Collaborative Care


Three reasons collaborative care can strengthen business outcomes.


By Krithika Srivats

The increased cost of healthcare in America is now standard dinner-table talk – and it’s evidently on the radar for payers and providers. As a result, there has been a widening window for emerging analytics and re-engineering solutions that use AI and machine learning to reduce operational efforts and the associated costs.

Despite these advancements, we must still ask ourselves: how will these developing services improve an individual’s health in a setting where the consumer has limited decision-making power, especially within the context of increasingly integrated hospitals, private clinics and payers? In 2019, where intelligent, customized experiences have become the norm for every consumer interaction, these challenges can directly impact business outcomes. 

Business process outsourcers (BPOs) can handle over tens of millions of interactions between payers, providers and patients – and as a result, have a rich understanding of the gaps that exist within those relationships. As we wait for solutions, we can mine knowledge from BPOs, like interaction patterns and experience expectations. Here, I have outlined a few ideas for collaboration that can help improve the experience for providers and consumers alike. 

1) Proactive collaboration reduces frustrating interactions. On average, providers interact with payers across benefits and eligibility, clinical decision-making and claims denials and grievances. These interactions comprise nearly 40 percent of providers’ time, leading to resource constraints in addition to relationship tension – ultimately impacting the patient. Although electronic data exchange solutions and accountable care contracts have been implemented, the improvement in resolution is negligible (less than 5 percent in best cases), according to internal HGS research. To solve this, BPOs can cross-skill resources to provide proactive education on the main pain points, like authorization decision failure points using a historical analysis of the top 20 denial categories. In a similar sense, claims denial-related clinical documentation integrity and coding inaccuracies can be contained through targeted provider webinars (based on top contributors to said errors) to help them align on the cost impact for both payers and providers. Finally, it is highly effective to deploy analytics and machine learning to provide insights on the behavioral parameters that often cause additional costs and resolution delays. 

2) Data sharing improves member outcomes. Most providers and accountable care organizations have more than 200 required reporting metrics. These reports not only have a financial impact on the provider, they also impact the payer financials. When a payer collaborates with a provider to retrace and extract key parameters relevant to risk adjustment, clinical claims review or HEDIS, the insights beyond the required compliance inputs must be tracked and analyzed. This will reduce duplicating efforts and prevent the burden of medical records submissions by providers. In return, payers should share these insights with the providers in order to help them align with the shared objectives of patient outcomes and reduced care costs. 

3) Connected decision-making is crucial. In an ideal world, providers should show adequate attention to payer involvement in patient care. These interactions can drive collaboration to positively impact patient outcomes. Most primary care providers are part of large health systems and frequently alter their network participation and locations. The patients’ ability to stay connected with the provider has been reduced by over 67 percent in the last 10 years, according to a recent study by a large payer based in California. That said, a collaborative care post-hospital discharge is crucial for preventing readmission, which is a penalty metric for most hospitals. Payer care management programs should focus on collaborating with providers – not only to better connect with their members, but also to help providers meet their quality goals. The result is a boost in compliance to quality reporting such as HEDIS.

Most industry leaders envision a future in which the payer and provider partner to work toward a common goal. These incremental steps will go a long way in creating sustainable, intrinsic behavioral changes. Thus, the combination of these collaborative strategies will reduce inefficiencies and interaction frustration and provide a better foundation for tomorrow’s customer focus. 


Collaborative Care Krithika


Krithika Srivats, vice president, Health/Clinical Center of Excellence, is the leader of HGS’s Healthcare Clinical Practice. She more than 20 years’ experience the healthcare industry with a diverse background in patient care, strategic disease management in the field of Alzheimer’s disease and related dementias, hospital administration and operations and integrated solution designing.  Since joining HGS in 2010, Krithika has developed solutions for healthcare providers based in North America and Asia. She has been a key contributor in the implementation of the first of its kind institutional care center for persons with stroke and Dementia care in India. Krithika has a MS in Occupational Therapy from the University of Indianapolis and a BOT in Occupational Therapy from Christian Medical College 

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