Editor’s Note: Rick Ingraham is the Director of Vertical Markets at LexisNexis Health Care.
A Russian proverb, “Doveryai no Proveryai”, was adopted by President Ronald Reagan in 1986 as he was preparing for talks with Mikhail Gorbachev. “Trust But Verify”. The degree to which an era of trust, while verifying, worked politically goes beyond this writer’s training but I would argue that the healthcare industry might be well served to work toward a similar culture.
It may indeed prove to be necessary if we want relationships between health payers and providers to evolve into one whereby verification becomes more of a mutual collaboration into what is “working and what is not”, rather than a system to penalize for poor performance.
A wide variety of health insurer/payer programs focused on provider performance have been implemented that were directed to drive physician behavior or practices that best minimize the cost of medical care rather than the overall efficacy and efficiency within the provider setting.
Accordingly, Pay-for-Performance (P4P) has taken a rocky journey as the programs either:
1) Primarily penalize the provider community via reductions in reimbursements with too little opportunity for bonuses (a carrot is better than a stick);
2) Fail to adequately factor and reward for the quality of the actual care delivered; or both. Given the Institute of Healthcare Improvement’s Triple Aim of Improving the Health of a Population, Improving the Care Experience, and Lower Per Capita Cost of Care has been consistently supported by all players within the healthcare continuum since the early 1990’s, current efforts to shift from a fee-for-service to value-based reimbursement programs might be considered long overdue.
The time spent to get to this point has, however, enabled a third player to augment the provider-payer relationship in better achieving the triple aim through the provider performance improvement arena: data technology.
Steps toward achieving healthcare consumerism’s critical components of Access (adequate and appropriate provider network availability); Quality; Affordability and Satisfaction are now being facilitated through technology that can leverage increased sources and data size.
Technology can now facilitate heightened provider-payer collaboration via accurate, timely and prospective modeling for performance considering a broader spectrum of variables include patient risk, case mix, and care/cost efficiency.
Additionally, traditional in-house data sources can be augmented with socioeconomic data to afford a more comprehensive view of the care provider and their impact on care success.
Going beyond preparation for the increasing value-based payment models and better movement toward the Triple Aim, there are additional pressures in-play that make measuring provider performance important.
Many health plans are moving toward narrow networks to manage provider reimbursement. Provider efficiency and quality measurements are critical.
The Affordable Care Act’s mandate for care network adequacy demands inclusion of the best possible providers located near patients needing the services required to manage all of their health conditions. A lack of providers in a specific geographic area may force health plans to include them in narrow networks but does not prevent the health plan from identifying and addressing quality.
Finally, an aging population, increasing in percentage of the total population over 70 and with increasing rates of chronic conditions, in conjunction with a forecasted shortage of new providers available to manage health outcomes dictates the need to monitor provider performance, identify ways to impact efficacy and efficiency, coach and mentor providers to get greater alignment to benchmarks, and build relationships of trust with the provider.
Certainly, the most prevalent movement within the provider performance solutions market has been the intensified attention within the insurer and government payer space around improving measurement of and communication with the provider community. Perhaps an even greater focus opportunity lies within fully integrated plan provider networks, accountable care organizations and even patient-centered medical homes.
Indeed, any enterprise taking on the mantel of quality affordable and coordinated care ought to consider a provider performance monitoring or management solution. Any care coordination and delivery discipline relies heavily on the fundamental found in today’s provider performance systems.
Best case practices or lessons learned at this stage that optimize provider performance solutions include:
· Remembering patients are not monolithic and illness burdens can vary widely. Case complexity also influences cost.
· Patient and physician compliance with established protocols of care impact future care.
· Establishing specific care management goals and identifying providers with a track record for exceptional performance can affect outcomes positively and control future costs. Identifying less robust performers can lead to improved collaboration to improve outcomes and avoid network expansion costs.
· Analytic tools are critical to establish provider performance and quality compliance with benchmarks when networks must be narrowed.
· Analytic tools must be flexible enough to fairly measure and accomplish appropriate and accurate comparisons under changing criteria and conditions. Filters and templates that yield logical sub-sets, reflect regional variations, create meaningful relationships through peer groups and can be applied repeatedly to monitor longitudinal performance, are critical.
· Provider Performance Management should enable greater insight into points of impact within any Population Health initiative. As these initiatives arrive at better and more focused impactful sub-segments of total populations, in addition to the traditionally most costly chronic conditions, operationalizing engagement methodologies with the most appropriate provider communities and the patients will be critical to more quickly working toward keeping sub-segments from moving into the classic 20% driving 80% of cost group while maximizing quality of life.
Never before has the clamor for analytic insight been as great as the industry deals with changing models of care delivery, care payment, care consumption, care supply and costs constraints and drains. Luckily, data technology now stands ready to support this era of change.
The question lies in how will the provider and payer communities react, respond and implement operational changes based upon data systems of intelligence?
Trust and Verify? The best provider performance monitoring solution should facilitate meaningful dialogue between physician and payer. Accurate measures of performance build trust. Trust, through verification of the data and measures, builds increased insight. Increased insight can improve every aspect of achieving the Triple Aim.