Healthcare delivery is in transition, and the onset of narrow networks is redefining how providers manage their clinical and financial businesses. Such networks, where patients get their care from a smaller community of providers, are aimed toward developing high-performing groups of physicians who collaborate to achieve clinical excellence and patient satisfaction.
Narrow networks are becoming increasingly prevalent as patients enter into public or private health insurance exchanges (HIXs). By some estimates, as many as 65 million Americans will be covered by insurance plans offered by both public and private HIXs by 2018. Beyond limiting patients’ access to a select number of providers, many HIX plans also require referrals for care obtained outside the network and for certain tests and procedures.
These factors, combined with the growing emphasis on value-based care and bundled payments, mean that healthcare organizations must find new ways to succeed in an emerging market environment.
What Do Narrow Networks Mean For Imaging?
Imaging is an increasingly important quality indicator, both for healthcare organizations and individual providers. As narrow networks take hold, however, they will fundamentally change the economics for both hospitals and ambulatory facilities that have and focus on image intensive specialties like radiology, orthopedics and cardiology. Payers are already keeping track of how many scans are being done, and Medicare will soon start measuring providers based on the extent of imaging overutilization and its effect on care quality.
For example, radiologists can expect to see more bundled-payment arrangements under which insurers agree to pay for one pre-op scan, one post-op scan and a maximum of two follow-up scans as part of a joint replacement surgical procedure. This type of scenario will certainly impact an imaging center’s revenue.
Advanced interoperability can help address this challenge by extending the reach of primary interactions between surgeons and imaging providers, as well as secondary or follow-up interactions among primary care physicians, the medical imaging provider and other specialists. Along the way, each provider benefits from reviewing critical patient images for reduced cost, increased referrals and enhanced patient care.
To position themselves for the new world of narrowing networks, providers must take action now. To be specific, the following five executive strategies must be considered to succeed in today’s narrowing field:
- Look at referral sources. Providers in both acute and ambulatory settings need to look at and evaluate which of their referral sources are at risk as employers do more direct contracting and accountable care organizations (ACOs) take hold. With changing patient populations, there’s significant potential for bad debt exposure as patients are responsible for more of their imaging costs. More specifically, medical imaging providers must be aware of how much patients owe, whether their imaging tests will be paid for as part of a bundled payment and who is within the referral network.
- Get the technology house in order. Whether an imaging provider participates in Meaningful Use (MU) is less important than the fact that its referring physicians are likely participating. Hospitals and outpatient facilities must be able to support the needs of their referring physicians, and those that don’t enable them to view medical images as part of the electronic health record (EHR) risk losing those referrals and the accompanying revenue.
- Tighten up the order and results process. The Advisory Board reports that patients don’t get their scans completed about 50 percent of the time, typically because they can’t afford to pay for them or they’re afraid of what the results might be. It’s often a quality-of-care issue, so medical imaging providers must tighten up and automate the process. For example, how does an ordering physician know that imaging has taken place and the results are ready in today’s healthcare environment? They get a fax, which is very outdated technology when compared to other industries. To manage narrow networks, the imaging provider needs to automatically get the information directly into the referring physician’s EHR quickly, efficiently and seamlessly. The referring physician needs to know that the patient took the test and that the results are in, so he/she can determine what he/she needs to do next for the patient. Working together as exemplified not only strengthens referral networks, but also aligns the major investments into EHR technology and order entry process as part of the proposed MU Stage 3 requirements.
- Enable image sharing. Hospitals and outpatient facilities need to improve image sharing amongst themselves as well as their referring physicians and specialists. Imaging associated with a patient being referred by his primary care provider to the orthopedist, for example, or by the orthopedist to a neurologist, will be considered as part of one episode under new care models. Advanced interoperability strategies enable different imaging providers to easily exchange information with healthcare systems directly into their EHR systems, enabling the inevitable narrow networks to take hold as well as support quality care initiatives.
- Band together. Collectively, providers and the imaging industry as a whole need to collaborate and create secure networks for image sharing, much like the banking industry has created secure networks for financial transactions. Creating real interoperability will generate leverage with HIXs and payers. Hospitals and imaging centers can go to a payer or an ACO and say, “We have this advanced imaging network. How can we work together to solve challenges with overutilization but also bring value to our practice?” Such a network will help the entire medical imaging community by creating a stronger value proposition for imaging services, solidifying referral relationships and giving them a seat at the table with respect to data governance and related issues.
Medical imaging is one of the most technologically advanced fields in medicine. It was the first to make widespread use of digital technology, and now it’s time to set the next bar. Imaging providers have already solved the technical side of viewing, storing and moving images. Now the community must try to solve the administrative and financial pieces associated with narrow networks. Advanced interoperability is the crux for achieving this higher level of integration.
These are fundamental institutionalized problems that we’re tackling, and now the technology is finally at a point where we can overcome these issues. Healthcare organizations and imaging providers just need to work together to solve them, not just for our benefit, but for the benefit of all healthcare and the patients we serve.