Regardless of which side of the payer or provider divide that you are on, it is important to remember that people gravitate toward healthcare because they are motivated to do the right things for the patient. Many are frustrated and exasperated by the unproductive busy work caused by requirements that are introduced in the name of improving the patient experience, improving the health of populations, and reducing the per capita cost of healthcare.
The people within CMS or commercial payers that implement these programs also care about patient experience, improving the health of populations, and reducing per capita cost of healthcare. They implement penalties around “poor” documentation, processes for prior authorization, referrals, and concurrent review—not because they want to cause pain—but because their experience tells them that when they don’t do these things variations increase, quality suffers, and costs increase without improving outcomes.
Payers impose these requirements hoping to “motivate” the provider to be more engaged on doing what is medically appropriate for the patient and no more. They want the provider to be proactive about what should happen if care progresses as expected. They want expectations to be set with the patient and their families about what they should expect from their care and where they should expect to receive it. They expect discharge planning to start at or before admission and any needs for support post-discharge to be identified early and planned for. They want the patient experience to be as safe and efficient as possible.
Providers have a choice when faced with these challenges. When the provider focuses on reducing denials but not improving decision-making and documentation, they will continue to have a “zero sum game” relationship with their payers, and they will continue to have to fight for every healthcare dollar. For providers who embrace the spirit of what is being asked of them, when they truly shift their thinking to seeking out and reducing unwarranted variations in care, a different path opens up.
Often this mindset occurs as providers migrate toward value-based payment models that reward good outcomes and lower costs. It is our experience that those organizations that use truly evidence-based guidelines as a foundation for organizational alignment to shift from a transactional model to a transformational model see much better outcomes. These organizations tend to experience fewer readmissions, shorter lengths of stay, and a more appropriate balance of observation vs. inpatient admissions. These improvements quickly drive measurable reductions in denials, payment penalties, and costs associated with utilization management and appeals.
Technology is also bringing some very interesting opportunities. MCG’s Indicia, for example, is designed to empower clinicians to do what is right for their patients and in doing so capture the key clinical components of those decisions and how the patient responds. That information, when transmitted to their payer, demonstrates that an informed care strategy was being utilized during decision-making. The provider will have and be able to share the condition-specific recovery milestones and demonstrate proactive patient care. Providers will also have the discharge milestones and indications needed to show they executed a better discharge and to help the patient have a safe, predictable discharge to the most appropriate next level of care.
With MCG’s Collaborative Care solution, providers can partner with their payers to share this documentation directly in the software solution that the payer is using, reducing redundant and inefficient data entry. When the payer is using MCG’s Cite AutoAuth solution, this documentation can be used to run automated rules to approve services or interventions for the patient. These approvals can cover everything from durable medical equipment to approval for a skilled nursing facility stay or home health services post-discharge. A quick, automated approval tool gives providers faster access to information and increases efficiency for both the provider and the payer.
As we work with our early adopters, we are finding that having a platform that facilitates and supports simple sharing of key clinical decision-making coupled with the ability to automate authorizations enables payers and providers to come together to discuss what is really important; that is, “how do we work together to ensure we are doing the right things for our mutual patient?”
