“Life moves pretty fast. If you don’t stop and look around once in a while, you could miss it.”
If that line sounds familiar, that’s because it’s a quote from the ever-wise Ferris Bueller in Ferris Bueller’s Day Off. Though the movie was released 38 years ago (if you’re an ‘80s kid, I’m cringing with you!), it still rings true today. Sadly, for healthcare, missing the changing times isn’t really an option. It’s happening at warp speed, and members are demanding we pay attention.
The good news? The number of uninsured Americans is decreasing. This means more people both want and need access to care. The challenge lies in finding doctors to care for them amid a growing provider shortage. Unfortunately, America is facing more patients with not nearly enough doctors to care for them. That makes building and managing provider networks even more important.
We’ve shifted from a time when provider network management (PNM) was all about giving members broad access to care – i.e., your traditional Preferred Provider Organizations (PPO) or Health Maintenance Organizations (HMO) – to a time when customized networks are essential to accommodate this changing dynamic.
Broad access to care was a lot like having dinner at a giant buffet. There was a whole lot on the menu, but not everything was great. Today it’s all about quality and cost-effective choices. Members would rather have something made-to-order – or better yet, delivered – than go to a buffet.
Custom provider networks are gaining more traction for just that reason. With costs skyrocketing, families are feeling the pinch. Lowering costs while ensuring quality is paramount. Finding the solution starts by re-examining how you approach PNM.
What is provider network management?
PNM is a critical aspect of healthcare administration. It focuses on creating and maintaining a network of healthcare providers to deliver high-quality, cost-effective care to members. This involves both selecting and contracting with providers and monitoring and optimizing the network to ensure it meets the evolving needs of members.
Ideally, an effective PNM strategy ensures members are receiving the best possible care without unnecessary costs. Payers also want to prioritize building good relationships with their contracted providers.
The evolution of provider network management
Let’s take a trip down memory lane. Back in the day, healthcare networks were designed to give you access to as many providers as possible. While that was great for access to care, it had – and still has – its limitations. High costs, long wait times and quality are just a few, and that’s just for members. This model can also result in administrative burden and inconsistent patient volume for providers.
As time has gone on, the demand for more flexible, high-performance provider networks has only grown. Members now want quality care without breaking the bank.
So, what drove this change? A mix of member expectations, cost and efficiency concerns, and the need for better quality of care. Not to mention rapid technological advancements like AI and changing member expectations.
Challenges tackling provider network management alone
Managing provider networks isn’t a walk in the park. Health plans face a ton of administrative and financial burdens. These challenges impact both cost and care quality. Common gaps in network coverage, including limited access to care, long wait times for appointments and high out-of-pocket costs, make things even trickier.
One of the significant challenges in PNM is finding and keeping primary care providers. After all, one out of four adult Americans doesn’t have a primary care provider. Customized provider networks can address some of these challenges by providing comprehensive and coordinated care, ultimately leading to better health outcomes.
Many health plans find a specialized network management solution to be a worthwhile investment in overcoming these coverage gaps. A specialist has the expertise to provide much-needed customized options (in other words, creating that made-to-order experience members want).
Network management companies may tailor networks to meet the specific needs of the health plan to improve access to care and fill coverage gaps, too.
How the right provider network strategy drives better outcomes
Ensuring provider quality and managing healthcare costs are crucial for any network strategy. Tailored provider networks, such as primary networks, wrap networks, supplemental networks and out-of-network solutions, can optimize member care by balancing cost and quality. Successful network strategies often involve networks and customized solutions that cater to specific needs.
One of the biggest benefits of tailored network solutions is their ability to meet the diverse needs of members. For example, primary networks focus on providing access to essential healthcare services, while wrap networks offer additional coverage for specialized care. Supplemental networks provide extra support for specific health needs, and out-of-network solutions ensure that members can access care even when they are outside their primary network. By strategically building and managing these networks, health plans and third-party administrators (TPAs) improve access to care, manage rising healthcare costs and deliver targeted services to their members.
Another key aspect of effective network strategy? Vendor consolidation. By consolidating vendors, health plans and TPAs can improve costs and streamline operations. This approach reduces the administrative burden on health plans and TPAs and ensures members have access to a wide range of providers through a single partner. Vendor consolidation also helps improve overall financial performance by leveraging solutions like payment integrity to ensure payment accuracy.
Embracing the potential of high-quality provider network management
The journey of healthcare networks has proven that quality and cost-effectiveness are not just buzzwords. They are essential for delivering the care that members deserve. Custom PNM is key to better health outcomes and financial sustainability.
Think about the potential of your health plan when it’s supported by a robust, customized network. Reduced administrative burdens, better ways to manage healthcare costs and ensuring members have seamless access to quality care are just a few of the benefits.
Building and managing the right network is a big obstacle alone. Consider partnering with a vendor who specializes in this and can alleviate the burden for you.
For example, Zelis Network Solutions offers primary networks, supplemental networks, wrap networks or specialty networks. They can help you build the right PNM strategy. One that ensures you provide members with the best possible care while optimizing operational efficiency.
Learn more about our suites of solutions or contact us today.
