Provider Information Gaps Threaten Success Of New Narrow Networks

By Tom White, Phynd

Healthcare today is a world of proliferating value-based arrangements. In addition to accountable care organizations (ACOs) – a flavor of clinically integrated networks (CINs) – “narrow networks” have emerged as a growing trend as the industry shifts to new alternative payment models.

Driven by major U.S. employers seeking lower employee healthcare cost without sacrificing care quality, these new narrow networks offer great promise. This promise is threatened, however, by challenges relating to provider information. Indeed, the absence of an established technology platform that delivers accurate, up-to-date information about the providers within these narrow networks could undermine this nascent value-based approach before it gets off the ground. Whether the problems stem from administrative inefficiencies, payment delays, gaps in network coverage and adequacy, reduced in-network referrals and utilization, or potential loss of market share, new narrow networks must address the provider information challenge to ensure success.

The Rise Of The Narrow Network

Narrow networks go a step beyond HMOs and tiered networks, and limit networks to only providers and hospitals that agree to meet specific quality requirements. Restricting patients to a smaller group of providers and hospitals allows payors to negotiate lower prices with providers and hospitals. They also can incentivize patients to use providers in an accountable care organization (ACO) or similar grouping that’s dedicated to care coordination, improved quality, and controlling costs.

Health plans featuring narrow provider networks continue to spread in ACA marketplaces, and now an increasing number of employer health plans are using them as well. But while narrow networks offer a creative way to decrease healthcare plan costs, they also exacerbate the challenge of managing provider information. Keeping track of which providers are in – and out – of networks is daunting. The lack of reliable data on network participation can sink a network’s clinical and financial effectiveness.

This looming threat hasn’t stopped an impressive list of corporate giants from forming narrow networks with local health systems. Disney, Boeing, Intel, Walmart, Lowe’s, and PepsiCo, among others, have all done so. This list doesn’t even include the recent announcement that Amazon is partnering with Berkshire Hathaway and JP Morgan Chase Co. to offer health insurance to its combined employees, which number more than one million. If they can devise a system that delivers better healthcare to their employees, while lowering costs, then widespread industry disruption is surely on its way

As with existing health systems, however, these new networks must manage a mix of ever-changing affiliations as they continually answer recurring questions. And this only widens the already exposed gaps in provider information requirements. Which doctors are part of which network? Which providers accept a particular health insurance plan? What are their specialties and sub-specialties? Not even Atul Gawande, MD or Warren Buffett could readily provide solutions to the continuous need to manage ever-changing provider affiliations.

The Challenge Of High-Quality Provider Information

Accurate tracking of provider network participation is vital for success in narrow networks. But, more often than not, the network management team’s principal tool to meet this challenge is … a spreadsheet. Clearly, this is an inadequate tool when providers typically average 20+ memberships in health plans, ACOs and CINs – and these affiliations can change annually.

Job Number #1 for network management teams, then, is to have an accurate, continuously-updated repository that clearly indicates which providers are in which networks.

Just how important is this objective? As any health system or employer will attest, inaccurate and incomplete provider information causes a variety of unfavorable business outcomes, including:

• Administrative inefficiency created by multiple (and sometimes overlapping) teams continuously researching providers to determine their current network affiliations
• Delays in payment due to inaccurate network-related provider information
• Gaps in network coverage and adequacy by not having visibility into providers’ specialties and subspecialties, which leads to imperfect provider targeting and recruiting
• Reduced in-network referrals and utilization (i.e., if PCPs don’t know which specialists are in or out of the patient’s network, network leakage will continue to occur), resulting in higher costs

High-quality provider information helps a network’s patients receive a clean bill of health, which, for narrow networks, ensures a clean bill of financial health. Nowhere is data cleanliness more important than at the birth of a narrow network.

Deploying The Right Information Management Platform

To combat these risks, narrow networks should deploy a provider information management platform – ideally in advance of formation. The capabilities of a provider information management platform should include:

• Provider profiles that can be continuously curated and maintained through external authoritative sources of truth (e.g., federal agencies and state licensing boards), digital outreach to providers and their staffs to maintain their profiles, and internal workflows to prioritize those providers that still need manual research.
• A national repository of pre-built profiles of all providers, supporting a simple enrollment process as providers join CINs, ACOs or assume new health system affiliations.
• The ability to securely share these provider profiles to both internal customers (health system websites that offer Find a Doctor search capabilities, EHRs such as Epic and Cerner for billing purposes) and external customers (individual consumer-members of a CIN, or employer-hosted websites supporting narrow network participation).
• Network plan management capabilities that support unlimited numbers of plans as well as the individual providers’ participation in these plans, including roster management and reporting.
• Service line management powered by a thorough and detailed clinical taxonomy to categorize individual providers by specialty, subspecialty, clinical terms, and consumer-friendly search terms.
• Location management capabilities that track all aspects of providers’ facilities, including address, other providers who practice in their locations and their specialties, tests and procedures offered, hours of operation, parking information, driving directions, language translation services available, etc.

Moreover, the platform should be able to support both the network management team’s need and sister functions in the health system to maximize the return on investment. A rising tide lifts all boats: patient marketing, patient access, revenue cycle, care coordination, and other functions alike will benefit by a platform to improve their quality of provider information.

These solutions include a pre-developed provider information data model – workflows that allow curation of provider data through external authoritative sources, digital outreach to providers to self-maintain information, and workflow that supports updates made by health system staff. A best-in-class provider information management system also offers an open API that supports inbound updates and the ability to update other systems of record in near real-time. These systems also can integrate with older legacy systems using HL7 or file-sharing.

Maximizing Network Management Operational Efficiency

For a new narrow network, the single most important question – often not easily answerable given limited tools – is: Which providers are in…and out…of our network? Accurately keeping track of network affiliations of myriad local providers is a fundamental requirement that has languished because of inadequate information management tools.

Network management’s key responsibilities include provider recruitment to expand network adequacy and market reach, and provider outreach and referral support. These all require access to high-quality provider information: who they are, what they do, where they work, and what networks they serve.

Without a proper provider information platform in place, new narrow networks will face myriad challenges, including administrative inefficiencies, payment delays, gaps in network coverage and adequacy, reduced in-network referrals and utilization, and potential loss of market share in increasingly competitive regional networks.

Deploying a proven provider information management platform is an optimal strategy to maximize network management operational efficiency. High-quality provider information helps a network’s patients receive a clean bill of health, which ensures that the narrow network has a clean bill of financial health.

About The Author

Tom White is CEO and founder of Phynd.