Fix patient access by recommitting to the fundamentals

By: Eliza Dailey

The problem

Patient access to care remains a problem. But I'll start with the good news: Our 2023 survey of health system strategic planners found that patient volumes were up in 2023 relative to 2022. The bad news is that providers are struggling to keep up with this demand. According to AMN Healthcare, the average wait time in 2022 was 26 days, which is an 8% increase from five years prior. And the backlog stretches even longer in some markets and specialties. At the same time, recent consumer data reinforces loud and clear that access is a key differentiator.

How to fix it

In 2024, I want every executive to recommit to the fundamentals of access to care. This includes things like standardizing provider scheduling templates, streamlining triage procedures, and ensuring you're measuring the right metrics (Hint: the right metric is not the 'amount of time to the third next available appointment').

It isn't the most thrilling work, but it's necessary. It was hard enough to manage patient capacity before, but now executives must do it in a fragile workforce environment. I lead our physician and medical group research and spent much of the last two years focused on physician employment dynamics. While it has always been challenging to balance patient access with physician autonomy, now physicians are demanding better work-life balance.

Executives must thread the needle between two mandates that are seemingly at odds: Deliver outsized access to patients and sustainable work-life balance to physicians. Providers can't afford to lose the volumes or the doctors. Those who turn this zero-sum game into a win-win proposition will emerge as the employer and provider of choice.

A few next steps:  

• Operational next step: Narrow down your number of visit types by pulling data from your scheduling system to get a sense of the most common visit types. One health system we worked with went from 150 to six visit types in primary care after their initial clean up, and improved efficiency and access without hiring any additional providers. On average, providers were able to see one more patient per day, translating to 55,000 additional primary care visits in one year.
• Workforce-focused next step: Identify one access strategy that is a win-win for patients and providers. My personal favorite is splitting up clinic hours into a morning and evening shift. This allows working parents to care for their kids in the afternoon and then log back on after dinner to deliver care asynchronously or via telehealth.
• Email me to schedule an agenda-setting interview and inform your care access research.

Fix the workforce burden by having a strong AI strategy that looks beyond Band-Aid solutions

By: Vidal Seegobin and Ty Aderhold

The problem

Can care standards be a solution to the margin and capacity pressures faced by health systems? We've observed that more predictable and evidenced-based workflows simplify the onboarding process, reduce clinical decision-making fatigue, and create a consistent experience that minimizes excess resource usage. Standardizing workflows has been a healthcare goal for as long as I've been a researcher. But with structural staffing shortages eating into our margins and undermining our ability to develop workable standards, it has felt like a luxury instead of a necessity.

How to fix it

I want to see all types of health systems embrace artificial intelligence (AI) as a tool to develop robust care standards and attract talent who will be able to work at top of license quickly.

Surveys show that younger employees prefer organizations that use technology to streamline workflows and make them more manageable. These organizations have a competitive advantage over other employers. Also, meta-analysis shows that decision-support technologies can elevate junior staff to high performance quickly, which is exactly what we need to handle complex patients who require hospital care.

My colleagues on the technology team make the persuasive argument that AI strategy entails technology serving critical business needs. I can't think of a more crucial and suitable use for AI than using it as an employer differentiator and scalable resource to help your junior staff leap over the "experience-complexity gap."

To effectively invest or build solutions that help staff and improve care standards, organizations need to prioritize solutions that address the root causes hindering their success.  In many cases, this means focusing less on Chat GPT and generative AI solutions. While these generative products offer transformative potential in the long term, there are other clear opportunities in the ambient listening, predictive analytics, and computer vision space that offer clinical support for staff without necessarily requiring generative capabilities.

Organizations should remember that successful innovation does not require piloting a brand-new AI solution. Instead, it can simply be adopting a more widespread AI solution that is just new to them. 

Fix tense plan-provider relationships by addressing shared pain points

By: Jared Landis and Max Hakanson 

The problem

It's no secret that plans and providers could benefit from some couples counseling. Providers often view payers as a necessary evil, while payers have many frustrations in how their provider partners operate. While this difficult relationship can be costly for both providers and plans, there's one party stuck in the middle that's also feeling its ill-effects: Patients.

The challenges between plans and providers can largely be categorized into two buckets:

1.       Everyday frictions that bog down both providers and plans in administrative minutia, such as prior authorization and the claims submission/denial process

• 89% of providers rate prior authorization requirements as very or extremely burdensome.
• Claims denials are growing, totaling 11% of all claims in 2022, up from 8% in 2021 .
• The authorization and claims process is costly for both plans and providers because of the extra labor and administrative costs. On the provider side, each chart retrieval costs $18 and each denial costs $79.
• Claims reprocessing cost payers $8-$12 and denials cost $62 , according to a 2023 Optum study on payer-provider abrasion.

2. Higher-level pain points around communication, dedicated resources, and payment methodology and timeliness

• Both payers and providers say a lack of upfront communication exacerbates frictions, admitting both parties are responsible for improving it. The misalignment lies, however, in how much responsibility each should bear.
• Providers want either standardized automated processes or high touch provider relations teams to streamline their revenue cycle workflows. But many payers do not have the scale, interoperability, or infrastructure to offer this now.

How to fix it

Before we can start to think about fixing the higher-level relationship, we first need to address the everyday pain points that consume large amounts of time and resources from both parties. One of the biggest pain points is prior authorization.

• The provider perspective: We asked clinicians who work in health plan utilization management (UM) departments what they wish providers knew about health plan's UM functions. Read what they had to say.
• The payer perspective: Learn how plans are (and aren't) using AI to automate prior authorizations and the challenges that remain.

Payers that have successful relationships with providers ensure their touchpoints are coordinated and centralized through a single point of contact.                                                                                                                                             

• Download our infographic to learn how to strengthen provider relations and reduce communication overload with a simple, disciplined approach.
• Read our take on how health plans can usher in a new era of payer-provider relationships by enabling physician partners.

Fix the delay to industry-wide VBC transformations by taking real action

By: Miriam Sznycer-Taub and  Clare Wirth

The problem

In our 2023 value-based care (VBC) events, there was a refreshed optimism and (dare we say) hope for advancing VBC. But the last 10 years have shown us that the healthcare industry underestimates the difficulty of this shift. We've seen momentum fall apart when partners aren't aligned in what they expect VBC to do. That's why executives we spoke with called the last 10 years hard, frustrating, and fragmented. One even called it "a joke."

How to fix it

Our wish for 2024 is that stakeholders from across the industry act on their 2023 realization. There's ample opportunity to transform healthcare clinically and financially — and doing that takes a village.

So, what should we do differently? We stop using the term VBC to mean everything. We stop treating other healthcare sectors like the enemy. We stop setting ourselves up for failure by recognizing what is and isn't achievable in the first year of value-based risk contracts. We prepare for challenges at the beginning, when progress feels impossible, because we know the results are worth it. We acknowledge the human transformation necessary to do the technical. We start new conversations. We plan big (and long term). We celebrate the true wins — because they are there. Only then will we actually move the industry forward.

Hungry for more? Accelerate your team's readiness for value-based care implementation with our on-demand courses.

Fix the information overload for clinicians by investing in technology solutions

By: Solomon Banjo

The problem

We are entering a transformative era of clinical innovation where providers are using tailored treatments, diagnostics, and technology to improve patient care. Even non-curative advancements have the potential to enhance patient quality of life and enable proactive and predictive care. A key challenge in 2024, however, is ensuring clinicians effectively integrate new knowledge into their workflows to deliver evidence-based care.

The pace of innovation far outstrips our current approaches. It takes the American Medical Association an average of 18-24 months to assign a CPT code, while during that same time there will be 25-35 FDA-approved cell and gene therapies, 300 AI algorithms, and at least 8,000 genetic tests entering the market. Medical knowledge now doubles every 72 days, and it can take over a decade for validated knowledge to become widely practiced. So, it's no surprise that 68% of physicians feel overwhelmed by the amount of information they need to keep up with.

The vast amount of medical knowledge is only one aspect contributing to information overload. Life sciences companies, in particular, heavily market their innovations and associated research to ensure patients have access to their drugs. As a result, clinicians have to sift through lots of medical evidence and innovations to make informed decisions.

How to fix it

Our collective goal is to amplify key medical evidence. Potential actions organizations can take to make progress on this challenge include:

• Evidence generating organizations must create easy-to-digest content that addresses the questions of a diverse group of physicians and clinicians. Keep in mind that the way people consume medical evidence is changing with online clinician communities playing a significant role in shaping medical consensus.

- Read our take on online clinician communities to learn about how clinicians gather information to build consensus and what that means for you. Then, use our decision guide to  craft a strategy for engaging online clinician communities.

- Learn more about how clinicians will use evidence in 2032, and what steps you can take to prepare.

• Provider and physician organizations must invest in partnerships and technologies to enable the shift from memory-based to technology-assisted decision-making. This shift should happen both at the point-of-care and in updating care standards. While we can reduce the amount of medical information, it's unlikely that we can make it manageable using only human efforts.

Fix the tech vendor-provider communication line by having them talk to each other

By: Paul Trigonoplos

The problem

Technology holds promise, but in healthcare, it also comes with pain. We heard overwhelmingly from our members that the partnership between tech vendors and providers was nosier, more challenging, and more difficult to navigate than in years prior. 

Providers are tired of point solution sales pitches for tech that doesn't lead to ROI. Several executives told us they feel like they're getting sold snake oil. They are tired of tools that promise one thing but only result in clinician frustration.

Vendors are tired of systems buying the wrong tech and cancelling contracts early because of it. They're also tired of having to rely on health systems to handle the change management and implementation, which tends to go awry. 

Two things have widened the gulf between these two sectors this year. First, money. Existing tensions have intensified by the fact that cash is harder to come by. Providers are working with slim-to-negative operating margins, while vendors experienced their lowest funding year since 2019. Second, clinicians are worn out. Half the time, clinicians don't see tech as the solution, they see it as the problem. Years of clunky technology and shoddy implementation cast a shadow over clinicians. Why would they be excited for yet another thing that might add to documentation burden or screen time when they just want to care for patients?

The real issue? Members share these concerns with us, but they don't tell them to one another. And because they don't have that conversation, they don't understand each other, so behavior change rarely occurs. A blame game ensues, and money, time, energy, and political capital go down the drain. 

How to fix it

It's simple. In 2024, I want these sectors to start talking honestly and openly, in spite of misaligned incentives and sometimes adversarial relationships. It is the only way they will build successful relationships and products, ones that actually make sense for the end user and do in fact make the practice of medicine better. 

Fix the transition to post-acute care by looking beyond individual care settings

By: Monica Westhead

The problem

Patients are experiencing worsening delays in transitioning from hospital care to post-acute care. Why?

• Long-standing challenges, like a lack of transportation from one setting to another.
• Newer challenges, like an increased volume of MA beneficiaries requiring post-acute services, and convoluted preauthorization processes for these services.
• Worsening staffing challenges. If there is no registered nurse available at the skilled nursing facility (SNF) to admit a patient, the patient can't go. This causes frustration in the hospital, as patients can't transfer out of the acute care bed, resulting in backups in the emergency department.

These delays not only have financial implications for hospitals, but also impact patient experience and overall care efficiency. The challenges with lengths of stay (LOS) primarily stem from financial issues. SNFs are facing reduced profit margins due to shorter LOS, lower reimbursement rates from MA compared to Medicare fee-for-service, and increasing care costs. These financial constraints further exacerbate staffing challenges, as SNFs are unable to offer competitive salaries compared to other healthcare settings.

How to fix it

As all healthcare sectors experience staffing shortages, organizations are doing anything they can to attract and retain staff. But staffing is a zero-sum game. Leaders need to think about the needs of the entire care continuum, not just their setting, when they consider staffing investments. Consider offering clinicians rotations between settings or opportunities to work across multiple sites of care to both improve flexibility and staffing in post-acute settings.

Start planning for discharge at admission and determine the right care setting and collaborating with post-acute care settings to understand what placements might be available. Begin the preauthorization process as soon as appropriate.

Work with SNFs to improve quality through joint training and infection control measures to reduce the need for avoidable readmissions, which helps free up more hospital capacity and reduce ED overloading.