Kaitlin Howard

By Kaitlin Howard

Kaitlin Howard is a researcher and writer producing insightful content across the healthcare revenue cycle. She has written and produced content for Zelis, Waystar, and Recondo Technology, as well as agencies. With a B.A. in English and Writing from University of Denver, Kaitlin stays current on market updates on claims management and healthcare payments, publishing a regular educational blog series on industry trends and Zelis offerings.

A network is only as strong as its providers.

As the frontline of care, providers are always ready to help to the best of their resources and capabilities. But sometimes, one provider is better suited to help over another.

The exact reasons why, however, might not be the most obvious.

For a provider network, understanding the strengths of each provider and the needs of the member is key. But what actually matters when reviewing a provider? What considerations must be taken into account? Where can provider metrics be seen and compared? What are some best practices to maximize the provider potential?

In a recent podcast, Paul Nance, Senior Product Analyst at Zelis, joined Future Healthcare Today to answer these questions and more.

As always, we’ll discuss the highlights below, and you can listen to the full podcast here:

The moneyball mentality explained

In 2003, Michael Lewis published “Moneyball: The Art of Winning an Unfair Game”.

The book tells the story of how the Oakland Athletics bucked conventional baseball in the late ‘90s and early 2000s by taking the road less traveled — a data-driven approach to the game.

Billy Beane, General Manager of the Oakland Athletics at the time, used data to analyze the best way to win games. Bean ignored conventional scouting to focus on on-base percentage (a figure most other teams discarded) as a means of evaluating talent.

What he had adopted was basically a behaviorist paradigm. Meaning: he tried to predict behavior, not by looking at the actor, but by looking at the observable behavior (aka every aspect of each baseball player’s performance).

By finding the right players who weren’t necessarily the best all-around but were good at what they did (and, certainly, a lot cheaper), Beane was able to create a successful team for the second lowest salary total of any major league baseball team that year.

Now apply that philosophy to healthcare.

When putting together a provider network, you want to be able to look at all the different dimensions of provider performance. Some providers will be stronger in different areas.

You can (and should) surface insights about how those providers will fit together to bring your members a stronger, more diversified network.

Provider networks: an overview

A provider network is a collection of doctors, other healthcare facilities, and hospitals that a plan contracts with to provide medical care to their members. These providers are called “network providers” or “in-network providers.” A provider that isn’t contracted with said plan is called an “out-of-network provider.”

When a health plan is looking to build a new network, they perform market research in the service area in which they wish to create a network. They typically find a few key health systems that they choose to become more competitive. This forms the core of the provider network.

They then round out the network to make sure it has the right mix of different specialists, primary care providers, and healthcare facilities.

Evaluating providers

Let’s set the scene.

You’re looking to build a network in the Kansas City metropolitan area.

The first step is to list all the healthcare providers within the KC metropolitan area.

Take that general list and start marking providers who are in the specific area of your network and members.

Now take into consideration the provider metrics.

How much do they charge for various services? What is the quality of clinical outcomes for said services? How good is the provider at accurately coding services? How happy are their patients?

Take a look at the dominant health plan in the KC metropolitan area. Then, ask yourself, “Will my provider network be competitive?”

How much overlap will your proposed network have with theirs? What is your composition of primary care vs specialists? Will your geographic area be broad enough to compete? Do you have a good mix of specialists, primary care providers, and healthcare facilities?

Best practice: use the market leader’s provider network to ensure you’re aware of and incorporating the major providers and practice locations within that area.

The wrap up

​​As a leading payments company in healthcare, we’re committed in our pursuit to align the interests of payers, providers, and consumers to deliver a better financial experience and more affordable, transparent care for all.

Within Zelis Network Analytics, we focus on provider networks and competitive analysis, as well as network build and optimization.

Meaning: We provide an analytics and insights platform to allow you to see what competitors are doing in terms of provider networks, compare your own network to your competitors, and gain insights into what makes a successful network.

Building a network can be time-consuming and full of challenges. We get it.

That’s why you need the capability to build, optimize, maintain, and sell your network with one unified platform.

To learn more about how Zelis can help you be more competitive when choosing healthcare providers, visit our Network Optimization Solutions page.