Health care’s “Triple Aim”—the goal of simultaneously improving quality, lowering costs, increasing patient satisfaction—is not a passing fad. It’s good business. Forward-looking organizations see that focusing on the Triple Aim will give them strategic advantages in contracting and in marketing, and help them gain market share.
They also see that to achieve these aims, they need to fundamentally alter the way they approach care and the way they do business. Rather than just providing care for their patients, they need to manage their patients’ health.
The transition from providing care to managing health is a journey. The journey starts with strengthening current capabilities, then branching out into new capabilities that may not be core to an organization’s current business model.
Part and parcel to managing health is taking on the clinical and financial risk associated with patient health, which calls for putting your clinical and financial house in order. To do so, focus on optimizing the people, processes and technology in following areas:
- Patient Access: Improve your ability to determine insurance eligibility as well as a patient’s ability to pay.
- Medical Necessity: Focus on complying with the health plan’s requirements for medical necessity documentation, as well as improving your denials management process.
- Clinical Care: Make sure you have clinical technology in place that allows for interoperability, that improves physician adoption, and that helps you streamline processes.
- Coding and Documentation: Center your efforts on clinical documentation improvement and preparing for ICD-10.
- Reimbursement: Concentrate on revenue integrity, including limiting denials, complying with claims processing rules, and collections.
Extending your health management capacity
Managing patient health requires taking on responsibilities normally borne by payers. When undertaken by providers, the following areas can be much more effective than previous models have been in helping patients maintain their health:
- Population Health Management: Pinpoint the people who have the greatest need and opportunity for proactive interventions, then implement services such as care management that can make a difference in their health.
- Care Delivery Model: Based on current patient mix and market conditions, develop a model that takes all stages of care—ambulatory, acute, post-acute—into account.
- Financial and Clinical Analytics: Use analytics tools to identify high-risk patients, predict with a high degree of certainty which patients will become high risk, determine the most effective interventions for a given population, and analyze clinical and financial performance.
Over the next several weeks, we will share eight posts that discuss each element of the value transformation journey, and provide insights into how organizations such as yours are making the journey from providing care to managing health.