For decades payers and providers have been building physician provider networks based on limited knowledge and data, and status-quo accounting of benchmarks where “low cost” equals “high performance.” This results in poor network performance and ultimately reduces how much high-quality, individualized care patients receive. As the competitive landscape in healthcare continues to shift, network strategy is becoming top of mind for heath plans and competition is growing for everyone from commercial payers to individual physicians.

Both commercial health plans and CMS are increasingly rolling out advanced risk-sharing payment models, accentuating the industry’s need for better risk stratification solutions and improved provider identification. No one wants to enter into these agreements blind and everyone wants to gain a competitive edge by having the most granular understanding of their available opportunity and how to hedge against potential losses.

Clarify Health offers a predictive network optimization solution that enables our customers to confidently expand into new markets, create high-quality provider networks, and assess provider network performance on the metrics that matter most to them.

How analytics can power better network design

Our Atlas platform is what sets us apart. Our continually growing database connects traditionally siloed datasets at the individual patient level to create longitudinal care journeys. As a CMS Qualified Entity (QE), we have data on 100% of Medicare FFS lives, over 56M Medicaid lives, and more than 160M commercial lives. For each patient, we have clinical history, claims history, purchase history, and socio-demographic information. This is especially relevant for organizations looking to expand into new markets and payment models because, currently, they often only have data on their existing networks and patient populations. Clarify’s Atlas platform fill in the gaps and then highlight the opportunity for success in new markets and uncover latent opportunities in existing markets.

Using advanced analytics to build a better network:

In addition to market expansion, this foundational dataset combined with predictive analytics, enables our customers to create and maintain the highest quality and lowest cost provider networks. We think of this as a three-step process:

1. Identify the optimal geographies to build a network, based on the type of members the network will serve, across multidimensional performance factors including reimbursement rate intelligence, provider performance, and market-specific demographics and composition

2. Determine who should be in that network, given the goals or your network design or plan type.

3. Monitor the performance of the providers in your network.

For example, if you’re an ACO thinking of expanding into CMS payment programs for Medicare FFS members, you want to pick the ideal providers for the performance model. However, your current provider partners are in value-based programs with commercial payers and you are thus limited to evaluating these providers’ performance solely on how they perform on this commercially insured population. How can you assess the performance of these providers to determine if performance would look different with the CMS Medicare FFS population? These are different patients. Clarify’s network performance solution will help you understand how each of your providers perform on the Commercial population and the CMS Medicare FFS population so you can select the right physicians to create high-performance provider networks.

Conversely, imagine you are an insurer entering a new market and looking to establish value-based, risk-bearing contracts with providers. You want to partner with providers who have high-quality outcomes but stay below expected costs. Using Clarify’s network performance solution, you can identify those specific individuals, add them to the network model, and monitor the performance of the network as designed. You can then use the cost and quality insights to set benchmarks and performance corridors that each provider must meet in order to earn shared savings.

Why you should care now:

Competitive organizations can’t afford to continue relying on limited data to build and manage networks. Building high-performing, low-cost networks now will determine whether your organization still exists in the next decade.

To learn more about this topic, download our 2023 Networks Playbook for Health Plans. In this playbook, you’ll learn three plays to design and optimize provider networks in new & existing markets.

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