Whereas managed care models can provide a direct path to influence outcomes, existing practices can be redesigned to drive value. The traditional usage management (MU) approach is a good example. For decades, health plan prior authorization (PA) processes have unwittingly frustrated doctors while providing insufficient returns for health plans. Yet an AP request provides one of the only planned medical services data signals before they are returned, which can be extremely valuable in enabling patient support and optimizing the impending care pathway.
With a more strategic approach to PA, UM programs can influence physicians’ care choices to reduce variation, improve outcomes, and support care coordination for chronic and costly conditions like cardiovascular disease (CVD). Instead of focusing solely on determining whether an authorization request for a specific procedure meets predefined criteria of medical necessity, health plans can work with doctors and patients to ensure that the requested service is suitable for this specific patient depending on their individual condition and coverage.
The Complexity of Cardiovascular Care
Let’s see how reinventing EM can help health plans manage the most expensive chronic disease: CVD. Nearly half of Americans have some type of cardiovascular disease, a category that includes coronary heart disease, stroke, and heart failure. By 2035, annual direct and indirect health care costs for patients with cardiovascular disease are likely to reach total over $1 trillion.
Unnecessary variations in the diagnosis and treatment of cardiovascular disease, exacerbated by multiple transfers between primary and subspecialty clinicians, can increase costs and lead to suboptimal outcomes. Cardiovascular care typically involves multiple points of entry and re-entry, from the emergency department (ED) to primary care physicians (PCPs), cardiologists, and hospital admissions. Additionally, the symptoms presented by a patient are often non-specific, leading to a complicated decision tree as clinicians try to rule out other suspicious conditions.
Once physicians have embarked on a diagnostic pathway in cardiology, they can order one of several diagnostic tests depending on the context, available clinical data, and physician expertise (i.e., say a PCP versus an ER doctor). As a result, clinicians often use more tests than necessary to reach a diagnosis.
After a patient has been referred to a cardiologist, variable adoption of new consensus guidelines can lead to non-compliance of care. In 2021, the American College of Cardiology (ACC) and the American Heart Association (AHA) jointly released new guidelines for the evaluation and diagnosis of chest pain and coronary artery revascularization. Coronary artery angiography (CCTA) is now the preferred diagnostic test for patients without known coronary artery disease (CAD), under the age of 65, with stable chest pain. The new guidelines recommend that revascularization be reserved for people with refractory symptoms or populations with high-risk coronary anatomy.
Managing a patient’s care journey
As long as legacy UM programs focus on managing individual codes and procedures of current procedural terminology, rather than the entire cardiac care journey, health plans will be limited in their ability to manage the cost and the value of cardiovascular care. Supporting the entire patient healthcare journey – across physicians, settings, and episodes of care – is crucial to improving outcomes, especially for lifelong chronic conditions.
An intelligent UM platform can leverage relevant, patient-specific clinical data to better understand a request for AP in the context of the patient’s care history. This holistic view of the patient care trajectory enables health plans to effectively manage a condition, rather than one disconnected service at a time. Using historical clinical data, claims, and outcomes, an intelligent UM platform can create condition-specific cardiology care pathways that guide the patient’s care journey from presentation to postoperative care and long-term management.
Using artificial intelligence and machine learning, an intelligent unified messaging platform can help health plans and physicians accelerate time to an accurate diagnosis, facilitate comprehensive management services of care and to improve the selection of invasive and interventional procedures. The key is evidence-based clinical intelligence that reduces variation in care, generates medical cost savings and improves quality of care.
Accelerate diagnostic time
When physicians are offered automated, evidence-based clinical advice at the time of authorization, they are more likely to select high-value tests and treatments. For example, a smart UM platform can prompt a physician entering a PA request for a single-photon emission CT/myocardial perfusion imaging test to select a CCTA instead. For a patient with a low likelihood of coronary artery disease before testing, the platform may first recommend a routine treadmill test or coronary calcium score screening scan, as suggested in the 2021 ACC guidelines. /AHA.
By prompting clinicians to select the appropriate evidence-based test, as recommended by national medical societies such as the ACC, an intelligent UM platform takes the guesswork out of PA while ensuring providers that the modalities evidence-based will be immediately approved by the health plan. This type of proactive unified messaging speeds up the diagnostic process and reduces unnecessary variations in the number and sequencing of tests ordered.
Identify the optimal procedure
Similarly, an intelligent UM platform can provide in-platform recommendations to guide the selection of surgical assessments or procedures. When a patient requires an invasive cardiac assessment or interventional procedure, an intelligent UM platform can help physicians avoid unnecessarily aggressive treatment by requiring proper documentation of indications.
By analyzing the patient’s calculated risk score and taking into account their medical history, the platform can provide recommendations for a procedure that meets widely accepted clinical criteria (such as national medical society guidelines) and criteria. appropriate use. Additionally, by recognizing high-risk patients, the platform can identify when a patient is a good candidate to proceed directly to procedures or surgery. This allows physicians to avoid more conservative care to immediately relieve a patient’s symptoms or reduce the likelihood of cardiovascular events (spontaneous myocardial infarctions [MIs]unplanned urgent revascularizations or cardiac death).
Enable holistic care management
Patients with cardiovascular disease often need to make significant long-term lifestyle changes and require prolonged support to avoid progressive clinical interventions. A smart UM platform can connect patients to available resources, such as a nutritionist, gym membership, ACC CardioSmart program, and/or mental health support.
Many plans have invested heavily in such managed care programs, but have difficulty enrolling patients in the appropriate service. Partnering with an intelligent unified messaging platform can help health plans realize greater ROI by identifying at-risk patients with cardiovascular disease who need targeted resources. For example, patients who have had an MI should benefit from enrolling in a cardiac rehabilitation program to improve their cardiovascular health.
Facilitate the coordination of care
If needed, a smart unified messaging platform can offer bulk authorization for each service related to a particular episode of care. For example, a cardiologist ordering a coronary stent may also order blood thinners for postoperative care. Consolidating multiple authorizations for a single episode of care saves health plans and providers time and money.
Bulk permissions can also enable communication protocols to ensure that procedure data, prescribed therapies, and postoperative care plan guidelines are shared with the patient’s PCP. By facilitating seamless coordination of care, a smart EM platform can encourage PCP tracking, improve medication adherence, and support proactive care management practices. Presenting actionable data to clinicians in real time, as they work on a patient’s case, can reduce post-acute readmissions and promote a higher standard of care for patients living with CVD.
Cardiovascular disease is likely to remain the costliest long-term condition for payers to manage. Adopting an intelligent unified messaging platform that encourages the use of evidence-based medical guidelines will increase the value of cardiac care for all health plan members. By enabling optimal care pathways for each patient, health plans can achieve the ultimate goal: better clinical outcomes at a lower overall cost.
