August 30 2019 Chuck Feerick

Defining High-Performing Networks: Three Core Capabilities of Market Leaders

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 measuring 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 of analysis that Clarify’s customers use to build high-performing networks that have a high “Referral Score”: (1) The existing referral relationships and patterns between PCPs and specialists, (2) Specialist performance on Cost, Quality, and Utilization, and (3) at the appropriateness of care performed or referred out by PCPs.

Understand current referral patterns

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. Clarify’s Network Performance Optimization Solution allows customers to dynamically build and model new network scenarios and see how these networks perform across Cost, Quality, and Utilization metrics. Going a step further, Clarify’s Network Performance Optimization solution provides an individual “referral” score for each provider as well as the overall model network which allows our customers to understand how the providers in a model network refer to one another. Our solution then allows our customers to go a level a deeper and see who individual providers most often refer to, and then add those specialists to their model networks – this ensures that referrals stay within your network and that patients also receive high-quality care.

Identify top performers

Using our data and insights, Clarify helps our customers design “Smart Referral Lists” that they provide to their PCPs to help guide referrals to top-performing specialists. Smart Referral Lists leverage Clarify’s deep set of Cost, Quality, and Utilization metrics 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. 

Measure clinical appropriateness

While important to ensure that referrals go 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. Using our deep claims assets and data science models, Clarify has developed a deep database of clinical appropriateness metrics and replicated the AHRQ measures to help our customers assess provider performance and support optimal referral patterns and better manage their networks. 

Clarify’s Network Performance Optimization solution helps payers identify which geographies are most attractive for expansion, enables the design of high-value networks, and provides insights into provider performance across cost, quality, utilization, and referral patterns. 

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

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