Healthcare Provider Network Management
The rise of telemedicine and retail clinics, narrow networks, and efforts to augment care quality and cut costs are examples of insight showing that companies are moving toward utilizing third party vendors for their healthcare provider network management. On the other hand, Henry Ford Health System is an example of a healthcare business that expanded its existing 'open scheduling' feature to accommodate more groups.
i. Insights into Companies Using Third-party Vendors for their Healthcare Provider Network Management
Efforts to Cut Costs
- Many companies are moving towards using third-party vendors for their healthcare provider network management to cut costs. Research findings show that six percent of companies providing benefits eliminated a hospital or health system from their network provider to reduce their plans' costs.
- Most companies are moving towards tiered networks, which categorize the providers in the network based on cost savings and quality of service provided. About 73% of all firms move to tiered networks to attain both quality and cost-efficiency.
- Likewise, approximately 13% of firms prefer tiered networks due to cost and efficiencies. Another nine percent use tiered networks for quality purposes, while only 4% of firms use tiered networks based on neither cost, quality, or efficiency reasons.
- Statistics show that 55% of companies offering health benefits cite that their biggest enrollment plan uses a ‘very broad’ network, while 37% claim that theirs is ‘somewhat broad,’ and 7% note it is ‘somewhat narrow
- When considering cost savings via narrow networks, 39% of employers claim that they cannot reduce network size to realize cost savings. Another 11% claim they can shift to narrow networks if they realize cost savings from 20% to 30%.
- Research findings indicate that only 8% of employers are directly contracting with health care providers; therefore, an estimated 92% who are not directly contracting are likely using provider networks.
- The employers who are directly contracting seek specific services, including "bariatric surgery, infertility, cardiac surgery, orthopedic surgery, oncology, maternity, and transplants."
The Rise of Telemedicine and Retail Clinics
- Alternative care settings such as telemedicine and retail clinics are fueling the adoption of third-party vendors in the healthcare environment to facilitate the management of healthcare provider networks.
- Since 2015, the percentage of large firms claiming to offer telemedicine has climbed from 27% to 39% in 2016 and 63% in 2017. Equally, in 2017, an estimated 75% of firms offering health benefits cover care offered at retail clinics, such as those located in malls, retail stores, chain stores, supermarkets, etc.
- The rapid rise is an indicator that many firms are using third-party vendors to deliver telemedicine services, which include messaging, video chat, remote monitoring, etc. Therefore, it is likely that large firms are using third-party vendors to offer some of these services.
- Research findings indicate that third-party vendors also contribute to security breaches in their networks. In 2018, approximately 56% of healthcare providers in a survey had third-party breaches resulting from one or more third-party network vendors.
- Healthcare providers are having a tough time understanding the risks third-party vendors pose to them, considering it costs about $3.8 million per provider to mitigate vendor risk. In this regard, provider networks pose significant risks to health benefits providers.
- An estimated 72% of the respondents in the survey claim that "increasing reliance on internet-connected third-party medical devices is risky." Equally, another 68% cite that migrating operations to the cloud while keeping medical devices connected to the internet can create unprecedented cyber risk exposure.
- Overall, investments to contain data breaches indicate that many U.S. healthcare firms rely on provider networks. For instance, over 50% of U.S. healthcare businesses have invested in network monitoring to discover suspicious activity on the network, one-third have invested in the domain name system (DNS) security system, 37% have invested in application security.
Reliance on Many Customer-facing Software Systems
- Healthcare businesses rely on numerous customer-facing systems that pose challenges when integrating new technology changes to these systems.
- About 53% of healthcare organizations take months to a year to implement new technological changes because an estimated 62% of them use from two to ten customer-facing software systems.
- Likewise, about one-third of healthcare organizations are not aware of the number of software systems they are using.
- In this regard, 58% of employers are planning to consolidate their technology platforms for simplicity, 49% are seeking to enhance agility, while 43% aim to migrate to cloud-based applications.
Varying Market Size Figure
- While the two market sizes provided in early research feature contradicting figures, in-depth analyses on the same have uncovered that the report citing the market at $3.12 billion provides a breakdown of the market based on components, platforms/services, and region.
- On the other hand, the report citing the market at $47.6 billion does not include any breakdown on the market, whether by parts, region, etc.
- Interestingly, a report by MarketsandMarkets quoted the market at 2.96 billion by 2020. In this regard, it is assumed that since two reports provide more related figures that focus on the component and platforms/services segment of the market, then their values appear more accurate versus the one claiming the market is about at $47.6 billion.
II. Key Players in the Healthcare Provider Network Management Market
TriZetto Healthcare Administration Solutions
- Cognizant’s TriZetto Healthcare Products are a suite of software solutions designed to assist businesses in improving "revenue growth, drive administrative efficiency, improve cost and quality of care, and improve the member and patient experience."
- TriZetto Healthcare provider network management solution features an "integrated provider data management platform," along with three core products that help healthcare businesses deliver quality and best value to patients, payers, and providers.
- The company's competitive advantage stems from its three core provider network management products, namely Cognizant TruProvider®, NetworX Pricer®, NetworX Modeler®, and NetworX Payment Bundling Administration. These solutions singly or together deliver enhanced provider reimbursement management solutions.
- The management platform claims to help businesses gain urgency, accuracy, efficiency, and cost savings while minimizing human errors and complying with regulatory requirements. Examples of companies using the platform include Pacific Source, Moda Health, MVP Healthcare, etc.
- Another competitive advantage of the provider management solution is its ability to return a greater value for every dollar spent via value-based reimbursement administration.
- The solution targets healthcare organizations looking to grow revenue, optimize administrative efficiency, reduce costs, improve quality of care, and elevate the customer and patient experience.
Ayasdi: Artificial Intelligence for the Enterprise
- Symphony Ayasdi solutions are powered through artificial intelligence (AI) and machine learning to extract insights from data with unrivaled speed, accuracy, and transparency.
- The company provides Clinical Variation Management (CVM) solutions to help healthcare organizations cut costs while driving high-quality care.
- Ayasdi's CVM rapidly analyzes healthcare providers' financial data and electronic medical records (EMR) to automatically surface patients with similar procedures to establish clinical pathways that result in the best patient experience.
- CVM's competitive advantages include enabling healthcare providers to accurately estimate the cost and quality of the expected treatment outcome. The CVM also integrates with the ERM of healthcare organizations to rapidly deploy intelligence throughout the healthcare facility.
- Importantly, Ayasdi's CVM analyzes hospital data to identify both positive and negative clinical variations to help reflect the collective expertise of the staff.
- Ayasdi CVM targets healthcare providers. The company serves the healthcare industry, along with the finance and public sectors.
McKesson Corporation: RelayHealth Pharmacy Solutions
- McKesson Corporation operates a diversified business model with numerous businesses, including pharmaceutical distribution, wholesale medical supplies, pharmacy services and technology, and solutions for biopharma and specialty practice.
- The company's provider network management is a pharmaceutical solution dubbed "RelayHealth Pharmacy Solutions," which is a nationwide pharmacy connectivity network.
- McKesson claims that its solutions can help companies struggling with increasing profitability, elevating operational efficiency, and improving compliance for businesses. RelayHealth Pharmacy Solutions improves drug adherence rates and streamlines workflow connectivity in the pharmacy connectivity network.
- McKesson's RelayHealth Pharmacy Solution's competitive advantage includes the ability to power over 18 billion pharmacy transactions annually. Moreover, the solution integrates with more than 50,000 retail pharmacies nationally.
- Another key advantage of the pharmacy connectivity network is the ability to offer solutions for different business segments, including biopharma companies, pharmacies, physicians, payers, and PBMs.
- The RelayHealth Pharmacy Solutions targets the larger healthcare ecosystem; however, it also specifically targets biopharma companies, pharmacies, physicians, payers, and PBMs.
- Genpact Limited provides a robust enterprise performance management (EPM) system designed to help companies "redesign corporate performance, improve insights, and enable action."
- The company's EPM includes an AI-based platform — Genpact Cora, which automates business operations, boosts agility, and provides timely insights and reports regarding the performance of the business.
- Genpact Limited EPM's competitive advantage stems from its consulting-led approach that utilizes governance and performance frameworks. The approach turns EPM into an important business driver.
- The EPM solution boasts over 100 blue-chip clients, more than 4,000 EPM domain experts, and a geographic footprint spanning over 70 countries.
- The solution claims to help "optimize enterprise performance management, improve planning, budgeting, and forecasting, streamline performance reporting, and create an effective EPM organizational model."
- Genpact Limited targets various industries, including healthcare, life sciences, insurance, etc.
- Atos/Syntel is a global provider of integrated IT, digital solutions, and knowledge process services. The company offers numerous solutions for the healthcare industry but none regarding provider network management.
- Examples of healthcare provider network management solutions provided by Syntel include its Enterprise Platform Solutions that help organizations redefine their business models and IT architecture to stay abreast of the rapid technological change.
- The company's enterprise platform solutions benefit from broader competitive advantages, including strong partnerships with technology companies like Microsoft, SAP, and Oracle.
- The solutions also support diverse business functions, including robotics and automation, digital applications, intelligent collaboration, cloud solutions, etc.
- Syntel's enterprise platform solutions claim to reduce TCO by between 35% to 45%, provides up to 90% test automation, reduces operational risk, improves system reliability, and advances up 20% faster time to market.
- Syntel targets various markets with its solutions, including the healthcare sector, where it offers services such as provider analytics, enterprise mobility, electronic health records (EHR), etc. Other industries served include life sciences, insurance, etc.
III. Case Studies: 'Find a Doctor' Feature
Henry Ford's Open Scheduling with Epic EHR Software
- The Henry Ford Health System, with six hospitals and over 250 service locations, sought to focus on attracting and retaining new patients.
- The company then decided that it would implement open scheduling, and roll out the capability to schedule an appointment to many groups previously underserved.
- Previously, the health system relied on an 'open scheduling' software provided by Epic EHR Software; however, its access was limited to specific groups. Moreover, the previous process also entailed calling into the company's call center or booking for an appointment online and following up with a staffer.
- In this regard, the Henry Ford Health System opted to expand access to open scheduling to support many groups and offer patients a simpler path at the point of conversion. It continued using the services of Epic EHR Software.
- Overall, the open scheduling solution returned positive results. For instance, it resulted in a "no-show rate of just 6% for self-scheduled appointments," which are lower compared to direct scheduling and other processes. Again, the open scheduling resulted in over 60% new medical record numbers (MRNs) to Henry Ford.
Ear, Nose & Throat Surgeons of Western New England
- Ear, Nose & Throat Surgeons of Western New England is a practice with three locations, seven physicians, and attends to over 150 patients a day. The practice also faced issues with patients' appointments, whereby they needed to be scheduled in about three to four weeks out.
- The healthcare facilities also relied on a manual waitlist for appointments, which disrupted the workflow, consumed more time entering the data and tracking appointments manually, and was unreliable and inconvenient.
- To solve these challenges, the Ear, Nose & Throat Surgeons of Western New England started experimenting with different third-party software and messaging apps to eliminate the use of waitlists. Lastly, the company found out that Everseat's solution worked perfectly for its business operations.
- Twelve months after implementing the solution, the practice claims to have started experiencing a significant difference in how patients filled open appointment slots. Cancellations started getting booked very fast, in less than sixty seconds.
- The app got adopted by both young and older patients and the hearing impaired who could not call to book or schedule an appointment.
To uncover insights that indicate whether companies are moving toward utilizing third party vendors for their healthcare provider network management, your research team began by exploring industry report focusing on provider network management solutions. We focused on reports, articles, surveys, and studies published by network management solutions' vendors, along with healthcare organizations, including Health Systems Tracker, KFF, Managed Healthcare Executive, Health IT Security, Catalyze, among others. These vendors contained both qualitative and quantitative data with insights suggesting that some actions taken by companies indicate an affinity for relying on services of provider network management.
Next, to identify five to six key players in this space, we relied on industry reports discussing the market size of healthcare provider network management. We focused on those players that are headquartered in the U.S. and offer services nationally. Based on initial research, some key players identified include TriZetto, Ayasdi, McKesson Corporation, Genpact Limited, and Atos/Syntel. Other examples, such as Infosys BPO and Mphasis Limited, are India-based. These companies are ranked key players based on the market share they hold in the provider network management market.
Lastly, the case studies provided were published by the respective third-party vendors of open scheduling solutions and feature examples of companies transforming from a company created "find a doctor" feature to one provided by third-party vendors. The case studies focus on Ear, Nose & Throat Surgeons of Western New England, and the Henry Ford Health System.