Managed Care - February 2009 - (Page 38) ceipts. Think of the costs for a plan to send, by traditional mail, an addendum to 20,000 providers! Contract modeling is critical for fully understanding and communicating the effects of terms. When modeling is based on current contract and claim information, plans can determine and analyze future costs with a high degree of accuracy. It is becoming an achievable goal now for a plan and a hospital to run the same set of claims to see if they come up with the same payment — and to do so before a contract is signed. Both parties agree on what will be paid for and how. Doing this up front will reduce costly delays later. That is true collaboration. While it may be easier for a network manager to simply make sure that networks are robust and financials are on target, that is a risky and losing strategy in the long-term. In the regulatory arena, the Sarbanes-Oxley Act dictates that if payments are not made according to contracts, organizations will face legal consequences — an argument for complete and transparent contracts. Protracted contract negotiations drain time and resources. More important, any remaining ambiguity in a contract has an unknown effect on an organization’s quality metrics. Payer information feeds into pay-for-performance programs and consumer-directed health plans. If it is too vague or not quantifiable, providers and members may not be able to obtain, use, or rely on it — putting the plan at a severe competitive disadvantage. It is also in the providers’ interest to offer their own innovative proposals to meet common goals. The technological solutions exist if we apply them. best in the business environment? • Does the system address the needs of providers? Will it help them to provide better care, receive timely, accurate payment for care and reduce their administrative burdens? This, of course, is essential for collaboration. With a technologic system in place, a plan can create the rules it wants to execute — and then make sure the rules are followed and measured. An improvement strategy When strategic rethinking leads to new tools, network managers and their improvement teams have four criteria to consider as they weigh them: • Does the technical design align with the overall technology vision? For example, is it on the right platform? Is the architecture right? • Do the business process approach and the implementation align with the vision for optimizing workflow changes? Are there internal transparencies so that all departments involved in contract approval — legal, risk management, marketing — understand what the others need? • Do the design, functionality, support, and value align with the vision for what will work It’s not as hard as some think An analogy to demonstrate where we are in bringing automation to the consumer can be found in the banking industry. Think back to the time when you went to the bank to deposit your check or waited six weeks for loan approval. In 10 years, automation in network management will be similar to today’s level of automation in consumer banking. Transaction turnarounds will be shortened for all involved; consumers will make choices based on widely available information, and customer service will be paramount. In our industry, the United States is moving toward a free-market approach, with consumer-directed health plans and pay-for-performance measures. The winners will be organizations that can readily transform payer information about quality and cost into useful information for patient and employer choices. Payers have the most complete claim information and providers have the detailed patient data. Network managers cannot resolve these issues alone. Organizations that will succeed are addressing these risks strategically, providing the framework and direction for their networks to thrive. I am fond of saying that changes in health care come slowly because too many of us think we must boil the ocean before we can drink the water. With reasoned steps toward economic alignment and data sharing, the solutions are not as complex as we’ve made them out to be. Leadership and success in our industry will come from those who wade in with small, strategic changes in their own organizations and in their own circles of influence. Success will breed success and others will follow. Ultimately, our progress will be evident in providers that are empowered and encouraged to deliver quality care, in strong bottom lines for payers that support them, and — most importantly — in healthier, happier patients. MC 38 MANAGED CARE / FEBRUARY 2009
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