While there is no one size fits all, there are a few “musts” to look for when determining your vendor.
You need someone with deep expertise in health claims data analytics and a dynamic platform that can employ and deliver data for use in initiatives that reduce waste and impact the bottom line.
Best practice: above all else, your vendor partner should be flexible and their solutions should be customizable.
Your strategy
Purposefully developing provider networks activates the single largest lever for bottom-line improvement for payers.
A high-performing provider is one that has invested resources. Meaning: they go beyond limited patient experiences to achieve best-in-class patient outcomes. An optimized provider network should offer transparent care and be measured by cost, health outcomes and efficient delivery.
What you focus your network on, however, is up to you.
Best practice: Some parameters to keep in mind include building and fostering plan/provider partnerships, segmenting patient populations, and implementing advanced analytics to create actionable intelligence. These critical areas help differentiate an organization, generate higher quality care, lower costs and improve overall business performance.
After partnering with your vendor, your overarching strategy should look something like the following:
- Share insights with PCP’s to collaboratively shift referral patterns to high-value specialists
- Design high-performing networks to increase utilization of high-scoring providers
- Identify and reduce low-value care services in targeted specialties
- Engage with low-scoring providers to help adjust their behavior and improve their scores
The wrap up
While the realized cost savings that result from an optimized provider network will vary from plan to plan, the value of optimizing is well documented and the potential impact is encouraging. (As demonstrated by the NeuGen case study we discussed above.)
Organizations that strategically manage and engage their networks will see substantial results in the form of both revenue and growth.
If you’re looking to get started optimizing your provider network, Zelis can help. Connect with us here.