Hello, everyone. This is Erica Spice Mason with
the Becker Healthcare care podcast series. Thank you
so much for tuning in.
Today, I'm thrilled to be joined by 2
guests from Quest Analytics to talk about the
benefits to payers of network benchmarking.
We have with us Sub S, the Senior
vice President of Network
at Quest Analytics
and Bob Tavern, the sales solution executive at
Quest Analytics.
Sub ba and Bob, welcome to the podcast
performance Thank you so much for being here
today. Thanks, Erica.
Thank you.
Yeah. Thrilled to have you both. And before
we get into our discussion,
I was hoping you both might share just
a little bit more about yourselves, give our
listeners some context.
So Ba, maybe we can have you get
us started.
Sure. Yeah. And, eric, thanks again for, having
us, on the podcast here.
So this is Sub sebastian Seal I've been
in the healthcare space
health and data space. I should say for
the... For a little of 20 years now.
Last 12 years,
I spend time at adopt, and then try
to that I've
work for another health care data company that
is no part of, Iq. And the common
thread across all, my tenure in these 2
companies is data analytics product and basically telling
a story with with data that's kind of
where,
I spend most of. Okay? Well.
Thank you, Sebastian. And thank you again, Erica
for the opportunity. This is Bob Kevin harris.
Sales solution executive at Quest Analytics.
I'd come from Healthcare Service
Corporation where I have the privilege and opportunity
to serve
across 4 major divisions for 25 years. Super
excited to join quest analytics and bring my
health care experience
forward in supporting our network performance and benchmarking
area of healthcare care.
Fantastic. I really appreciate the intros from me
both, and it sounds like you've definitely got
the expertise to drill down a little bit
more into this topic of
health plans and their network performance. So
Sub ba, I was hoping you could get
us started and just kind of give us
a bit of a broad idea of this
topic area,
how do health plan networks currently measure performance.
And what metrics are most critical for evaluating
the efficacy of these networks,
Sure. What great way to kick off this
this topic or this discussion here. So help
plans should typically
have about 5 or 6 major areas that
they would measure themselves on.
And in the list I'm gonna talk about
is in no particular order,
they're all equally important. So first, it comes
to mind is clinical related measures. Like,
outcomes,
which is, like, he measure that's a measure
of care and service,
then, quality measures and patient safety, hospital like,
required conditions come this this bucket and then,
population, health management, which is, how are they
managing their chronic condition of the prop of
the population and preventive care, early detection, things
like that. So that's the first... That's the
first 1. And then
the second area of measurement here is
utilization, like, how is the utilization across, like,
say,
resource management and the services management going on?
So meaning,
what is the geometric mean length of stay
of my,
set of my members when the encounter sepsis.
Like... So, the utilization is a big,
component of measurement for for help... Plans and
also, like, how many tests are done,
prevent you or diagnostic and things like that.
The third area of measurement is
plans cost management,
which is mostly, like, medical expenses, what's their
medical loss ratio? What's the total cost of
care, again, a big
measurement area for health plans.
Then the the fourth 1 will be,
wanna say member satisfaction.
Like, this is an important, piece of measurement
because they want their members to be happy.
They want, I mean,
a member retention is a is a big
measure for them, and it comes out through
age gaps and that can impact their ratings
with Cms and also that will indirectly kind
of impact the payment.
So... And then
the fifth the 1 is operational efficiencies,
again, timelines of care, claims processing
efficiencies, these come to mind in that. And
then last but not least, at least, from
a measurement standpoint regulatory and compliance related. These
are and say, are they meeting in Secure
standards or,
they are they in line with, compliant with
state and federal
regulators
agencies. So those are kind of broad candidates.
There's a lot more under of them that
they measure. But I think in every other
measure they make can roll up into 1
of these
6 buckets that I just mentioned.
Each And that's fantastic. Thanks so much, Sub
ba. So it sounds like we're looking at
clinical measures,
utilization, cost management.
Member satisfaction,
operational efficiencies and compliance, you know, it's a
pretty wide range of measures that
payers are looking at to measure their overall
performance. So I wanted to take that just
a little bit
further and
considering all of those elements, can you kind
of discuss the role that benchmarking plays
in and how this helps payers really improve
their network performance as well?
Yeah. I mean,
the the 6 measurements that I talked about.
So let me extend that,
into your next yep, the question around benchmarking.
These 6 measures are not mutually exclusive. The
age measure kind of, like,
leads into the others, or so your cost
management can be a function of utilization and
clinical outcome. So they're they have very good
relationship between each other.
So
benchmarking can create real measurable goals for these
health plans.
They reveal performance gaps in these areas for
health plans.
And, they also can highlight areas of improvement.
They also can highlight best practices, and they
create awareness around, what the industry standards, are,
etcetera, etcetera. So I'll give you a couple
of examples here. So if I'm a health
plan, Like, I wanna know what is the
risk adjusted
30 day mortality rate for chest pain,
patients, chest pain period. For my members with
provide us in my network.
Versus those in my competitors network. Right?
And if the rate is comparatively higher
I will... I as a health plan will
ally align in sign incentives
to improve this outcome or are just provider
composition in my network. So members have access.
To higher quality providers. So that's can that's
an example where
benchmark can come handy. The other thing is
it's not only about clinical outcomes. As I
mentioned earlier
benchmarks can also help with cost management initiatives.
Like, for example, care coordination. How often
my members that I've been through a surgery
post discharge, end up in an un scheduled
Event.
Versus my competitors. Right? Because that is an
expensive,
affair for,
work from from emotional standpoint from dollar standpoint
everywhere. Right? So if my number is higher
than market average,
I need to take action to,
like, increase care coordination. So there's a flow.
There's there's there's a follow,
call with, with the Pcp post discharged within
5 days or something like that.
And
the other
important thing that Benchmarks can provide is, do
I have more low value care providers
compared to my... To the market median? Right?
It's not always comparison against your competitor or
the next next health plan. But what is
the market median?
Meaning, these are providers that have increased
utilization with no evidence of improved clinical outcome.
So do my... For example, do my
antibiotics go directly to any knee surgery
without trying physical therapy like that because that's
I mean,
that can increase the cost of care without
trying everything before going to the next 1.
Next big
item, which is.
So benchmarks can
really be critical to our gaps
subsequently diagnose the problem and measure the impact
of any corrective
action. So again, I know, Bob, you you
probably have dealt with this directly, I mean,
in your in your time during your time
and the payer.
Anything you would add for the roll of
benchmarks here?
Absolutely Sub ash.
Benchmark and services are really several roles and
helping the how plan, evaluate network performance.
A few examples would be helping to service
baseline plans for health plans.
Through which network performance can be measured,
compared against utilize and evaluating network performance of
the physicians and facilities,
in the cases of network contract affecting, rate
adjustments,
negotiations and renewal,
also supporting, the provider and vendor contracts,
acting, with contracts that are based to its
Sla and performance guarantees,
pay for performance, fee for service models,
And also look looking for, like for, like,
comparisons against
provider specialists for member satisfaction.
Additionally, they they can also be utilized,
within payer
organizations for achieving marketplace
differentiator. So for example, on C qa
to, the point you mentioned earlier a population
how how could health equity initiatives.
They're also used by regulators to help to
establish the standards or which payers are required
to achieve,
for example, state departments of insurance, Medicaid Rfp.
And then lastly, really focusing more around the
quality lens.
Of those providers
and how do we ultimately steer members into
higher quality
providers and helping them with their health care
decisions?
Yeah, Bob S, these are such great insights,
and I think it really...
Everything you've shared really speaks to how benchmarking
can
provide a lot of insights in so many
areas of the business. I think we've touched
on patient or member satisfaction.
We've talked about clinical quality, we've talked about
the quality of specialists and how providers are
performing against
market performance and
I can only imagine that these measurements,
while helpful. They're probably rather complex
to
not just track and measure, but also to
monitors. So, Sub, I was hoping you could
shed a little bit of light on the
role of third party benchmarking services. You know,
what role do they play in helping payers
evaluate
network performance. And if you could share any
examples
of how those services have provided actionable insights
for network improvements that would be fantastic.
Yeah. I mean, I think
benchmarking
as a topic in itself is is pretty
complicated. Like, even you could you could have
benchmarking in in a better idea of ways.
Right? So 1... The first 1 is, like,
you you compare against yourself. That's still, like,
I mean, how did I do as as
a health plan,
last year compared to this year. Right? So
that's fundamental that's foundation and everyone should be
doing And that's a bare meeting. Right? You
compare against yourself year over year and and
are you trending in the right direction. Right?
And and this is not super complicated
and doesn't necessarily need a third party resource.
So, like, because you got all the data,
you crunch the numbers. Again, you need some
analytics talent in in house we kind of
do that. But you crunch the numbers, and
you see how you're trying and most help
plans do this. Like,
not not rocket science. Right? The the challenge
comes in, like I mean, knowing what the
market capacity is I think that's where things
start to get
tricky and and complex. Right? If if my...
Again, I'll I'll go back to, like, say,
if my members
when they end in the hospital for pneumonia,
they're in the hospital for,
say, 4.3
geometric millions,
as zinc inpatient stays.
Is that good bad? Like, I mean, okay.
Last year, I was 4.2 and 4.3 and
going up. But... I mean, So knowing in
what the market is, I think is is
very important and that's what Benchmarks will
do. Right? And so there... There's a lot
more I can go deeper into into, like,
the third party services. But again,
I, I
love to get it here from Bob his
point of view because, Bob, you were in
leadership role at health plan and and you...
You dealt with this, like, first hand? Like,
did you do, like, homegrown
benchmarking or did you go outside and and
and source it from outside? Like, and what
are the pros and cons of each approach?
Should light on that.
Absolutely. There... There definitely is some homegrown
benchmarking,
but it's also limited. Typically line of business
level. So we... We've noticed different levels of
benchmarking when you're looking at a commercial population
versus a government
population.
You know, the other thing that we're we're
thinking more about is, you know, just the
health equity lens and how do you, know,
ultimately,
deliver guidance on actual insights from paying attention
to race ethnicity,
language,
cultural competency,
inclusive programs for,
diverse member populations and ultimately how do you
deliver a network that's gonna help to meet
that member
population where they are in close proximity to
what they need
and based on the type of care that
they're looking for.
Yeah. I mean, going back to your question,
Eric around, like, I mean, third party,
benchmarking service
actually, they they assume... They are in this
in this space for a,
from a very long period of time, they
have a lot of data
understand the nuances of it. So there are
advantages to the third party sources where they
have a data infrastructure talent pool and to
maintain this on an ongoing basis. Right? And
then,
the other advantage is they have a very
broad, holistic and, like, global view of the
problem. At hand. Because it's like,
because of that 10000 hour role, if you
if you know, on a given. If when
you do this over and over, again, you
you tend to get better and better and
your experience kind of speaks very clearly. Like,
that's what when somebody is, like, doing this
purely
on a day in day out basis,
So they can identify patents very very quickly,
and they have the ability to layer
additional data
on top of the simple comparison. Like claims
data, for example, they can take claims data
on top of network data and provide much
deeper insights, which is critical because sometimes your
superficial, just comparing counts getting misleading. I I
might have 25 percent of my provide an
network in really high efficient bucket,
but are you really getting activity
for this from this 25 percent... This 25
percent drive only 3 percent of your activity.
That's not good. Right? So that level of
detailed analysis,
can be possible when somebody is, like, really
doing it on on a day to day
basis.
Mh.
Yeah. I really appreciate those add ons. S
and and Bob, especially your perspectives from all
of your time at a payroll organization. This
has been a great discussion. Our time has
come to a close so quickly, but I
just wanted to thank you both again for
for joining this discussion and also Sub sebastian
highlighting some of the capabilities and
and really the capacity that third party
services can
really help
organizations
with in terms of understanding, having access to
the benchmarking data, understanding the nuances
and analytics as well. So again, thank you
both for for being on the podcast today.
Yeah. Thank you very
opportunity in. Definitely enjoyed the the conversation. Thank
you, Eric.
Great opportunity. Appreciate it. Oh, thank you both
again, and we'd also like to thank Quest
Analytics for sponsoring this episode today.
Listeners, please be sure to check out other
Becker healthcare podcasts at becker hospital review dot
com.