Posted by: Jenny Laurello
Affordable Care Act, Infrastructure, PPACA, Technology infrastructure
Guest post by: David T. Smith, Senior Director of Product Management, McKesson Health Solutions
With the passing of the Patient Protection and Affordable Care Act of 2010 (PPACA), an estimated 32 million more individuals will require access to health care services. To meet the needs of a rapidly expanding pool of members with unique needs, health plans are exploring innovative health care products, alternative care delivery models and new reimbursement designs.
Health plans need to innovate in all of these areas, and they must do so in a carefully yet coordinated manner. Innovation requires more than simply breaking down the barriers that exist between different system and data silos, and more than just eliminating paper-based exchanges between different parts of the organization. Health plans need to step back and look at the technical interplay of all products, networks, delivery models and reimbursement systems as a single, integrated entity. Indeed, a single, integrated entity is what a health plan needs to become to enable greater access to higher quality care at a lower cost.
Design for Care
So, how do you become this single, integrated entity? Today, let’s start with the fundamental issues such as data and provider networks. In subsequent articles, we’ll extend this discussion to talk about provider contracting and reimbursement.
Technically, a fundamental step is to establish a single source of enterprise truth for your provider/practitioner data. This single source of truth must have a relational information model that enables the storage of a wide range of relevant information: provider demographics, provider affiliations, identifiers (e.g., legacy identifiers, NPIs, crosswalk rules), contractual relationships, product information and more. Additionally, this system should leverage rules-driven workflows to enforce data governance policies during the intake process and while ongoing maintenance activity occurs over the data’s lifetime.
A frequent mistake is the reliance on a legacy claims system to capture and maintain this information. These systems were not designed to maintain a 360-degree view of your providers/practitioners, and the customization required to make them do so is costly. Once you have data you can work with, you can begin to create optimized networks. The more data you have to work with, the more distinct networks you can create. The ability to create these highly tailored networks is critical because they will become the core building blocks for creating unique value to each one of your customer segments.
Consider the following: In the Network Performance Management group (formerly Portico Systems) at McKesson Health Solutions, we have developed a solution that a payer can use to automatically create networks – for example, narrow, specialty care, client-specific, disease-specific – virtually any kind of network you can imagine. A payer can create a description of the character of a given network, using both implicit and explicit criteria such as geography, specialties, provider types, quality indicators, contractual relationships and contract owner. After building this criteria-based expression, the network management system automatically designs the network based on the criteria.
The ability to automate network designs by leveraging flexible criteria-based expressions offers many advantages. First, payers can lower their provider administrative costs. Inherent in the network design automation processes are the day-to-day maintenance tasks that take place during the lifetime of the provider data (e.g., new providers, evolving specialties, changes in membership populations). Therefore, the quality of the network will be higher than one that a payer maintains manually.
Additionally, by having a systematic process for the creation and maintenance of provider networks, the payer has the option to build on existing networks. It’s no longer necessary to start from scratch each time. This approach enables the rapid creation and consideration of alternative models. Most importantly, it enables a payer to align network models very efficiently in response to – or in anticipation of – client demands, care delivery changes and reimbursement experimentation.
Beyond administrative efficiency, automating this process also supplies a competitive advantage by increasing the speed to marketnew products. Based on the criteria expression, a payer can model a variety of slightly different provider networks that are linked to specific member-facing products and their associated contracts.
These flexible linkages between the products and networks, along with their associated contracts, gives the payer greater insight into what these changes are, and also how they impact their existing provider relationships and network membership. Network design changes affect the provider-facing products (the varying relationship options between a provider and payer) as well as their member-facing products (the market-facing products that customers buy). The network management system must be intelligently aware of all these components in order to streamline the change process and produce networks that have the goal of providing high-quality, affordable care.
Alignment Is the Key
Ultimately, designing for affordable care is all about the ability to work with all your information to model and then implement new, innovative networks that are optimally aligned to deliver the right care to the right people at the right price.
You can start to imagine, too, how these same ideas can be extended into the realms of contracting and reimbursement, which will be the subject of later articles.
So, take a deep breath and look around. You’re going to need a thorough understanding of what your infrastructure looks like today in each area of provider operations. Once you know what your data and systems infrastructure looks like, you’ll be in a position to plan a migration toward a data model that all your processes can use effectively. You’ll also be in a position to see where you may need to make changes to your physical (or virtual) infrastructure so that you can make the most of this information going forward.
For more information, please visit McKesson Health Solutions.