Robert Hart, Director of Product Strategy, Lumeris
Anna Libers, Senior Director Product and Solutions, Lumeris
Understanding the patient and provider experience
As health system leaders aim to restore financial stability and address the current volume impacts from COVID-19, many have expressed growing interest to participate in value-based models to help mitigate risk. But in many markets, the shift away from fee-for-service reimbursement has been slow, and the path to value has been harder than expected for organizations to show demonstrable outcomes.
For health systems to succeed in the near-term, they need to develop effective care retention capabilities to understand where care is delivered—both inside and outside of their own network—and operationalize the changes needed to improve in-network care utilization. With the right elements, health systems can deliver more coordinated care and promote a safer patient experience across all lines of business, including fee-for-service. Effective care retention activities can help position organizations for success in future value-based arrangements.
Persistent network challenges
Most health systems and provider organizations can experience upwards of 50-60% of care going out-of-network (OON)[i]. Along with the associated lost revenue, out-of-network care disrupts care coordination population health efforts and can lead to fragmented care.
Health systems and providers face numerous challenges to managing in-network care. Aside from the need to adapt physician practice workflows, referral processes and organizational alignment, there are technical, systemic and operational issues that can hamper care retention efforts. Technical issues with tracking clinical data across multiple EHRs and delayed claims data contribute to the limits of effective network utilization tracking and being able to make informed decisions. Further, operational processes in physician offices can still be manual or difficult to update and maintain. Accountability and governance across the health system level can vary, causing inconsistency in driving network initiatives. It is essential to understand how all of these activities impact the patient experience and prevent seamless care continuity.
A data-driven operational approach for coordinated, in-network care
Health systems need a comprehensive approach to align leadership and front-line clinicians to drive change around improving in-network care delivery.
- Analyze data to provide a baseline understanding of where care is being delivered and how referral patterns impact in-network care
- Incorporate input from physician practices and workflow assessments to understand the operational barriers that may prevent care retention
- Implement foundational elements and activities geared toward enabling a high performing, value-focused network such as the provider directory, specialist and primary care engagement, and practice communication and governance
- Educate leadership and front-line care teams about the importance of care retention and its impact on care quality
- Focus on the patient experience with better coordinated care to support population health, improved patient access and better health outcomes
- Work with physicians to optimize operational processes, reviewing network utilization data regularly to identify improvement opportunities
- Align strategy and tactics across multiple stakeholders from clinical, marketing and finance teams
Key drivers of success for improving care retention
Several elements are critical to enabling care retention:
- Cultural alignment and accountability to improve care coordination: Health system clinical and administrative leadership must be aligned toward the goal of delivering high value, in-network care. Even more important is a commitment to the enabling resources and operational changes needed, fostering shared accountability with physicians, care teams, medical directors and system leadership.
- Data and insights to review opportunities: Data and advanced analytics are essential to identifying the key patterns and opportunities around network integrity and care retention. However, technology and data alone will not solve OON care delivery challenges. The data needs to be applied to informing operations and practice workflow changes. In some cases, starting with the highest priority service lines can help focus efforts and drive engagement to then build on over time.
- Care team engagement and best practice sharing: Routine performance review is essential for understanding the impact from any operational changes. In addition, regular review allows for the sharing of best practices amongst clinicians to encourage behavior change, inform action plans and optimize referral practices.
Embracing the journey
Health systems looking to shift toward outcomes-based, population health care delivery need to connect with their patients at all points across the continuum and ensure efficient, high quality care. To do that, health systems need to enhance their care retention capabilities and adapt their operations to better align patient needs and coordinate care.
[i] Massachusetts Examination of Health Care Cost Trends and Cost Drivers, 2011;
Outpatient care patterns and organizational accountability in Medicare, 2014.
