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VALUE PROPOSITION IN PAYOR‐PROVIDER RELATIONSHIPS
Presented byPieter Rijken
Director International Provider Contracting
Major obstacle to growth
“inability of providers in medical‐travel destinations to enter the networks of the developed markets’ payors.”“Mapping the market for medical travel” , McKinsey & Co, May 2008
• What tools health plans use to optimize their provider networks• How this translates into the Payor‐Provider relationship• The Value Proposition defined
THE VALUE PROPOSITIONWhat you will learn:
What are healthplans looking for?
• Accessibility• Transparency• Cooperation• Technical advancement• Quality outcomes• Patient satisfaction• Price (Value for money)
• Disruption analysis• Innovation• Efficiency• Practicing evidence based medicine
• Adhere to international standards (Milliman, Interqual etc)
The optimization process in 3 steps
All providers
• Credentialing• Contract terms
Pre‐select providers
• Utilization
• Analytics
Provider network
What tools do health plans use:
• Credentialing/Contract terms• License• Qualifications• Equipment• Bedside manners• Practice standards• Site visit/patient reviews• Quality of care• Accreditation
• Utilization/Analytics• Utilization review• Data analysis
• Member Population/Needs• Quality outcomes• Episode Treatment Group (ETG)• Electronic Data Warehouse (EDW)• Predictive modeling• Usual and Customary Reimbursement (UCR)
• Etc.
Accreditation
The International Society for Quality in Health Care
European Society for Quality in Healthcare
The latest addition to data analytics:
Episode Treatment Grouper® (ETG®)
Episode Treatment Groups® and ETG® are trademarks of Symmetry Health Data Systems, an Ingenix company
An episode of care consists of all clinically related services for one patient for a discrete diagnostic condition from the onset of symptoms until treatment is complete
What is an Episode of Care?
• ETG: proprietary software from Symmetry• Close to 1000 ETGs• Homogenous (statistically and clinically)• Examples:
• Sinusitis• Esophagitis• Hypertension
Episode Treatment Groups® and ETG® are trademarks of Symmetry Health Data Systems, an Ingenix company
Episode Treatment Grouper® (ETG®)
Efficiency Index (EI) CalculationCondition* Dr.’s number
of episodes Dr.’s actual costs for those episodes
Specialty avg cost per episode
Expected Cost (Dr.’s # of episodes x spec avg cost)
Sinusitis 10 $1450 $110 $1100
Esophagitis 5 $2000 $400 $2000
Hypertension 6 $2000 $350 $2100
Totals: $5450 $5200
* For example, by Episode Treatment Groups®Episode Treatment Groups® and ETG® are trademarks of Symmetry Health Data Systems, an Ingenix Company
Source: “Understanding Episodes of Care” Presented by Physicians Advocacy Institute, Inc.
Efficiency Index = actual/expected = $5450/$5200, or 1.05
Most important criteria are the access to:• Quality care• Physicians/clinicians who deliver results• Availability• Expedient treatment/intervention• Clinical trials• A desirable location for recuperation• Internationally accepted standards of
care/treatment protocols/Clinical pathways (heart attack/diabetes/hypertension/stroke etc., etc.)
• Uniform billing, i.e. use of internationally accepted coding standards. Ask payors what they prefer.
• Only 40% of foreign patients in key medical tourism hospitals are actually there as medical tourists ‐ the rest (60%) are either expatriates or there on emergency care because they were traveling in that country when they became ill
• When looking at travelers who specifically went to another country for a procedure, 72% of them are looking for the best technology or a better provider than what they can get in their home country
“Mapping the market for medical travel” , McKinsey & Co, May 2008
Key Findings from McKinsey Report on Medical Tourism
Other observations from report:
‐ 40 % of patients want best technology regardless of cost. This may include experimental, traditional or disallowed treatments,
‐ 30% looked for high quality and lower costs for medically necessary procedures/treatments,
‐ 15% were after quick access to medical care, specific treatments that are not available in the home country, or there is a significant waiting list for an elective procedure,
‐ Only 4% was looking for lower costs for discretionary medical care (includes cosmetic surgery, wellness and/or spa treatments)
“Mapping the market for medical travel” , McKinsey & Co, May 2008
• Cooperation give and receive information when asked, willingness to adapt to new requirements, etc.
• Transparency expectations should be clear from both sides• Accessibility provider’s access to payor’s customer service
and payor’s access to provider and provider’s administrative staff
• Technology up‐to‐date• Quality outcomes
The payor provider relationship
• Make it a goal to seek opportunities to interact with payors’ data• Dump the routine batteries of tests and move to evidence based medicine
• Everyone participates, i.e. everyone in the practice needs to be on board
• Use smart Electronic Health Records, in a format that is compatible with your payor plans.