Editor's Note: This is part two of a two-part series.
A Better Mousetrap
A new generation of collaboration has been tested in Minnesota through the Institute for Clinical Systems Improvement. This is a partnership between payers and providers.
Once it is determined that a diagnostic imaging exam is needed, the patient and physician together review the appropriateness criteria. This decreases the many back and forth calls to the insurance company, creates a bonding experience between the patient and physician and provides the physician the additional security of knowing the best test was ordered for his patient. It also improves patient flow and clinic efficiencies.
For the patient, the test is ordered with fewer delays and rescheduling and contributes to faster diagnosis and initiation of care.
Health plans benefit through reduced staff to support prior notification and consistent appropriateness criteria.
Employers reduce employees' exposure to harmful radiation and are assured that their employees are receiving appropriate care.
6. Care integration capability. includes payer-provider collaboration, regional health information organizations, virtual care delivery, and e-prescribing.
The market leading organization reaches beyond traditional modes of collaboration and communication—like the pilot mentioned earlier in Minnesota. These tactics can provide great benefits.
7. Evaluation and improvement capability> is the collection and measurement of data to evaluate processes and programs. This includes data repositories, clinical informatics and benchmarking, outcomes measurement, process tracking, and reporting.
Market leaders not only have a data repository but data is easy to extract and manipulate. All clinical and member specific data populate the data repository regularly to be used effectively.
In the area of Diagnostic Radiology, not all reports are created equal. In a study in Academic Radiology, a study focused on the American College of Radiology standards, it was found that 86% of reports were deemed as satisfactory. A focus on radiology reporting could enhance the value from the test. Another survey in Radiology Reporting stated that 49% of referring physicians did not feel that the radiology report sufficiently addressed the current clinical question.
Focusing on improvement in radiology reports can benefit all stakeholders.
Market leading organizations use business intelligence gained from data. For example, by reviewing ordering patterns, problematic ordering patterns can be identified. Cost and utilization data can be used for facility contracting. Member satisfaction can identify quality of imaging facilities. Pricing information can aid in transparency—important as patient responsibility continues to grow.
8. Provider relationship management> Includes pay for performance, transparency, and network strategy. Becoming customer-centric requires more than just thinking about the potential benefits of these activities, it requires implementation.
Market leading organizations focus on improvement. Pay for performance and high performing networks can be used for adherence to clinical guidelines, better radiology reports, and higher quality for patients. Network strategies can target the most qualified providers (Radiologists and equipment—credentialed and accredited) to provide optimal access, accurate and complete clinical information through reporting, and network access to enhance the patient experience. Benefits include better patient care and communication, decreased cost and risk to the payors. A well-designed program results from integrated collaboration from quality management, network, payer, and patient involvement.
With data, the link can be made between radiology utilization and outcomes. This data can be used for identification and confirmation of health patterns, benchmarking, measurement of the efficacy and safety of certain treatments, variation, identification of high quality, low cost providers, and comparative benchmarking.
Radiology is moving towards an evidence-based, decision-making model. Employers, consumers, payers, and providers are demanding credible and actionable data.
To move ahead, a payor can review the use of advanced diagnostic imaging, create a steering group to develop strategies for implementation.
Measuring value is imperative.
Truly successful care management looks beyond one diagnostic test and at the full value chain. With time intensive processes imposed on one link in the chain, the chain can break. Only through collaboration of the patient and provider can a solution be achieved that is sustainable long-term. Patient care and patient outcomes benefit.
Marybeth Regan, PhD, is an expert in disease and care management. She has written numerous articles on strategies for care and disease management. She may be reached at Drmarybethregan@aol.com.
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