First, we focused on streamlining the processes for four high-cost areas: provider directories, credentialling, and prior authorization, as well as for processing claims, recognizing each creates a notable burden that could be simplified with certain tech-enabled steps that would standardize data flow. Our first set of recommendations are as follows:

· Collection of Data for Provider Directories – State and federal law require that health plans provide members with directories with information on in-network providers, which could be streamlined by using a single platform to exchange directory information. It’s currently estimated that maintaining provider directories costs physician practices up to $2.76 billion annually, with a single platform saving U.S. practices at least $1.1 billion per year.

· Collection of Data to Support Credentialing of Providers – Both hospitals and health plans conduct credentialing to ensure providers are up to date on education and licensure, but as any physician, physician’s assistant, or nurse can attest, it can be a lengthy process that leaves them on the sidelines waiting for approval when they could be administering care. Using a single platform to facilitate credentialing with multiple health plans can save clinical practices almost 40% on credentialing costs per month, while simplifying the process.

· Centralized Claims Processing – Modeled after the banking industry’s automatic clearinghouse, which allows for the secure, standardized transfer of money or financial products between two parties, a centralized health care claims clearinghouse would standardize the electronic transmission of billing information across providers and payers. Harvard’s David Cutler has estimated this approach could conservatively save $300 million per year, and effectively reduce fraud in the system.

· Collection of Data to Support Prior Authorization – While prior authorization can be important to manage cost and ensure appropriate use, it is also burdensome for clinicians. This can first be simplified by requiring prior authorization to be done electronically, instead of by phone or fax. Some states like Massachusetts and Michigan are already taking steps to automate or standardize this process.

Administrative Streamlining: Harmonization of Quality Measures

Finally within this priority area, the Council recommends action on the excessive and duplicative array of metrics providers are required to capture:

· Longer-Run Harmonization of Quality Measures – We at the Council widely support quality, data, and measurement, but agree the inordinate number and confounding diversity of quality metrics today meaningfully detract from our ability to interpret data effectively across systems, and unnecessarily burdens providers. For example, CMS uses more than 2,200 measures and metrics across its programs alone. One estimate put quality reporting costs at $15 billion per year for providers – a total that could potentially be cut in half with standardization. Harmonizing quality metrics has widespread industry support, although will take coordination among many stakeholders.

The Need, Examples, and Next Steps

My colleague and friend, Vanderbilt health care economist Larry Van Horn, has long argued that, “An insurance system is the last way you would choose to finance or pay for anything.” And if we were starting from scratch, we’d likely redesign our current system. But realistically working within the confines of today’s structure, we can start by simplifying some of the administrative burdens that have been erected largely to support the complex billing and insurance apparatus that finances healthcare. This is “low-hanging fruit” that policymakers, regulators, and health care executives can get behind.

It can also serve as a guide for private sector innovators and entrepreneurs looking for way to improve efficiencies and productivity within our health care sector. Thinking of my own experience through Frist Cressey Ventures, we are working with a number of tech-enabled companies that are squeezing out waste and making a difference in the administrative health care burden:

· One example is Memora Health, which partners with providers, payors, and pharma organizations to digitize existing clinical workflows to enable remote care initiatives, support member engagement, and accelerate clinical trial operations. The company’s platform integrates and automates complex care workflows, supporting care teams by intelligently triaging patient-reported concerns and data to appropriate care team members and providing patients with proactive, two-way communication on their care journeys.

· Another is DexCare, an access optimization platform that offers health systems the infrastructure required to scale and optimize digitally enabled care across a broad array of business lines, thereby eliminating the waste and inefficiencies of siloed administrative and management functions.

· Carta Healthcare is also making a difference this space. It uses technology to remove mundane and time-consuming administrative tasks from clinicians’ shoulders by harnessing the value of clinical data through its combination of AI-driven technology and a multidisciplinary team of experts. The result is high-quality, trustworthy datasets for use across a healthcare organization’s initiatives to operate more efficiently, optimize care delivery, improve patient outcomes, and allow clinicians to practice at the top of their license.

These are just a few examples within my own sphere of private sector innovators making a difference. But for largescale change, we’ll need engagement and commitment at the top of federal and state government, and from within the leading, legacy health care systems.

With the backdrop of the debt ceiling debate coloring today’s political climate, we encourage lawmakers to look to our report for recommendations that can achieve real health care savings as they address burgeoning federal spending. Likewise, we hope states, the laboratories of democracy, will also take up this charge and demonstrate how acting now can improve quality and value while effectively slowing health care spending growth. We as a Council recognize achieving these changes won’t be easy, but we offer this road map to begin the process of change.

Source: Forbes