Navigating the Journey from Providing Care to Managing Health

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. Focusing on the Triple Aim will give organizations strategic advantages in contracting and in marketing. It may also help them gain market share.

Achieving these aims requires a fundamentally different approach to delivering care and managing the business end of health care. Beyond treating illnesses and injuries, health care providers need to manage their patients’ health.Miles Snowden, MD, MPH, CEBS Chief Medical Officer, OptumHealth

The transition from providing care to managing health is a journey. The journey starts with strengthening current capabilities, then branching out into new areas that may not be core to your current business model.

Strengthening your core capabilities

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 patient’s payer requirements for medical necessity, 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 shoulder 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 populations that combine great need with great opportunity for intervention, then implement services such as care management that can make a difference in the health of patients.
  • 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 analytic tools to identify high-risk patients, predict with a high degree of certainty that a patient 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.

–Miles Snowden, Chief Medical Officer, Optum

2 thoughts on “Navigating the Journey from Providing Care to Managing Health

  1. Pingback: Navigating the Value Transformation Journey: The Role of Patient Access and Medical Necessity | Healthcare Exchange

  2. Pingback: Navigating the value transformation journey: Data and analytics to provide actionable information | Healthcare Exchange

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