As the access point for patients, provider networks carry significant influence over the cost and quality of the care each patient receives. The efficiency of the network is a primary concern for organizations that seek to reduce care variation by standardizing around prudent care that maintains quality while eliminating waste. Hence it is of utmost importance to measure risk-adjusted provider performance to steer patient care towards in-network top performers and intervene at lower tiers to address issues. Also a concern for organizations is the composition of their patient networks themselves. Increasingly viewing themselves as consumers of health care and selecting/moving to networks they perceive best suit their needs, successful organizations will need tools to attract and retain their ideal membership.

  • Provider Performance and Efficiency involves evaluating provider cost of care and performance as well as encouraging data transparency. Clearly displaying care and quality score measures that account for patient risk, facilitates provider behavior modification to deliver more efficient care and drives optimum provider utilization. Detecting provider quality issues such as over and underutilization of resources and care protocols that do not match the regulatory mandates or contracts are critical for risk-based business models.
  • Network Management strives to make organizations more efficient by standardizing care and operations around top performers and attracting and retaining high-margin members within the network. Member leakage due to out-of-network referrals by providers needs to be identified and addressed. Steerage of patients to preferred providers helps in managing the utilization of high-value services cost effectively.
  • Key Industry Challenges Addressed

    • Measure risk adjusted provider efficiency to make like-for-like comparisons between groups and individuals
    • Forecast and monitor key metrics like network leakage and quality measures (HEDIS, Stars, P4P, & ACO)
    • Evaluate members by type to make informed decisions about how to design packages and programs that resonate
    • Right-size incentive packages to drive desired behaviors at the maximum return on investment

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Insight-Driven Outcomes: A Focus on Risk, Quality and Provider Networks

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Value by Design: A Population Health Primer for Provider Groups

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Time to collaborate on Population Health -
by Rose Higgins

Time to collaborate on Population Health