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Introduction 

Few health plans or healthcare provider organizations feel they’ve achieved their goals of improved outcomes, lower cost and higher satisfaction. Yet, these goals of managed care continue to gain momentum. Coronavirus disease (COVID-19) has increased the imperative to prioritize patients based on medical needs. And CMS is signaling they will continue to pressure health plans and their networks to prove they deliver quality at an affordable cost. 

One of the reasons for not achieving goals is health plans and providers are still struggling to unify their efforts. Pursuits of value-based reimbursement arrangements have been rolled out with requirements that have led to unintended consequences. Volume and variability spring from every health plan program, and it can sometimes overwhelm providers with variety and complexity. This growing demand can steal time away from patient encounters and challenge provider organizations with a seemingly infinite number of requests to accommodate. And the patient lives at the tail end of this confusion — coping with illness, uncertainty and perhaps a challenging care plan. 

This problem is not going away. Solving it requires answering three questions:

  • How can health organizations achieve better outcomes without burdening clinicians with administrative variability and documentation demands? 
  • Even with interoperability streamlining information, how can the specifics of each health plan program come to life in each provider organization? 
  • How can we help to ensure that each patient actually receives the best and most complete set of services their health plan and provider team can offer them?
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We believe the “how” is through a new role — Chief Outcomes Officer. This position would consider the factors of providers, health plans and all patients to help ensure that the data exchange is productive, requirements are streamlined, and consumers can access all available health and support services. 

The industry has experienced this before. When the consumer experience emerged as a driving element of growth, the Chief Consumer Officer, or some version of it, became a standard position. Now, health care is poised to enter a similar phase of transformation — this time toward a singular, coordinated effort between health plans and providers to improve outcomes.

This paper will explore how this new role — Chief Outcomes Officer — could reduce costly administrative variability and redirect resources and workflows to deliver and document improved outcomes. 

It will illustrate how a centralized position or a strategic partner can standardize, simplify and streamline the needs of various quality programs — increasing the time physicians have to spend with patients. And it will share a vision for how this approach can remove administrative burden and link the goals of disease/care management programs to risk adjustment and quality programs. 

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Alleviating administrative burden 

Despite good intentions, health plan risk and quality programs have created an excessive administrative burden for providers. 

A desire to be unique has created variability

As health plans strive to differentiate, they have developed a variety of programs that they believe will help them achieve their business goals, improve the health outcomes of their members and differentiate them in the market. And they can launch from two sources — the ability to anticipate risk from the financial side and the ability to improve population health, which is driven from the clinical side. However, this creates a problem of variability for providers, who are burdened with the unique demands of each health plan relationship. 74% of providers say that variation in health plan processes is a significant challenge in meeting program requirements.1  And, this increases to 84% for larger health systems which have 2 - 5 times the number of health plan contracts.  Health plans acknowledge that their programs can create challenges for providers, but they underestimate the impact of program variability.

On average, provider organizations contract with about 10 health plans.1 If each health plan has unique expectations, data requirements, forms and incentive programs, that multiplies the number of processes a provider has to manage in order to receive value-based reimbursement. As a result, provider organizations are having to invest in technology and staff just to manage the various health plan administrative processes rather than deliver care.

The cost of administrative variability

77% of health systems experience moderate to serious problems with staff capacity to support health plan risk adjustment and quality programs.1 Also, over 50% of large provider organizations experience moderate to severe financial impact arising from the various demands on staff, processes and technologies from health plan risk adjustment and quality programs.1 

The strain is on physicians directly as well. The time spent on documentation and follow-up is cutting into the time that clinicians can spend on patients, with about a quarter of physicians spending less than 12 minutes per visit.2  Clinicians can also be frustrated when they are asked, via their EMR, to treat patients differently based on their coverage and the unique requirements of each health plan. In fact, 74% of providers say they are challenged by variation in health plan processes, changing processes and adding to clinician workloads to participate in programs.1 While the front office cares about proper billing, and rightly so, the clinician needs to know about the patient. The variance in authorization, required documentation and order sets flows from the business side of the organization right into the patient/clinician encounter. Unfortunately, it is dominating the exercise and reprioritizing clinician time and attention away from the patient.

We need to be clear about expectations regarding time required that come from the health plan and compare those to the real-life experience of the provider. Only then will health plans be able to see the number of administrative hours being unintentionally created because of variability. Once the severity of these unintended consequences is clearly laid out, the solutions will come into focus. 

How a Chief Outcomes Officer could help 

  • Take stock of every piece of health plan data that is being introduced to the provider workflow, and every piece of data that is being sent back.
  • Take inventory of risk adjustment and quality incentive and outcome-based programs. Determine how much common data can be shared and how much unique data is required. 
  • Seek input from network providers to identify pain points of variability and look for opportunities to facilitate a common provider experience to reduce variability and the associated costly administrative burden.
  • Dialogue with program developers to illuminate the volume of documentation they request and work directly with individuals doing the documentation to brainstorm ways to streamline these requests.
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Increasing focus on outcomes 

The motives for moving from fee-for-service to value-based care are fundamentally correct. Value-based care seeks to provide a more holistic, preventive approach that takes a complete view of the patient into account. 

However, the basis for many health plan programs come from different perspectives and different objectives.  For example, risk-adjustment programs are often led by Chief Financial Officer with a focus on the specific documentation required for them to receive funding reserved for member benefits. Quality programs are typically led by the Chief Medical Officer with a focus on Star and Healthcare Effectiveness Data and Information Set (HEDIS) measures. 

“These programs are hard for the patient to understand and patients' preferences are rarely accounted for or undermined because they're unaware of what is available to them and how to use services. Need to do more to incorporate patient choice into the stream of care models.” Physician Practice, Large1

72% of providers feel there is misalignment of program needs and metrics or targets with improved patient experience.  And, CMS with their language of “patients vs. paperwork” is signaling that there will be even more scrutiny on these programs. 

If health plans are going to get full provider buy-in to these programs it not only requires addressing the administrative variability changes, it requires demonstrating the alignment of these programs with improved outcomes.  “They are going to have to prove that things are getting better,” OptumInsight CEO of Payer Services and Solutions Benton Davis said. “Health plans are going to have to become much more engaged in consistently demonstrating improvement in the health status of their members.”

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How a Chief Outcomes Officer could help 

  • Educate providers about the variety of health plan-provided benefits that each patient can access.
  • Follow up to ensure that clinical programs are being fully optimized and utilized to treat the complete health picture of the patient.
  • Follow up with patients to direct them to the proper site of service or plan benefit for evidence-based preventative care and chronic condition management.
  • Make sure that patient transitions out of the hospital are coordinated and that they get the post-acute care they need. 

 

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Turning to a transformative new role 

Almost all (95%) provider organizations recognize the positive impact of payer risk adjustment and quality programs on patient outcomes.1

“With risk adjustment programs the insurer is more involved in the patient experience system rather than the standard for-profit approach. Insurers are exempt from charging higher premiums to people in poorer health or denying them coverage.” Physician Practice, Medium

However, there is still room for improvement.  Only 36% of providers feel there is a substantial impact from these programs on HEDIS and STARs results, and those that don’t see a positive impact on outcomes site lack of focus as the primary reason programs are not having an impact.1.

We believe these challenges can be addressed by a new role that exists between health plans, providers and patients. This position could facilitate data exchange, work with programs to meet their goals, and help patients find the care they need and desire. By eliminating these gaps and disconnects, a Chief Outcomes Officer could help health care organizations deliver on the ultimate promise of value-based care. 

Ready for part 2? 

Read how a chief outcomes officer can eliminate unnecessary administrative burden, and improve outcomes.

Read Part 2: Unlocking the potential of a Chief Outcomes Officer

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Benton Davis

CEO – Payer Services, OptumInsight

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Tiffany Diamond

Senior Vice President, Payer Marketplace, OptumInsight

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References

1 Frost & Sullivan. The Impact of Health Plan Risk Adjustment and Quality Programs on Healthcare Providers. presented to Optum. July 23, 2020. 

2 Statista. Amount of time U.S. primary care physicians spent with each patient as of 2018. Physicians, Hospitals & Pharmacies page. Statista website. 

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