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Roundtable on Health Care: High-Performance Networks – Crain’s Chicago Business

An increasing number of organizations are building “high-performance” networks (HPNs) into their health plans, providing employees with access to a comprehensive set of high-quality doctors, hospitals and specialists within their geographic region, while also lowering costs for employers. But not all networks are created equal. Three Chicago-area executives involved with HPNs shared their thoughts on how quality and cost measures factor into the networks, and how an employer can select the best one to meet its needs.

How is your organization involved with HPNs?

Iqbal Shariff: Best Home Healthcare Network treats people who have typically been through knee surgery or heart surgery and have moved beyond hospitals and rehabilitation centers back home, yet need to still be seen for follow-up. This is short-term care, with an average client remaining a patient for about 45 days. We began our journey with HPNs several years ago when some health plans started asking us to participate in smaller groups of transitional care providers that were more optimized and data-driven. That was our first indication that some of our partners were moving beyond just thinking about HPN concepts and starting to implement some of those concepts into their operations. At this stage, we’re seeing these discussions become more regular, and more practical, with most of our other partners.

David Cooke: The Tandem Family of Companies works with clients to create the best HR strategies to help attract and retain key talent for business growth. When assessing benefits options, we consider whether HPNs make sense. If the client’s geography matches up with the HPN, we explore the option as part of their medical benefits offering. We also help compare various medical insurance options as a part of that strategy.

Tom Kunst: UnitedHealthcare has offered HPNs for many years as part of our commitment to driving value-based care and making health care more affordable for the people we serve by connecting them to high-quality care providers. Two of the best examples of the HPNs we offer here in the Chicagoland area are the UnitedHealthcare NexusACO and UnitedHealthcare Charter. We introduced Nexus in 2017 as a national accountable care organization—or ACO—plan that enables large employers to offer a single plan design nationwide. The plan has a tiered network, with tier 1 featuring local ACOs across the country. Here in Chicago, Advocate Aurora Health is a tier 1 provider. Charter is a commercial benefit plan we introduced in 2016 that features focused networks of care providers that have demonstrated a commitment to delivering high-quality, cost-effective care. We partner closely with Advocate Aurora Health on this plan as well, with Advocate being the featured ACO in the network.

What’s driving the increase in HPNs?

Cooke: One factor is systems that allow providers to accurately track and measure claims and encounter data. Until very recently, most provider systems—with the exceptions of HMOs—lacked internal financial reporting to track their expenses. Because they can now track, measure and understand their data, HPNs can enter risk-bearing arrangements with employers and insurance companies.

Kunst: HPNs are a great example of how the health care system has evolved as a result of the shift toward value-based care. And we all know what’s been driving that shift, namely the unrelenting increase in health care costs. All health care payers—insurers and employers alike—have been laser-focused on finding ways to curtail those costs without jeopardizing access to or quality of care, and HPNs are a great way to achieve that. The move toward value-based care over the last several years has also resulted in insurers and providers growing more comfortable with close collaboration. That’s enabled these sorts of networks to really mature and flourish in a way that’s beneficial to patients by helping to bring down their health care costs while giving them an improved health care experience and access to providers that have a proven track record of delivering high-quality care.

Shariff: Health plans continue to pursue improvements in service reliability, consistent clinical outcomes and financial predictability in the in-home transitional care settings. The HPN model drives process efficiencies that can provide these benefits beyond more traditional, legacy health plan models.

What’s the number one question or concern you’re hearing about them?

Kunst: It varies by employer and its current benefits and network strategy, but the number one question is around access—who’s in the network? What are the benefits versus the traditional benefit offering? Clearly, employers and members are concerned about affordability and balancing access vs. cost. HPNs address both quality and affordability.

Shariff: Typically, the number one question is “Where do we start?” Most plans are aware of the shift toward HPNs but there are many different approaches. It’s natural for them to reach out to their vendor-partners and seek feedback.

Cooke: We hear two questions or concerns frequently—mainly centered around the network of providers. Employers want to know how broad the network of participating providers is and whether employees will be able to get the care they need. Employers are concerned that their employees will be able to access the professionals they need, that they’re provided adequate choices and can connect with providers when they need to.

What are some of the benefits to using an HPN?

Shariff: The primary benefits are better patient outcomes and lower total network costs, both of which are an immediate result of using more services from higher-quality care providers. However, the longer-term benefits of the more optimized process models are where the real savings and performance gains can be found.

Kunst: First and foremost, HPNs address affordability for the employer and member without sacrificing quality. They also lead to an improved care experience through coordinated, patient-centered care, and in most cases, improved benefit plan designs and lower cost-sharing for employees and their families.

Cooke: Medical cost reduction is the number one benefit—a top-performing HPN can save an employer 10%-20% of their medical claim costs. Since participants are accessing care through high-quality, cost-effective providers, the savings get passed back in the form of lower insurance premiums.

What types of services are generally included—and not included?

Cooke: Most services are included with the HPN, except for pharmacy and drug expenses, and organ transplants. Centers of excellence—specialized programs within health care institutions that supply exceptionally high concentrations of expertise and related resources for particular medical areas—are really the HPNs for transplants and other significant surgeries.

Kunst: One of the hallmarks of HPNs is a patient-centered care coordination model. That’s one of the benefits of featuring a high-quality provider in the network. By incentivizing your employees to get care from a provider with a proven track record of delivering high-quality care, it makes it much easier for that provider to in turn coordinate your employees’ health care in a way that’s beneficial for your company and your employees. For example, members enrolled in our Charter plan select an Advocate primary care physician who serves as their health care navigator and is responsible for coordinating their care. That coordination not only strengthens the patient/physician relationship, but it makes it far more likely that members will receive the preventive services and screenings that are appropriate for them and that can help ward off more serious health issues. It also increases the likelihood that members will be referred to high-quality specialists if they need more advanced care. This type of physician-directed, coordinated care within a single local health system helps ensure that employees’ health care needs are managed more efficiently and effectively, which in turn leads to better outcomes and lower overall costs.

Shariff: The most obvious example would be moving from an on-demand model to a planned model; in other words, working much more closely to anticipate clinician demand and to plan appropriately. Another typical service extension would be a dedicated physician contact representative or similar liaison to help reduce delays and errors during the discharge process. These improvements and investments offer far greater optimization gains than their cost charges on paper, and they break down the barriers that can’t initially be automated out using software.

How can the success of an HPN be measured?

Kunst: Employee satisfaction—and hence, increased enrollment at open enrollment—is the best measure of success. Certainly, cost savings and trends are also critical inputs to measure as part of the overall benefits strategy.

Shariff: Obviously, there are financial measurements and cost savings that offer one view of success, and they’re very important. However, there are more complex measurements such as the amount of time and internal expense when transitioning care, ability to transition care with fewer errors and fewer inefficiencies, and other measurements that go beyond pure cost savings. The benefits of an HPN really should go deep into many aspects of internal process performance.

Cooke: An HPN’s success can be measured in two ways. The first method considers what level of cost savings are achieved by utilizing the HPN when compared to other non HPN medical providers. This can be measured by tracking utilization, quality outcomes and overall costs. The second way considers whether the overall health of the employees participating in the HPN improves over time. This entails capturing a baseline of employees’ health, then any progress through annual wellness exams. A broker or benefits administrator can assist in analyzing this data; for example, Tandem HR provides clients with this information through robust claim analytics reports.

What effect has the COVID pandemic had on HPNs?

Cooke: While it may be too soon to tell the total effect the pandemic, the HPNs that are bound to have better performance are those that embrace telehealth. The HPN is incented to provide cost-effective care, so when the shutdown occurred, employees relied on being able to communicate with their doctors via video.

Shariff: HPNs in general have been more resilient to the stress imposed by COVID, and the advantages go beyond financial. HPNs are inherently designed to streamline the process models between care providers and their resource pools. With COVID pushing many staffing systems to their limits, HPNs have extra “cushion” due to their metrics-based approach and their inherent openness to change.

Kunst: COVID has increased interest in HPNs as employers were concerned about the health and well-being of their employees and were looking for opportunities to save premium dollars without shifting costs to employees through higher deductibles and co-insurance.

How do you see HPNs evolving in the future?

Kunst: It’s a journey. HPNs and value-based care will continue to evolve based on the needs of employers and their employees. Collaboration between payers and providers will deepen with an aligned focus on improved member health and experience.

Cooke: HPNs will continue to develop and improve on their risk-bearing contracts with employers and insurance companies. The better the care they deliver, the more business they’ll obtain. The more business they obtain, the more successful they’ll be. It will be a win-win situation.

Shariff: The health plans that partner with home health providers first are at a clear advantage. One evolution that you’ll probably see is that, because HPNs are so data-centric, those early adopters—the health plans as well as their transitional-care partners—will have a “data advantage” over later adopters. As those data advantages grow on both sides of the relationship, you’ll see the early adopters moving more aggressively and with more innovation to extend the HPN model to other less traditional areas of their care systems. A great example of this is networks starting to work together preemptively, shedding their non-HPN relationships to secure their positions with other early HPN adopters. This could prove to be very disruptive to local staffing and resource pools like you see in transitional care providers.

How can an employer tell if an HPN is a good fit for their organization?

Shariff: It’s critical to look for an HPN that understands that it’s not like implementing a new accounting system or software platform; HPNs have a fundamentally different view on performance, process improvement and even risk/reward with their extended network service providers. They’re not a new flavor, they’re a cultural shift. The HPNs you talk to should be able to discuss a vision that goes beyond pure cost savings and financial benefits—both for them, for you the employer and your organization.

Cooke: When considering an HPN for your organization, leverage your benefits experts to verify that your employees will have convenient access to the HPN’s providers. Also, it’s critical that the chosen HPN commits to providing you—the employer—with robust data to show their cost-effectiveness on an ongoing basis.

Kunst: Most employers offer employees a choice of network access and price points and provide incentives to choose HPNs. While most employers aren’t ready to eliminate traditional networks and move exclusively to HPNs, we anticipate that more employers will be open to that approach in the future, moving aggressively in that direction given the focus on quality and affordability, and getting the most value for the care of their employees.

What advice do you have for an employer considering an HPN?

Shariff: Start now and expect to ask for inputs from a broad range of sources, including home health care and transitional providers. It’s this extended network service model that enables many of the HPN benefits, so it’s helpful to get a variety of opinions.

Cooke: Adopting an HPN is a big step. The cost-effectiveness of the plan must be balanced with the ability of broad-based PPOs to attract and retain employees.

Kunst: Every year employers wait to implement an HPN, they’re missing out on a meaningful opportunity to bring down their health care costs and improve the health and well-being of their workforce. Offering an HPN demonstrates that a company is committed to making sure its employees have access to quality, affordable, patient-focused health care. And it gives the employer peace of mind of knowing that its health benefits provider and the health system featured in the HPN share a commitment to providing high-value health care that lowers the total cost of care while improving employees’ health outcomes and patient experience. The cost-savings associated with this model of care can be significant. Companies and their employees can save as much as 15%-25% on premiums compared to a traditional PPO. Our experience over the last several years since introducing a couple HPNs here in Chicago has shown us that employers are increasingly gravitating towards these high-quality, cost-effective health plan solutions and are happy with the results they’re seeing.


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