Ashley Tidd partners with payers and provider groups to help them utilize healthcare analytics to increase their competitive footprints in existing markets and expand into new markets as quickly and efficiently as possible. Historically, this process could take years to plan and implement, and then analyses of overall performance meant a year or more before changes and iterations could be made. Today’s market environment requires faster speeds and insights in order to remain agile in an increasingly competitive landscape. In this video, Ashley will share three tips to help you design high-performing and market-competitive networks efficiently and at scale.

Video transcript:

The traditional process for designing and optimizing provider networks is ripe for innovation. While the health insurance industry has created new provider network models that focus on reducing healthcare cost while also improving quality, there has been very limited innovation in how teams go about actually designing those networks. However, network design is of central importance to health plans. And today, we’ll discuss three ways you can be more efficient and scale your process as you grow into new markets and new lines of business.

My name is Ashley, and I’ve been partnering alongside payers and provider groups to utilize healthcare analytics to drive optimization for over five years now. Many of our customers are seeking to increase their competitive footprints in existing markets, as well as expanding into new markets as quickly and efficiently as possible. Historically, this process could take years to plan and implement, and then analyses of overall performance meant a year or more of analyzing performance of the new networks before changes and iterations could be made. Today’s market environment requires faster speeds and insights in order to remain agile in an increasingly competitive landscape.

Let’s get started discussing a few tips for designing high-performing and market-competitive networks efficiently and at scale.

First, you’re going to want to address a central challenge in network design, assessing provider performance. Here I often see a few problems. Many times plans don’t have the data they need in a new market. Maybe they’re not case mix adjusted so your performance scores are not apples to apples. The key ingredients to having precise provider performance benchmarking is one, a large data set of claims and other data sources to help provide that national market intelligence. It also has to be accessible on demand. Advanced risk adjustment is a second piece and case-mix adjustment to accurately and fairly evaluate providers on quality and efficiency measures. You also need a flexible grouper. So when you want to evaluate a provider, you can do it in a number of different ways, whether that’s an episode of care, the total cost of care, or 12 months of care. Finally, you have to be able to accurately attribute care down to a specific physician in a subspecialty. High-performing provider networks give you an advantage financially. It reduces your medical cost and grows revenue. It improves marketability by ensuring high-value providers are in network and improves quality of care.

The second way to be more efficient is to leverage competitive intelligence comparing your existing networks. Exploratory model networks against real-world competitor networks side by side will allow you to make better design decisions. When modeling networks look for an analytics partner that lets you explore your competitors, whether that’s within your current market or expansion area.

It’ll allow you to see their efficiency and quality measures and referral patterns. You’ll want to be able to compare at the NPI level overlap between your networks and your competitors’ highest-performing networks. With that level of intelligence, you can ensure that your network is aligned to high-performing providers in your competitor networks. To boost your competitive overlap immediately creating a more marketable network. Analyzing existing high-performing networks or those with high star ratings can give you good indicators of which providers to target to enhance the value of your own plans.

The third efficiency gain is being able to predict real-world network performance before going to market. The challenge today is that it often takes multiple years before you can have enough data to essentially make truly informed decisions on optimal network design. When you’re entering a new market, you are prioritizing speed to market and you’re often having limited insights on the providers because you don’t really have the claims or you don’t have the data in that market. And after going live, you’re still making decisions with partial information and not necessarily knowing what the impact of any network changes could potentially be. So it’s usually only after a few years and a strong analytics capability that you start to make real evidence-based network decisions. To accelerate speed to market, take a dynamic modeling approach that predicts essentially the real-world impact of network changes on cost, quality, and referral patterns. It is possible to map and modify geographic parameters, add and remove providers, whether those are PCPs, specialists, facilities, and instantly model the network quality, efficiency, and referral patterns. With this approach, high-performance networks can be designed in days versus say months, even years.

The ability to make informed decisions about new network performance or sculpting of existing networks leveraging historical provider performance and referral patterns substantially reduces the time to get your networks to high quality and efficiency performance. As healthcare payers continue to refine their existing networks and grow into new service areas, competition both of existing and new market entrants is and will continue to be fierce. Speed to market is key, but so is developing a network that has both high levels of quality and high levels of efficiency for your members.