Over the last few months, COVID-19-related events have been a stress test for our entire healthcare ecosystem. And they continue to be. If this were an exam, we would score a “D” at best. Don’t get me wrong; this overall grade is no reflection on the contributions of individuals such as our doctors and nurses on the frontline, rather that we as an industry and society must embrace and, more importantly, act on these learning opportunities.
Learning Opportunity 1: Technology
One silver lining of recent events has been the rapid adoption of new technologies. Telehealth is the obvious one, but coordination between payers and providers has seen noticeable transformation (although not without its hurdles). For example, with more of us working from home, limitations on a fax-heavy ecosystem are exposed. At NantHealth, we have firsthand experience supporting our payers with transformative technologies to adapt.
Amidst all this progress, however, pre-authorizations have not gone away, and there is no sign that they will. What this means is that provider offices will still need to go through these administrative steps. The implicit in all of this is that provider offices are hurting financially; it’s an unfortunate inevitability that many practice office administrators may not return to work in the immediate future. This presents an opportunity for pre-authorization tools, like Eviti Connect and NaviNet Open, to automate these steps as much as possible.
Learning Opportunity 2: Legislation
At a state level and national level, there has been a surge of legislative changes – ranging from “The Families First Coronavirus Response Act” (FFCRA) to more than 140 bills at the state level. There is no doubt of the positive intent to enable care, but these changes are driving uncertainty like:
- What changes will remain?
- How many (and which) will revert? And when?
- What modifications should we expect?
With all this change, payers and providers are under tremendous strain – you may be feeling this too. Compliance teams, legal departments, managed care groups, and revenue cycle management teams are all challenged to keep up with each state’s governance. New techniques are being adopted to align with this legislation, for example, new testing workflows and payment models. However, too much is open to interpretation.
“Healthcare reform” is easy rhetoric to lean on, and dare I say, a lazy answer. We can’t expect to unwind decades of effort to support mandates nearly as quickly as COVID-19 has instigated other changes to the practice of medicine. Still, we can better inform care planning decisions through greater transparency into the requirements of the moment. When such critical insight is available at decision time, providers, payers, and patients can be more confident that care and coverage are aligned.
Learning Opportunity 3: The Difficult Questions
If we step back from the chaos and uncertainty for a moment, it may be possible to imagine a utopic future where everyone has the information they need to make sound, timely care decisions in the best interest of the patient’s physical, mental and financial health. The challenge begins in how we achieve universal adoption of new tools, technologies, processes, and rules.
A patient’s medical history is essential for physicians to make informed diagnoses and plan appropriate treatment. But where does all this data live, and how does the physician get to it, who owns it, and how do we protect it? For years we’ve seen Health Information Exchanges (HIEs) attempting to aggregate and share patient data, but there are boundaries to those systems that are inconsistent with how and where we seek care. Today the global industry is rising to this challenge on a tiny scale to implement COVID-19 contact tracing. No doubt, new paths forward will come of this, along with further questions about privacy to which today’s laws are blind.
To be truly successful, we also need business models that align incentives between payers and providers, and even the patient, who is too often left footing the bill. Value-based care and shared risk are promising, but also increase reimbursement complexity. They require careful tracking of patient attribution, performance metrics, and outcomes. Payers are trying to manage provider networks and coverage terms that vary down to the individual employer groups they cover. Providers are entering into such contracts with multiple payers and struggle to know which terms apply to the next patient who walks in their door. One thing is certain, to be better prepared for the future now is the time to adopt and embrace digital technologies – interoperability has never been more critical.