Image of business leaders with venn diagram illustrating the point where Quality, Utilization and Cost converge

Pairing Member-Centric Provider Access with Supporting Services Is Key to Sustainable Health Spending

Self-insured employers understand the importance of providing access to high-performing, high-value providers to ensure members are offered the most effective health plan. Designing a network to achieve smarter, better, faster healthcare requires far more than a network of providers and facilities.

Employers require data transparency to identify the specific healthcare services their members need. They also need flexibility in network design to provide that access, along with quality and overall program value for their health plans.

For example, a high-performing contracted network might be appropriate for a health plan with members in close geographic proximity, while an open access solution could be a more aligned approach for a self-insured employer with a remote workforce. Others could benefit from a hybrid design that leverages aspects of both models while creating consistency across their program.

A strong place to start is considering how to balance quality, utilization and costs as you establish your network as the foundation of a broader platform for your members. When you combine a well-crafted, data-driven network with defensible market-based pricing and a range of care and claims management solutions, the result is a fully integrated health ecosystem – built to enhance transparency, enable quality decision-making, and improve total spend savings by 20-40 percent.

Low-value care is a significant source of inefficiency in the U.S. healthcare system, with estimates suggesting that 10-20 percent of annual healthcare spending (around $350 billion to $490 billion) is lost on unnecessary and often harmful care and wasteful spending. A high-value network model, “credentialed” through the use of big data and advanced analytics, will consistently drive quality care and sustain high customer satisfaction alongside lower plan expenses.

And as healthcare costs continue to increase, employers’ interest is trending in the direction of value-based care contracting models. While only 6 percent of employers had developed direct contracts with providers in 2019, 22 percent were considering a move to that model. Based on feedback from employers we engage with each day, the number of employers interested in value-based and direct contracting models is climbing.

Whichever model of provider access makes sense for your plan, you’ll need supporting solutions to drive optimal improvements in quality, utilization and costs across the life cycle of every claim. A holistic ecosystem will integrate high-value networks and open access models with enhanced solutions that bridge the divide between robust analytics and member-centric services.

  • To ensure you optimize your network model, consider evaluating and integrating comprehensive supporting solutions that could include:
  • Access to provider quality and cost data for transparency
  • Concierge-level navigation for personalized member guidance to the right care at the right time and right place
  • URAC-accredited case, disease and utilization management offerings to validate quality and improve access and target appropriate levels of care before services are rendered
  • Solutions that target quality, proper utilization and enhanced cost savings for high-cost services such as behavioral health, cancer care, dialysis, maternity care and ambulatory surgery
  • Detailed analysis of claims pre- and post- payment to ensure fair, defensible, market-supported reimbursements
  • Open, non-contracted reimbursement strategies as a stand-alone option or wrap solution. Historically referred to as RBP, these models have advanced considerably since their inception.
  • Solution for seamless, assured claim reimbursement
  • Expert bill review with provider signoff for high-dollar claims in and out of network
  • Cost-saving specialty pharmacy solutions
  • Full-service claims management
  • Advanced analytics and predictive modeling to uncover continuous cost-saving opportunities

With fully insured health plan costs rising by roughly 9 percent each year, the key to sustainable spending lies in the power of the fully integrated health ecosystem and a review of self-insured and self-funding options. When you combine all the elements necessary to drive improvements in quality, utilization and costs, you create synergy that lowers the Claim Cost ArcSM and supports strong, vigorous and healthy lives.

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About the Author: Rob Gelb is Chief Executive Officer of Vālenz®, the industry-leading ecosystem offering self-insured employers unrivaled data transparency to pinpoint members at highest risk, address gaps in network designs, ensure appropriate and accurate charges, and expertly navigate members to optimal care solutions for substantial cost savings and improved health outcomes.