By Krithika Srivats, Vice President, HGS Healthcare Practice Office
The rising cost of healthcare is dinner-table talk at households across America. And it’s clearly high on the agenda of challenges for payers and providers. In response, there has been a widening scope of emerging analytics and reengineering solutions created primarily to reduce operational effort and hopefully, cost, through highly automated digital innovations led by intelligent machines. Yet the question remains: How will these developing services effectively improve individual health in an environment where the consumer has limited decision-making abilities, as well as a lack of transparency and connectedness from growing integration of hospitals, private clinics, and payers? In today’s world, where personalized experience is the center of every consumer interaction, these challenges have a direct impact on outcomes.
Large business process outsourcers (BPOs) handle over tens of millions of interactions between payer- provider and patients and have deep understanding of the gaps that exist in these relationships. While we wait for solutions, we need to leverage the knowledge that exists in these pockets of excellence. To this point, and in light of industry focus as per a recent Forbes article, I suggest three ways to improve care connectedness, including:
- Proactive collaboration to facilitate and reduce frustration of interactions. At an average, provider organizations interact with payer organization across benefits and eligibility, clinical decision making, and claims denials and grievances. These interactions are estimated to comprise almost 40% of the provider time, leading to not just resource constraints but also a perpetual relationship tension, which ultimately impacts the patient. While electronic data exchange solutions and accountable care contracts have been implemented, the improvement in resolution is negligible, according to HGS internal research, at less than 5% in best cases. To solve for this, BPO companies can cross-skill resources to provide proactive education on key pain points, such as authorization decision failure points using historical analysis of top 20 denial categories. Similarly, claims denials-related clinical documentation integrity and coding inaccuracies can be contained through targeted provider webinars, based on top providers contributing to such errors and help them align on the cost impact for both payers and providers. Lastly, it is highly effective to deploy analytics and machine learning to provide historical insights on behavioral parameters that are causing additional cost and delay in resolutions .
- Connected decision making. Ideally, providers should show adequate attention to payer involvement in their patients’ care. Such interactions can drive collaboration to positively impact patient outcomes. Most primary care providers are part of large health systems and frequently change network participation, as well as locations. The patients’ ability to stay connected with the provider has been reduced by over 67% in the last decade, according to a recent study by a large payer in California.Hence, a collaborative care post-hospital discharge is very critical for preventing readmission, which is a penalty metric for most hospitals. Payer care management programs should focus on collaborating providers to not only connect with their members but also to help providers in meeting their quality goals. The result is an increase in compliance to quality reporting, such as HEDIS.
- Data sharing to improve member outcomes. Most providers and accountable care organizations (ACOs) have more than 200 required reporting metrics. Not only do most of those have a financial impact on the provider, these same reports also impact the payer financials. When a payer works with a provider to retrace and extract key parameters relevant to risk adjustment, clinical claims review or HEDIS, the insights beyond the required compliance inputs need to be tracked and analyzed. This will reduce duplication of effort and reduce burden of medical records submission by the providers. In return, payers should share the insights with the providers in order to help them align with the common objectives of patient outcomes and reduced cost of care.
Most industry leaders envision a future in which the payer and provider are partners working toward a common goal, and these incremental steps will go a long way in sustainable, intrinsic behavioral changes. All of these collaborative strategies are designed to reduce inefficiencies and interaction frustration and provide a better foundation for tomorrow’s customer focus.