Network Management: Align Providers with Plan Goals

Aligning Providers with Plan Goals

Provider performance can be measured and normalized for the types of members in their care and used to allocate shared savings. Provider buy-in can be enhanced with data-driven incentives to benchmark performance relative to peers. Under a population health model, networks and payers need to align providers with healthcare plan goals. Working together with providers, payers can improve care quality, reduce unnecessary medical spend and manage population risk.

Payers have access to a wealth of data that can be used to motivate providers to adjust their behavior toward plan goals. An analytics engine can help you to extract insight from data brought together in a single comprehensive warehouse. The data can enable provider performance profiling, pay-for-performance (P4P) modeling and adjudication, and pharmacy formulary compliance tracking and intervention.

Pay-for-Performance Management

Pay-for-performance (P4P) programs help change provider behavior to meet plan goals. These programs require sophisticated metrics to gain provider buy-in. Payers may have multiple P4P programs. What-if functionality can help you design new incentive programs. Managing your P4P program requires P4P adjudication, reporting, trend tracking and payment calculations. This information can be shared with physicians to show them where they fall on the spectrum within their specialty, and shared savings can be allocated based on performance.

Profiling Providers to Identify Outliers

Intelligent healthcare analytics let you monitor provider networks. Efficiency metrics can help you quickly understand which groups and networks are performing well — and which are not. HEDIS and Accountable Care Organization (ACO) reporting measures help you profile care guideline compliance for providers throughout the year.

Primary care physician scorecards can offer population-based, risk-adjusted determinations of efficiency, both at an overall level and for high volume or cost areas. Episodic analysis can provide insight into how providers differ in their performance compared to their specialty peers, as well as compared to national and regional cost benchmarks.

Engaging Physicians by Making It Easy

Incentives can motivate networks to close gaps in care. In doing so, it is important to avoid creating extra work for physicians. Embedded workflows can help to proactively engage physicians and members and improve timely screenings. Provider staff can see members' gaps in care when scheduling appointments, and customized letters and call lists let you take action to alert physicians and members about gaps in care with minimal extra work on the part of the physician.

Supporting Providers in Lowering Pharmacy Costs

Insight for pharmacy management can help you mine opportunities to reduce pharmacy spend. Pharmacy-related metrics can help you to understand drug usage, identify which members have costly drug regimens and alert the prescribing physician to the opportunity to switch to a cost-effective therapy. Making it easy for physicians and building in effective incentives can motivate changes in physician prescribing behavior.

Learn how McKesson Risk Manager™ can help you analyze physician engagement and performance on a real time basis and manage pay-for-performance programs.

Next: Manage High-Risk Members and Transitions