White Papers

Health benefits are complex. Employees don’t understand them as well as they want and need to. Care navigation can help fix the problem.

As the winds of digital transformation sweep through the healthcare sector, the need for healthcare organizations to maintain long-term customer relationships is creating a patient-centered experience. Rising patient self-reliance has transformed care delivery norms, empowering patients to participate in their healthcare proactively.

Quality management strategies in healthcare can be challenging to implement without standardized metrics as different patients may have widely different problems. To ensure high-quality care, treatments need to be personalized as they don’t necessarily always align with standard, template-based processes, making tracking difficult and creating quality gaps. This whitepaper covers strategies that one can adopt to facilitate quality management and improve health outcomes.

Healthcare organizations have shown interest in a model that could implement private sector approaches to risk-sharing arrangements and payments while minimizing administrative burden and downside risk. The payment model options available under Direct Contracting can be appealing to provider organizations since the model is expected to reduce burden, focus on beneficiaries with complex chronic conditions, and boost participation from organizations that have not yet engaged in Medicare FFS or CMS Innovation Center models.

ACO REACH, a new payment model from the Centers for Medicare & Medicaid Services (CMS) will replace the current Global and Professional Direct Contracting (GPDC) model on January 1, 2023.

Existing provider network management solutions are often developed for a single purpose, cobbled together with a disjointed combination of homegrown and legacy IT. They have been supporting evolving organizational needs such as credentialing portal, provider data analysis, and more. However, this approach is not a long-term solution to provider network management needs and prevents payers from gaining an unbiased, unified view of provider performance. Relying on claims data alone is insufficient.