Payers Should Be the Quarterbacks of Patient Care

Imagine being the quarterback who is unable to call the play until after the ball is snapped. Think of the chaos as tackles, running backs and other players do their best to advance the ball. But, with no direction, they are destined to fail.

Bevey Miner

Health plans and other payers are like that quarterback in terms of timely access to patient data. As patients move from physician to physician and care setting to care setting, a patient’s health plan is the only entity that can see a complete patient picture. The difficulty is that information generally isn’t compiled until a claim is submitted.

Admission, discharge and transfer (ADT) notifications have become more common as federal mandates require notification of a patient’s primary care physician or next healthcare destination as patients are admitted to and discharged from the hospital. But real-time event notifications to health plans, the true quarterbacks of the care process, can benefit patients with multiple health issues and comorbidities. By directing patients to the proper follow-up care, managing preventive screenings, and playing a more active role in patient care, primary care providers utilizing health plan recommendations can reduce costs while increasing the effective management of patient conditions, resulting in overall better health.

Health plans forced to the sidelines

Demographic research from the CDC shows that more than half of American adults (51.8%) have at least one of 10 chronic conditions, and 27.2% have two or more. The Advisory Board estimates that 18% of patients with one or more chronic conditions whose symptoms are readily ignored — such as uncontrolled high blood pressure — will become a high-risk patient and incur treatment costs far in excess of average. Care management (facilitated by the patient and his/her care provider) can reduce rising-risk patient escalation by one-third, states the Advisory Board, noting that intervention at the provider level is key.

Managing chronic conditions and getting people to receive recommended screenings such as mammograms and colonoscopies was a challenge even before the pandemic hit. During the initial nationwide shutdowns in March 2020, the incidence of preventive screenings dropped by more than 80%, depending on the study and the time frame, and fewer screenings inevitably leads to higher cases of disease.

Estimates from the National Cancer Institute predict nearly 10,000 excess deaths over the next decade from just breast and colorectal cancers. Imagine the cardiology, urology, gastrointestinal, and general practice visits that were missed and the number of emerging conditions that were left undiagnosed. Helping people manage their chronic conditions improves patient health, while reducing the overall cost of care, paradigms that barely existed during the pandemic shutdowns.

Everyone is responsible for patient care

More than 90% of health plans in the U.S. — HMOs, POS plans and PPOs —use the Healthcare Effectiveness Data and Information Set (HEDIS) to measure performance and care quality. Managed by the National Committee for Quality Assurance (NCQA), HEDIS comprises one portion of NCQA's accreditation process.

For consumers, HEDIS measures are used to compare health plans against others and against regional and national benchmarks that include 70 unique measures of process, structure, outcomes and patient satisfaction. HEDIS measures address the continuum of care from prevention and managing chronic conditions to acute care.

Besides the obvious profitability motive, health plans are invested in the health of their patient populations. Unchecked diabetes, for example, can lead to expensive hospitalizations and other interventions that impact patient quality of life. But caregivers can’t manage care according to a health plan if they don’t know what a patient’s status in a timely manner.

Health plans assist caregivers in learning — eventually — what’s going on with patients, but that’s not sufficient to support the Triple Aim of better individual and population health while reining in costs. Hospitals already must send ADT notifications to downstream providers, and sending real-time information to payers can be accomplished without increasing expense or workload.

Notifications can address critical events including admission, discharge, gaps in care, and abnormal tests that are communicated in real time. Creating visibility into member utilization can help health insurance providers identify gaps in care and improve health outcomes. Current technology allows notifications to seamlessly flow to payer case management systems, so quality of care can be maintained.

Industry-agnostic notifications

Real-time event notifications to an enterprise care management solution can improve payer/provider relationships and speed patient care delivery. Closing critical communication gaps streamlines transitions of care and improves care coordination as a patient navigates the healthcare landscape. Notifications can engage providers within existing workflows, rather than add to administrative burden.

Automated care alerts to providers within their EMR workflow can trigger appropriate follow-up care after a member utilizes an emergency room or inpatient facility. By developing a follow-up process for patients using care plans, 70% of provider sclosed care gaps.[1] The benefits are tangible for patients through early diagnoses, leading to timely medication reconciliation and lower readmission rate.

True interoperability has long been the holy grail of healthcare communications. But with so many competing medical information systems that focus on physicians, hospitals, labs, imaging, payers, and more, communication among IT systems remains elusive. To deliver better and more timely care management to patients, payers should work with providers to adopt a technology-agnostic communication strategy to receive real-time event notifications and take their rightful place as quarterbacks of patient health.

Bevey Miner serves as global health IT strategy/chief marketing officer for Consensus Cloud Solutions, Inc.

[1] Consensus: 2021 Industry Trends Survey for Healthcare (2021)