Payers and providers share goals around emerging models of healthcare delivery, such as values-based care i responsible care organizations (ACO). But inadequacies in current communication between the payer and the provider often disrupt the flow of timely care and lead to unnecessary hospital readmissions and poor outcomes. What is needed in this partnership is standardized, fluid, real-time data exchange to help both parties become even more efficient and effective in providing members with the right care at the right time.
Until recently, a payer only knew when a member was using care after filing a claim, a latent workflow that does nothing to improve patient care. With real-time notification of admission, termination, and transfer (ADT) notifications, payers can help guide members toward better care options while reducing costs through actions such as eliminating redundant evidence before it occurs. the cost. These real-time notifications give the case management team the ability to contact the member and provider when it is most important. For example, if payers receive real-time admission notifications, they can quickly pass tests to speed up the diagnosis. If a hospital member is discharged, payers can coordinate care in the next care setting.
Much of the discussion about the exchange of data between payers and providers has focused on 21st Century Care Act and blocking information. New guidelines on the implementation of application programming interfaces (APIs) and new CMS rules on interoperability and information blocking are also driving these discussions.
ADT’s automatic electronic notifications are reforming payers and providers as natural allies to improve healthcare outcomes and reduce spending. ADT automatic notifications can fill much of the current data exchange gap. Here are three ways ADT notifications can help payers and the members they serve.
1. Reacts quickly to reduce costs and improve results
Receiving real-time automatic ADT notifications allows payers to respond more quickly to members’ needs. This may mean aligning an acute care center within the network or ensuring that the member meets a follow-up appointment with a primary care physician or posthospital discharge specialist, as payers have already negotiated favorable rates. with network providers.
Network providers are likely to offer lower out-of-pocket costs to the member. The payer’s ability to direct that person to one of these providers, rather than allowing hospital staff to choose off-network providers, will also result in a lower claim amount and affordability for members with high deductibles.
In addition, recognizing gaps in member compliance care and explaining it to the provider and helping members increases the scores on the Health Effectiveness Information and Data (HEDIS) set. Payers can extract graphs from vendors, meeting HEDIS requirements.
When the payer can offer management of care to members and direct them to the most appropriate providers, this leads to better health outcomes, a reduction in redundant care, and a better experience for the member.
2. Be more proactive in your member’s care journey
Patient apathy, combined with a lack of proactive care from caregivers, can lead to hospital readmissions, poor health outcomes, and increased health care spending. But a study from the University of Pennsylvania showed that assigning a team of doctors, nurses, social workers, and community health workers to take a hands-on approach can improve patient outcomes and reduce costs. He study of 29 patients showed 55% less hospital admissions, 74% fewer total hospital days, 65% less 30-day readmissions, and a total reduction in direct costs of $ 1.64 million.
Boosting proactive efforts streamlines admissions, helps coordinate inpatient and outpatient care, and addresses the underlying causes of frequent hospitalizations. It is important that the proactive care planning process also includes payers.
Statistics show that only 5% of high-use patients in the United States are responsible for more than half of the country’s illnesses. total health costs. However, real-time ADT notifications that provide information about each step of a member’s care trip can improve the visibility of that trip to increase both the care outcome and the payer’s end result.
For example, if a long-time smoker is discharged after hospitalization for a respiratory problem, the payer may contact this patient to recommend a program to stop smoking and then follow up to make sure the member is taking corrective action to improve their health.
In addition to cost savings, the association of payers with providers can generate significant savings in the time it takes for the core management team to invest in the progress of the member’s health.
3. Increase interoperability between payers and suppliers
A payer using ADT can encourage hospitals and post-acute providers to speed up real-time data exchange. This increases the interoperability between the payer and the providers and a wider interoperability towards the goal of more perfect care.
Emerging technology allows vendors to access any electronic health record system (EHR)., secure direct messaging or digital cloud fax technology (DCFT). Care managers partner with providers to ensure that the member is not readmitted to the hospital and that follow-up care is provided at the right time and in the right environment.
When providers send electronic ADT notifications across their existing platforms, overall network interoperability increases. This not only benefits direct communications with suppliers, but also provides another important benefit for businesses.
When hospitals send an ADT to a patient’s primary care physician, they provide the physician with the right tools to make actionable decisions, proactive follow-up, and assist with the patient’s recovery as soon as possible.
Real-time ADT electronic notifications connect providers and healthcare teams wherever patients receive care. Notifications are sent directly to providers’ workflows, EHRs, or payer care management systems.
In the end, receiving patient data in a timely manner allows for multiple benefits:
Payers can coordinate and eliminate gaps in care while managing the health of members at the point of care; and patients can receive faster treatment based on real-time data, which translates into improved health outcomes.
About Bevey Miner
Bevey Miner serves as Global Health IT Marketing / Strategy Director, Consensus Cloud Solutions, Inc.. With more than 20 years of experience in healthcare technology and digital health, he has been instrumental in leading strategy, product management, business development, marketing and marketing. Bevey has been influential in leading innovation in care coordination, patient involvement, population health, and interoperability, as well as advocating for policy change with the federal and state governments.