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By Roxy Nacu, Director of Center of Excellence for Healthcare Engagement at HGS Healthcare
From delayed or avoided healthcare procedures to lost insurance coverage, COVID-19 has affected almost every aspect of our lives. The primary effects have been well documented, and the secondary effects will present transformational challenges to the healthcare system. Increasingly, there are three emerging areas of opportunity to treat healthcare patients post-pandemic:
Provider data management
Health plans that own inaccurate and poorly managed provider directories are already challenged with dissatisfied members, provider abrasion and fines. Post pandemic, PDM challenges will only accelerate. The demographic shift to less populated communities may impact members’ access to care and their ability to find updated information in their plan’s provider data.
PDM will increasingly serve as a critical health system touchpoint across these areas:
- Access to care: Poor provider data management hinders effective patient-provider matching and negatively impacts patient satisfaction.
- Provider referrals: A lack of complete and reliable data about specialists leads to misdirected referrals and acts as a barrier to patient retention within networks.
According to a recent American Medical Association survey, handling the surging prior authorization (PA) requests translates into a “high” or “extremely high” burden for 75 percent of physician respondents. More than 90 percent of surveyed physicians reported that the prior authorization process delays patient access to necessary care. As we slowly ease into the “new normal,” the potential consequences of delaying treatments will drive an increase in prior authorization requests.
As we emerge from the pandemic, the utilization management (UM) bottleneck will only worsen, with patients feeling the burden of the delays and will begin their own follow-up for status updates. An impact of this will be a potential increase in appeals required before receiving the needed care. These issues, compounded by data integrity challenges, indicate the need for a proactive data-driven program to provide visibility into the downstream impacts of inaccurate authorizations, thereby reducing unnecessary repetition. The rapid maturity in cognitive automation and predictive analytics supported by robust data sources, and a wealth of domain expertise from UM service providers, enable payers to to evolve traditional UM work into an intelligent authorization process.
Nurse triage and telemedicine
The fear and anxiety related to contagion have fewer people visiting hospitals for the care they need. In fact, nationwide, 80 percent of adults said they are concerned about getting COVID-19 from another person in an emergency room. And 29 percent said they have delayed or avoided medical treatment, according to a recent survey by the American College of Emergency Physicians and Morning Consult. Recent studies also suggest that the pandemic has led to an 80 percent decrease in routine appointments, resulting in a 45 percent decline of newly identified cancer patients between March and April. These statistics further affirm the long-term adverse effects of the postponed care and delayed disease intervention, as it later creates a high-cost scenario including harder-to-treat cases and diminishing health outcomes.
While people have not completely moved away from concerns about face-to-face interactions, nurse triage hotlines and other telemedicine services can relieve the burden and remediate the impending effects of deferred care. Telephonic nurse triage (nurse advice hotlines) provide clinically appropriate guidance with RNs who assess the caller’s condition and direct them to the most appropriate level of care. Nurse triage support is also a front-line reputation enhancer for a provider as a reliable resource for screening, guidance and care. With so many individuals ignoring symptoms and afraid to visit providers, nurse triage can serve as a tool to monitor and remind patients of the importance of going to the hospital when emergent treatment is needed.
Healthcare business process outsourcing (BPO) organizations can provide the requisite domain expertise to anticipate the impact on provider networks, identify provider data inaccuracies, and execute an agile response to correct and prevent inaccuracies. By bringing forward thinking and innovation to provider engagement data management, BPO firms enable health plans to compete more effectively with current COVID-19 era and post-pandemic market conditions. Similarly, a BPO organization can help to build an effective and efficient prior authorization process, driving increased collaboration between payer and provider clients for precision-focused UM programs, sharing of best practices and development of intelligent automated workflows to drive efficiencies. With their ability to provide rapid expansion and scale, nurse triage call support enables healthcare providers and their care teams to focus on delivering critical care for those in need—keeping them dedicated to their core mission.
In these ways and more, COVID-19’s direct impact on healthcare organizations and consumers will be significant. Despite the optimism of pandemic ending, lasting effects may include layers of physical and mental health issues, depleting healthcare providers and resources, and a surge in healthcare costs. Today’s healthcare organizations must push toward “better normal” with continued efforts toward improved care outcomes via innovation, transformation and enduring agility.
ABOUT THE AUTHOR:
As HGS Director of Center of Excellence for Healthcare Engagement, Roxy Nacu is a certified professional Lean Six Sigma (LSS) Master Black Belt practitioner with more than 16 years of experience in BPO. Over the years, she has had diverse roles in Operations, Quality, and Business Excellence Teams supporting different domains, predominantly Healthcare. She is passionate about LSS concepts and practices for their unique balance of discipline and standardization, concurrent with the intent to transform and innovate.