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Why Provider Data Is Key to Effective Managed Care Coordination and Growth


Managed care organizations need to look at how they can better manage their provider data-or risk getting left behind in a pile of spreadsheets.

Healthcare technology

Managed care spending is poised to accelerate dramatically in 2019, spiking from its current level (approximately 20%) to upwards of 30% of overall healthcare spend. This acceleration is spurring health systems to focus on better care coordination.

It’s needed: risk has shifted to health systems and providers from commercial payers. Health systems must be laser-focused on managing the cost of care delivery. There will be winners and losers: health systems delivering the highest quality at the most affordable cost will win patient volumes-and market share.

Related article: Three Ways Health Organizations Can Improve Data Use

Better care coordination starts with better provider data. Health systems must meet the operational challenge of managing provider data for thousands of participating providers in their value-based care networks. Provider information transparency for patients, providers, payors, and partners is a requirement-sharing what networks and health plans they participate in, how providers are tiered. Managing this deep level of provider data is daunting for clinical network managers, who typically manage provider information using archaic tools, adding inefficiency and potential errors to the mix.

With a growing premium placed on outcome- and cost-conscious referrals, it’s clear that coordinating information in the new healthcare world requires a new information management tool focusing on one key aspect: provider data.

The provider information management challenge

Take the case of a Clinically Integrated Network (CIN) in one of the nation’s high population density regions. This rapidly-growing, physician-led CIN is sponsored by a leading academic medical center, and boasts several thousand employed providers working with nearly as many independent community providers. This CIN’s stated goal is to optimize the health of its region’s residents, transform the care experience for patients and providers, and manage the total costs of health care.

In the five years since its formation, the CIN has grown quickly and now has nearly 200,000 attributed patients across the region from multiple value-based arrangements. Those aligned patient numbers will be increasing by more than 40% in the coming 12 months. The CIN’s goal is to stay ahead of national trends in use-mix of alternative payment models (APMs) which are expected to continue growing.

The rapid growth of the CIN has created a challenge for the team’s day-to-day roster management of providers, including tracking each provider’s specialty, areas of clinical interest, location, availability, and other data necessary to ensure effective in-network care coordination. This information must also be readily searchable by the care coordinators and analysts on the population health team. And this provider data management challenge is not contained just to value-based care-providers participate in more than 20 commercial health plans, clinical networks, and accountable care organizations-and they constantly change affiliations. Managing so much provider information taxes network management, marketing, registration, scheduling, IT, and revenue cycle teams.

Value-based/managed care leaders report that inaccurate and incomplete provider information causes a variety of unfavorable business outcomes, including:

  • Administrative inefficiency created by multiple (and sometimes overlapping) teams continuously researching providers to determine their current network affiliations

  • Delays in payment due to inaccurate network-related provider information

  • Gaps in network coverage and adequacy by not having visibility into providers’ specialties and subspecialties, which leads to imperfect provider targeting and recruiting

  • Reduced in-network referrals and utilization (if PCPs don’t know which specialists are in or out of network, patients may leave the network), resulting in higher costs

A root cause? The tools that value-based/managed network teams today must rely on: massive spreadsheets with thousands of rows and hundreds of columns. What’s needed is a new provider information management platform that supports core functions to maintain operational provider data: provider enrollment, management, reporting and search across a health care enterprise. The spreadsheets need to go to keep pace in the era of managed care.

Related article: Four of the biggest challenges faced by health information organizations

2019: The year of provider information management

The growth in managed care will make 2019 the year that health systems make provider information management as a strategic priority, as vital as patient information management. Value-based/managed care teams need provider data management tools that scale across the enterprise and span the end-to-end experience of all patients, providers, payors, and partners.

Tom White is the CEO of Phynd Technologies.

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