Network Strategy Part 3: New tools help physicians manage costs, fill care gaps

Under pressure from large employers to improve patient satisfaction, care quality and cost management, physicians and hospitals are finding help on all 3 fronts from new and emerging innovations in technology and data analytics.

In fact, these new tools are helping improve the experience of providers trying to thrive in new, value-based payment systems designed to shift more of the accountability for cost control and quality improvement to them. From pharmacy management to electronic medical records to referral programs, these tools are giving providers new, more effective ways to help their patients get the most cost-effective care available.

For example, over the past year a new online solution called PreCheck MyScript made a surprisingly strong impact with important, larger implications for health network cost and quality management. The application makes it easier for both doctors and patients to learn—in the doctor’s office—how much a prescribed drug costs and out-of-pocket expenses patients should expect, based on their specific plan coverage.

In a survey drawn from 30 million patient visits over the past year, patients and doctors reported picking an alternative to the doctor’s first-choice drug 27 percent of the time they had the option, choosing a lower-cost medication instead.  Because the PreCheck tool can often be embedded in the patient’s electronic medical record (EMR) instead of in UnitedHealthcare’s portal, doctors were more easily able to review key cost data and alternative drugs within the record without having to click away to the plan’s Link information portal, an internal, online storehouse of patient information for physicians.  And they could do it seamlessly, before the patient left the office.

“This kind of information is hugely important for all constituents in terms of member satisfaction, provider satisfaction and cost transparency,” said Tim Kaja, Chief Operating Officer for UnitedHealthcare networks. The surprise and dismay of members at unexpected out-of-pocket drug costs is a key source of unhappiness with their doctors and plans.

Collaborating with EMRs is part of a comprehensive, long-range UnitedHealthcare initiative to support and sustain provider networks, including Accountable Care Organizations (ACOs), which deliver high-quality, efficient and cost-saving care over time.  PreCheck and a new set of clinical applications within EMRs rolling out this fall follow in the wake of financial tools in the Link portal that give clinics key real-time knowledge of factors such as how much of the patient’s annual deductible remains, their plan’s level of coverage and copays expected.

“We aim to differentiate ourselves by providing more actionable information to providers better, faster and cheaper than anyone else,” said John Monaghan, Vice President, Delivery System Strategy at UnitedHealthcare. “It’s not just about having the right doctors in the network, but doing the right things to help them maximize care.”

He cited the example of a North Carolina multispecialty group ACO, in which an onsite core team comprised of analytic, clinical and network experts identified unexpectedly high emergency room use in a commercially covered population. Closer review revealed that the spike was related to cardiac events – again at a level unexpected in a non-Medicare population. The ACO created its own cardiac advisory group that alerted primary care physicians of the findings, prompting them to be more aware, and to probe prescriptions, lab tests and other records for subtle signs of imminent heart disease that might have been overlooked.  As a side benefit, the ACO also informed its other insurance carriers so their members in the region could be similarly reviewed.

“With our data, we can give groups a line of sight they otherwise wouldn’t have into their entire population, identifying trends and even additional questions to ask their patients, putting reminders in their EMR and the like,” said Monaghan. “They can treat the cardiology population more effectively if they can focus their resources.”

On a smaller scale, the technology surfaces data that a primary care doctor might not know in real time, such as that one of their patients was treated in the emergency room last night after a car accident. Another example could be a flag tipping a gastroenterologist that a patient is taking medication for back pain that might have implications for intestinal issues.

Practice pattern hot spots, such as excessive and costly referrals out of network, are another area where daily, weekly, monthly and/or quarterly data reports can help ACO managers know where to focus their attention. 

In the case of applications already embedded in the EMR, like PreCheck MyScript, the feedback from data processing is even faster. When a doctor prescribes a drug during an office visit, a checklist pops up in the patient’s EMR, including the patient’s eligibility, level of coverage, drug cost, a set of 3 alternatives to discuss if cost is a problem for the patient, and whether prior authorization is needed.

The new tools coming out this fall, embedded in EMR software, will enable doctors to close other information gaps during a patient’s office visit – again without having to click away from the patient’s EMR, the core of the doctor’s workflow during an appointment.  When a referral is ordered for a procedure, for example, the new tool will show nearby options for lab services and their costs, existing gaps in the patient’s care to be attended to immediately, plus overall estimated costs of the referral claim, all while the patient is sitting there.

“The prescription for the lab downstairs might be 5 times more expensive than a preferred lab network just across the street,” said Kaja, who said he’s excited to see the impact of that capability on the rest of the office visit.

It might sound minor or extremely technical, but fast, real-time in-EMR loading and presentation of expected claim costs and options, plus the names of designated high-quality, high-efficiency providers for referral, has the potential not only to cut costs significantly, but also to raise patient satisfaction levels critical to HEDIS scores and commercial coverage ratings that drive reimbursement.

It’s also valuable for clinic-level financial management to have the capability to deliver data in real time. 

“In health care we’re always thinking about right care, right time, place and cost,” Kaja said. “It’s also about transparency in where all that is. When a patient walks out the door without paying their (out of pocket) balance and waits for an Explanation of Benefits (mailed form), up to 70 percent goes to bad debt. In a high-deductible plan being able to know and collect right away is very important to a physician and ACO.”

UnitedHealthcare currently has ties to 110 commercial ACOs across the country and over 600 across all lines of business. Not all have adopted plan design features that emphasize efficiency and quality over choice, for example, out of concern they might fall short in attracting members. The chicken-and-egg conundrum is that critical mass—in the range of 25,000 members—is needed to manage volatility in claims and achieve predictable results.

“We’ve learned some lessons over the past 5 years,” said Monaghan. “We’ve got ideas about what worked and didn’t. It takes a long time for results, more evolution than revolution.”

Over time, he said while he is convinced that systems on a “glide path” toward delivering value-based, efficient care consistently will prevail. But it’s still early in the game. ACO success will come from integrating 1) product strategies to reward or require reliance on primary care providers and designation of quality and cost-efficient specialists; 2) clinical programs that capitalize on the potential of real-time data to improve care, efficiency and member experience, including out-of-pocket cost transparency; and 3) sound health plan-network collaboration.

18-8905  8/18