3. Assessing Organizational Risk/ Improving Contract Positioning
Having that kind of actionable insight allows High Performing Networks to accurately assess their organizational risk via both predictive modeling and cost utilization analysis, which could give you a leg up when it comes to contracting rates with payers, according to Taylor.
“Payers are so hungry for clinical data that it really puts the bargaining chips in the hands of the providers who have a much more complete picture of their populations. The High Performing Network uses the same predictive modeling and risk assessment tools that payers use, but the quality of the data that fuels those tools is much higher for the network than the payers. This can provide significant advantages in contract negotiations and provide a competitive edge in a network’s market. It’s quite an enviable position to be in,” he said.
4. Evaluate the Patient Experience
Evaluation of the patient experience is important for a network to become high performing. Having insight into patients’ satisfaction and experience with physicians, practices, facilities, programs, etc. is critical for understanding the patient’s view of success. Because most patients aren’t paying for more than a small percentage of their health insurance costs, it’s easy to lose sight of the fact that the patients are the consumers of health care, and their opinion matters.
“The High Performing Network recognizes that delivering high quality, cost effective care isn’t enough. Our value to the patient is measured by much more than our ability to keep them healthy and address their ongoing medical needs,” said Taylor. “We must demonstrate that we have enough time to answer questions during an office appointment, be available after hours, have clear and accurate billing procedures, and prove that he or she is valued customer and not a burden.”
Bringing It All Together
Predictive modeling and risk assessment, cost and utilization, and patient experience information is important and required for operational excellence, but it can easily get lost if it isn’t displayed in a consumable fashion, said Taylor. It’s also easy to think of each of these types of information separately, which is sometimes very reasonable, but the real power lies when you bring it all together.
Your physicians’ clinical, financial, utilization, and patient experience outcomes will likely look like a bell curve for any given metric. Understanding why often requires more than one type of information, preferably from the same data set and using the same system to bring it all together. For example, maybe Dr. Smith’s diabetic patients cost more because they are sicker (financial, utilization, and risk assessment/case mix severity analyses). Maybe Dr. Jones does more hysterectomies appropriately based on her patients profiles (clinical and utilization analyses). Maybe Dr. Johnson’s heart failure patients have higher readmission rates because his patients can’t get in to see him in a timely manner (clinical, utilization, and patient experience), etc. The High Performing Network uses all the information and tools at its disposal to create a 360-degree view of its patient, providers, facilities, and services, and it proactively uses that information to make improvements.
Like any part of the process, taking on the tasks of a High Performing Network can be extremely challenging. Taylor has said from the beginning that the maturity process isn’t easy. Still, Taylor points out that the things worth doing are often accompanied by obstacles, and network maturity is no different in that respect. “The work is hard, and the journey is long, but the rewards of network maturity are real,” he said. “Remember the orchestra. Harmony doesn’t just happen. It’s created by using the right players at the right time. Find your rhythm first—we think this maturity model can help you do that—the rest is up to you.”
