Admittedly, I’m new to provider network management. I’ve spent years working in healthcare, but this is my first time working with payers from across the nation to improve the access, adequacy, and accuracy of their provider networks. Lucky for me, I got a behind-the-scenes view through Quest Analytics Vision Quest. As a session moderator, I heard from industry executives and gained insight into the questions and comments on the minds of people working every day in this industry. I learned a lot from this experience, and here are five of my light bulb moments.
1. Provider Network Management challenges require creative problem solving
Building and maintaining provider networks is difficult. It becomes even more complicated when tasks such as identifying gaps in your network, finding a provider in the area that will fill the gap, and understanding the value the provider will bring to your network before contracting with them – all significant requirements of the job – are relegated to being manual tasks. That’s not even to mention that some of these manual tasks produce the data and reports that are submitted to the state and CMS. It makes the job nearly impossible.
Dee Bellanti, Director of Provider Network Operations at HealthNow New York Inc. shared how she partners with Quest Analytics to solve her day-to-day challenges. The partnership has allowed Dee to streamline manual processes and develop new, “creative” ways for her organization to manage and understand its networks. A few of the pleasant surprises included optimizing provider negotiations with termination analysis, enhancing monthly board reporting, increasing the efficiency with provider recruiting, and saving time with submitting HSD exception requests. Dee described how she now runs network “what-if” scenarios in minutes using Quest Enterprise Services – a process that used to take hours.
2. Telemedicine is viable and scalable but there are still obstacles
Although we are still dealing with many of the traditional barriers to the adoption of telemedicine, including patient and provider acceptance, reimbursement challenges, and restrictive regulations, we are seeing an increase in the volume of telemedicine visits without an increase in costs to healthcare providers. This is good news as the viability of telehealth has been in question. The expectation is that the volume of visits may decrease as the pandemic fades. However, telemedicine will still be a viable and accepted option for care as industry silos break down and patient adoption grows.
According to Dr. Bill Lewis in his session, “Tracking the Transformation of Telemedicine,” patients are utilizing telemedicine more now, as they have to deviate from their normal patterns of care. The studies show we are seeing patients with chronic illnesses adopt telemedicine at even higher rates. Providers are embracing telemedicine across services with 30 percent – 40 percent of providers transitioned to telemedicine offerings. This transition means that the demand is present, and providers can scale telemedicine offerings. To foster the innovation, health plans will need to continue to stay abreast of these new technologies and work with regulators to ensure adoption, reimbursement, and coverage.
3. As health plans expand, data and networks must be scalable
Krista Lehm, Director of Provider Operations Group at Cigna Medicare, in her session, “Building Efficient Networks,” discussed how to overcome the complexity of data integration and management that comes from mergers & acquisitions. It is truly weeks and months of working across siloes to break down data management processes, workflow issues, and even terminology differences. It all comes down to having a singular process, the appropriate tools, and hierarchies of accurate data to build “that one book of record” for data.
As Krista described it, “with ensuring accuracy, it’s not being loaded into five different systems. That piece of data goes into one place. And then it flows through all the other systems.” This type of automation has increased the quality and accuracy for Cigna across all lines of business. By addressing and improving their data management process first, they’ve been able to create organizational efficiencies. This has allowed them to reallocate their time to focus on creating better ways to help their members have access to care.
4. Today’s expansion efforts require faster access to analytics
The days of only running network analyses once a month are over. According to Sherye Loveall, Director of Network Data Analytics and Reporting at UnitedHealthCare, their Medicare expansion efforts have grown exponentially due to automating their network access and adequacy analyses. They now run their analytics every week. “We could start cleaning up the data to produce quality data. We can see, download and strategize the data by looking at our Adequacy results. We are able to see week-to-week if there are any new gaps and who we can contract with to fill those gaps,” said Loveall. This was monumental for Sherye and the team as they oversee the Medicare Advantage product and are responsible for expansion as well as maintaining compliance, which includes closing network gaps in less than 90 days.
5. Available datasets must grow for health plans to care for the people they serve
In the roundtable session, “The Future of Provider Network Management,” Juan José Orellana, Rita Johnson-Mills and Frank Ingari agreed that the future of provider networks relies on more social data. Orellana said in response to Johnson-Mills’ statement about health plans tracking social data, “as you start thinking about payers and providers in this space, it is really an opportunity for these folks to take an activity that’s been rooted on compliance and regulatory aspects, and take ownership for it and differentiate themselves.”
And he’s right. As more data around demographics, culture, access to technology, access to transportation and the other social determinants of health become readily available, it will be up to providers and payers to find opportunities to expand their networks in innovative ways – to provide not just adequate, but superior access to care.
My colleagues and I are ready to work through all the questions and challenges presented at Vision Quest. For me, the two days showed the large amount of work there is to do in improving provider network management. And I look forward to working with industry leaders and our clients to meet those challenges and continue to advance access to care.