Fierce Q&A: Optimize provider networks to drive quality care


I'm sure anyone reading FierceHealthPayer over the last few years has noticed a constant thread throughout many of the articles and editorials. Namely, that payers and providers must work together if they have any interest in improving the quality and efficiency of care.

However, it's often easy for people such as myself to advocate for lofty goals (and, admittedly, sometimes admonish the failure of attaining said goals) when you're not the one on the ground doing the actual nitty-gritty work. So that's why I welcomed a recent white paper from the folks at UnitedHealth's OptumInsight. It provides specific examples of how one concrete step--optimizing provider networks--can help facilitate more harmonious working relationships between payers and providers.

Purposefully developing provider networks takes a lot of time and resources. But it's worth the effort because it activates the "single largest lever for bottom-line improvement" available to payers. And by collaborating with providers toward creating high-performing networks, payers can help transform healthcare management and delivery, according to the white paper.

To learn more about how payers can enhance their provider networks while improving their relationships with providers, FierceHealthPayer caught up with Paul McBride, senior vice president and general manager of network management and operations at OptumInsight.

FierceHealthPayer: What characteristics contribute to an ideally optimized provider network?

McBride: An optimized provider network is one that offers transparent care and can be measured by cost, health outcomes and efficient delivery. Optum recommends that a provider network be based on certain parameters, including building and fostering plan-provider partnerships, segmenting patient populations according to engagement and membership, and using advanced analytics and engagement to create actionable intelligence.

Together, these are the critical areas of focus that help differentiate an organization from its competitors, generate higher quality medical care, lower costs, and improve financial and overall business performance.

FHP: How does optimizing a provider network benefit insurers?

McBride: Today's healthcare landscape is an increasingly dynamic and competitive one. Health plans must constantly identify ways to improve care and manage costs to succeed or even continue to operate in some cases. The single greatest driver of improvement--both in terms of quality of care and cost efficiency--is for payers to leverage their relationships with their providers.

Provider network optimization focuses on creating more effective working relationships between health plans and providers by targeting key business areas, including increasingly sophisticated engagement strategies, performance measures and incentives, and analytics. These efforts influence overall care quality and cost-effectiveness, and differ from a payer's conventional focus on broad network access and unit cost management and then engaging providers on a primarily transactional basis for administrative issues.

An optimized provider network provides higher quality medical care, lower costs, and better bottom line financial performance for both payers and providers. Health plans that create and maintain the highest quality and most cost-effective provider networks are able to differentiate themselves in the marketplace, especially among valued group customers, regulators and a surging individual market.

FHP: Does creating limited or narrow networks achieve the same goals as optimizing an existing network? Why or why not?

McBride: There are several working definitions for narrow networks, but generally the concept is used in reference to setting up a subset of payers' overall networks to provide services for a specialized benefit plan. Selecting a subset of high-performing providers to compete successfully for certain members, such as for individuals in an exchange environment, is one way to begin to optimize the network. 

However, an optimized network requires more than only selecting and contracting with the right providers. It requires supporting that network financially and with information to help the providers improve performance on cost and quality, which is best done in an active and sophisticated way rather than through a standard program across a broad set of providers.

FHP: What role does data analytics play in improving provider networks?

McBride: Payers have access to an abundance of data, but they sometimes struggle in converting it into actionable information. Today's sophisticated databases, data-mining capabilities and statistical analytic tools can capitalize on the potential of these data to help providers make ever more informed healthcare decisions. For example, data-mining techniques build predictive models that identify which members are most likely to need certain services, which members are most likely to experience specific disease conditions and which providers to focus intervention or support programs on. They also can detect and measure evidence-based medicine gaps in care, which form the foundation for provider quality measurements and incentive programs.

Plans also might use these measures to engage with providers concerning anticipated needs for patient intervention. These advanced analytics, coupled with engagement strategy translate into action from providers and better health outcomes for patients. The overarching equation is simple and it works: "Advanced analytics + engagement = actionable intelligence."

FHP: How do you define a high-performing provider?

McBride: A high-performing provider is one that has invested resources, leveraging them beyond limited patient experiences and achieving best-in-class patient outcomes. High-performance is a continuous process rather than a destination. Recognizing that there is no one-size-fits-all solution, organizations that meet or surpass rigorous performance measures are considered high performers.

FHP: How should insurers handle any potential pushback they might receive from providers as they work to optimize their network?

McBride: Engaging with providers on quality and cost improvement programs can be difficult if not managed correctly. The most successful collaborations involve a variety of techniques that emphasize shared objectives and ensure those goals are being met. For example, insurers might use industry standards and accepted measures, peer grouping and benchmarking, and care gap identification techniques to gather critical data and then push actionable solutions as close to the point of care as possible.

The conversion of data into actionable information that is integrated into a provider's workflows to improve population health using evidence-based medicine is the solution. This is not the kind of thing that can be done transactionally or evenly across a broad network, so finding the right provider partners who are positioned to succeed with the right program enabled in the right ways is critical.

FHP: Have you calculated or quantified the cost savings payers could achieve by optimizing their provider networks?

McBride: The cost savings that result from an optimized provider network vary from plan to plan. The value of optimizing provider networks, however, is well documented. Organizations that strategically manage and engage their networks can see substantial results on their bottom line--in the form of revenue and growth, as well as medical and administrative cost improvements. For example, a Blue Cross Blue Shield plan that worked with OptumInsight saw a 5 percent reduction in premiums offered to members who chose high-value over high-cost networks.

Editor's Note: This interview has been edited and condensed for clarity.