Provider Networks and Patient Choice: Improving Outcomes

cheri-bankstonBy Cheri Bankston, RN, MSN, Director of Clinical Advisory Services at Curaspan
Twitter: @Curaspan
Twitter: @CheriBankston

Under the Conditions of Participation (CoPs) for Discharge Planning, hospitals must determine the appropriate level of care and provide a list of home health agencies (HHAs) or skilled nursing facilities (SNFs) that are available to the patient as options of care. When it comes to HHAs, a consideration for including a particular provider is that the provider is able to serve the patient in the area where the patient resides, or in the case of a SNF, the area requested by the patient. In order to assist beneficiaries with selecting a high-quality post-acute provider as we move from volume to value, provider networks are increasingly more important than ever. While CMS has not outlined any specific criterion that deems a provider “high-quality,” the goal is to provide patients with more information on quality performance and resource use of providers at the time they are making a decision, all in support of providing patient choice, achieving optimal outcomes And offering better access to care. Currently, a way that we can measure quality is through the CMS Star Rating program. Through this now available measure, discharge planners or case managers working for hospitals are able to highlight those provider networks that will best fit the needs of the patient, counseling patients about their available choices, and more importantly, uphold the patient’s right to choose.

As mandated by the Affordable Care Act’s value-based purchasing initiative, hospitals are pinned up against financial risks associated with post-acute care for patients. To minimize the risk, hospitals are working to establish high-quality provider networks. While it may be concerning that this hasn’t always been a focus, for many hospitals and health systems, upholding the standard of Medicare policy – patient freedom of choice – is challenged by potential financial incentives and penalties for the bottom line. In essence, the quality of care provided to the patient after discharge impacts the reimbursement levels for hospitals and ACOs.

To the untrained eye, provider networks may appear to narrow patient choice, but what those networks actually do is create a set of higher quality post-acute providers that can improve patient outcomes without impeding access to care. Payers have been using ‘provider networks’ for years so this concept is not new – what is new is that this idea is now also being applied to hospitals.

To be a successful ACO, getting there depends on having a history of high-quality, positive outcomes with provider networks. For example, if a SNF has a high rate of patients going to an emergency room, but these patients aren’t admitted to the hospital, these scenarios must be evaluated and compared to other providers with the same level of care and less non-emergent emergency room visits.

What your organization should know about patient choices and provider networks:

  • Knowledge starts internally. Ensure your team understands how to inform patients and families about their choice in provider networks. Clarify that provider networks are policy-informed, backed by specific criteria and data, and not just favoritism or bias.
  • Physician and patient communication is important. If a physician writes an order for a specific provider, whether the provider is in a network or not, the patient must be notified and allowed to consider the physician’s preference when making their choice. Using provider networks is not a mandate. At the end of the day, patients are the decision-makers, they are the ones making the decisions and should feel empowered to do so.

Quality outcomes and patient satisfaction are what is going to drive provider network success. To prepare, hospitals should have a well-organized strategy in place that defines how to get in a network, how to stay in a network and how to meet the responsibility of offering patient choice among appropriate and available providers. By partnering with all providers, both in and out of network, hospitals will be able to continuously monitor performance metrics, outcomes and patient satisfaction, which will not only improve quality of care for patients, but also forge strong relationships with post-acute providers.