When looking at creating or optimizing high-performing provider networks, the first thing most payers focus on is provider performance on cost, quality, and utilization. What is often left out of consideration is referral performance

Do your Primary Care Physicians (PCPs) refer appropriately, or are they referring out cases they should have treated themselves?

Do your providers refer to high-value specialists?

Do your providers know which specialists are the best fit for a specific procedure type for an individual patient?

When designing a high-performing provider network, it is critical to keep these components in mind in order to control for cost and ensure high-quality patient care.

There are three crucial components to building high-performance provider networks with high “Referral Scores”.

1. Understand existing referral relationships and patterns between PCPs and specialists

Referral patterns are hard to change, especially when moving into a new market or trying to ensure you’ve built a high-performing network that also meets adequacy standards. When designing your provider network, you’ll want to understand not only individual performance on cost, quality, and utilization but also how the providers in your target market interact with each other. Does the provider you’re contracting with refer to high-quality specialists or downstream partners? Should you consider contracting with those specialists to ensure your patients or members are staying in-network? 

2. Identify top-performing specialists on cost, quality, and utilization to create smart referrals 

Once you know who the top providers are in your network, you can design “Smart Referral Lists” for your PCPs to help guide referrals to top-performing specialists. An advanced way to approach smart referrals is to create custom scorecards by provider and specialty type so that PCPs can find the best referral for each individual patient and their care needs. Using this approach, you can ensure continuity and consistent high-quality care for your members. 

3. Measure clinical appropriateness of care performed or referred out by PCPs

While important to ensure referrals go to the top-performing, in-network providers, it is also essential that care is referred appropriately. Today, 20% to 30% of referrals, across all conditions, are for clinical cases that a PCP could have safely treated¹ on their own. Understanding clinical appropriateness is an important factor in evaluating the performance of a provider partner, and in managing the overall performance of your network. 

These three factors will help any network strategy leader evaluate provider performance on referrals when designing a high-performance provider network. However, while valuable, this data isn’t always readily available to health plans. When Cigna was looking to expand into new Medicare Advantage markets, they struggled to evaluate provider partners in markets they didn’t yet have a presence. Because they had experience building high-performing provider networks in other markets, they already had a playbook – but they knew they needed to bring in external market intelligence data through Clarify.

How does Cigna define a high-performance network? 

There are certain metrics that apply across the board, but you need to deeply understand your target market, the types of customers in that market, the utilization patterns, and who you can partner with in order to determine what the best design would be for that marketplace.

Austin Scott, Cigna

At Clarify, we work with the nation’s leading national, regional, and digital health plans to identify which geographies are most attractive for expansion, enable the design and management of high-value networks, and provide insights into provider performance across cost, quality, utilization, and referrals. To learn more about our work with health plans or to find out how you can leverage the Clarify platform to build, grow, or manage your provider networks, contact us here

Source 1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160594/

Last updated: 02/17/21

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