Aligning Care Management
Our commitment to building stronger care provider partnerships starts with a focus on the care of their patients, our consumers. One way we're doing that is by better aligning care management.
Instead of relying upon the traditional case-manager-to-consumer relationship model, we focus on a case-manager-to-care-provider partnership model. By aligning our case managers with individual care providers, we see more seamless, improved experiences for all parties involved. As our case managers collaborate with care providers directly on our consumers' care, clinical teams are experiencing a broader and deeper reach when it comes to care coordination.
The aligned care management model is still in its early stages. We are working under this new care management model with nearly 400 care providers and, to date, it has shown great promise. This more direct team-based approach has helped reduce emergency room use, supported expedited admissions to home health, met needs related to social drivers of health, and helped with recovery from addiction.1
As a part of this evolution in care management, and in an effort to "walk the talk" when it comes to true collaboration, our health plan affiliates have begun cobranding outreach efforts to consumers, letting them know that their care provider and payer are in this together. By doing so, we hope the complex needs faced by patients feel more manageable to them. As this program evolves, we aim to double the number of care providers with whom our health plan affiliates are aligned during 2023.
As part of our approach to care management, our care managers are increasing their direct engagement with our consumers using a data-driven personalization tool, which helps:
1. Increase direct engagement with digital interactions.
Opting for digital communication over letters and calls helps increase engagement and allows for a more timely and appropriate intervention, which helps improve health outcomes.
2. Increase improved patient outcomes.
By utilizing health personality data to tailor outreach and drive positive health outcomes, engagement with consumers has increased on average for 23 Medicaid markets where the program is live. In fact, in two pilot markets where this data was used, the engagement rate increased by 15.3%.2
3. Reduce adverse patient outcomes.
By piloting this innovation, care management is becoming more personalized and more effective, and can help reduce adverse health outcomes.
Using personalized data also helps decrease the care management burden for care providers.
Effective and efficient access to data is critical for payers, care providers, and most importantly, patients. It's why we're simplifying the authorization process for care providers and our consumers through increased electronic medical record (EMR) access across the country. Facilities that partner with our health plan affiliates to allow their teams to access EMRs benefit from a more timely and efficient inpatient authorization process. This reduces administrative burden for care providers to help ensure our consumers receive timely, holistic care.
This collaboration has proven immensely successful in a number of ways from the payer's and the care providers' perspectives.
To date, the care providers with whom we share data via EMR access have experienced a considerable decrease in administrative work related to information requests, a decrease in denials, and a quicker review turnaround time compared to those without EMR access.
Inpatient Reviews Comparing Facilities With EMR Access Against Those Without EMR Access
Requests for Clinical Information, 60%: No EMR: 8.8%, EMR: 3.51%
Denials for Lack of Information, 56%: No EMR: 5.01%, EMR: 2.20%
Specialist-to-Specialist Review, 73%: No EMR: 0.22%, EMR: 0.06%
Appeals, 79%: No EMR: 0.24%, EMR: 0.05%
Turnaround Time (in days), 21: No EMR: 1.5, EMR: 1.2
Source: Internal analysis (2022).
Healthcare, an industry representing close to 20% of the country's total gross domestic product,3 remains reliant on archaic technology, and fax machines are the biggest culprit.
To illustrate how large a problem this is, care providers in our affiliated health plan networks send 20 million documents annually as part of requests for prior authorization.1 The process helps ensure that planned interventions are appropriate and that patients aren't left to pay for care out of pocket. Far too many prior authorization requests, however, are received by fax, which creates an administrative burden for care providers and for health plans.
We're working to automate cumbersome processes like this using digital platforms. For example, we created an artificial intelligence-driven tool for accelerated clinical decision-making that takes pages of faxed clinical information and uses artificial intelligence to match that information automatically to the corresponding medical policy criteria to help expedite review and authorization by our medical staff. This technology, which is patent pending, is unlike other solutions in the marketplace as it offers complete transparency in a case determination, leveraging only data that is available in the consumer's specific medical records.
In 2023, we expect efficiency to grow and reduce the administrative burden for more than 750,000 outpatient and inpatient authorizations for consumers with Commercial, Medicare, and Medicaid coverage.4
Innovations like this power accurate decision-making, accelerate the review experience, standardize care review, help improve patient safety, and enable more effective care programs. Ultimately, we hope it also helps care providers believe in our commitment to make administrative pain points a thing of the past.