Articles

by Robert Capobianco
This article was published by MedHealthWorld on 4/29/2011.

Health plan organizations in the post-era of insurance reform are transforming their relationship with providers in order to increase their competitive differentiation, reduce costs and enable higher quality care for their members. With its Integrated Provider Management (IPM) platform, Portico Systems enables health plans to simplify the design, maintenance, reimbursement and performance management of provider networks, while facilitating provider-patient collaboration. As Robert Capobianco, Portico’s Director of Marketing explains, “Health plans utilize our platform to turn provider networks into critical building blocks for designing value-based products; enabling performance-based contracts and orchestrating value-based payment models. Our platform utilizes automation, rules orchestration and integration to enable these capabilities while reducing costs for health plans and increasing the ease of doing business with the health plan for providers.”

Portico was founded in 1997 as a service organization that worked with the early inception of provider management. Gradually developing their offerings, Portico changed to a product company in 2004 focusing on IPM solutions. Currently, Portico has 40 healthcare customers, which approximately cover 42M lives.

The key benefit of Portico’s IPM solution, beyond the new levels of convenience that it offers to payers, is that the platform enables a more intelligent approach to how networks/care teams are organized for care, how contracts can be created for care, and ultimately how payment for provider services can be based on performance; not volume. Capobianco explains that in order to achieve this new relationship between health plans and providers, the end-to-end management of the provider lifecycle needs to be flexible, automated, transparent, care-aware and efficient. He further explains that the key to reducing cost and maximizing the benefits of the payer-provider relationship is to focus on ways of matching the right providers with the right patients; constructing provider contracts that account for performance and quality and orchestrating provider payments based on the value of services provided. Portico’s IPM approach enables health plans to start this transformation through its five solution suites: Agile Network Management, Lean Provider Administration, Collaboration, Value-based Reimbursement, and Provider Intelligence.

Agile Network Management is at the center of the innovations emerging in the relationship between healthcare providers and health plans, according to Capobianco. Ranging from network composition analysis to the automated rollout of the network, Agile Network Management is absolutely key to new network designs such as Value Based Insurance Design (VBID). Capobianco explains, “The big change in the market right now is the competition for group and individual markets are increasing. At the same time employers are demanding value-based products. This requires health plans to offer products and their supporting provider networks that are more tailored to those specific customer segments and their care needs. Needing this tighter alignment between products and networks makes a lot of sense says, Capobianco. There has been a message in the healthcare market for years now stating that care need to be constructed around the consumer, and in order to do this on a large scale, the product(s) the consumers are buying also need to be designed to best serve the consumer’s epidemiology.”

Lean Provider Administration involves deploying automated workflows, enabling greater data governance and increasing internal and external integration to reduce provider administrative costs. Capobianco explains that typically provider management processes involve unnecessary manual intervention and a high reliance on paper. Additionally, the lack of a central source of truth for provider information usually results in the creation of redundant and siloed provider systems/applications.“While the health plan is able to perform in its current state, there’s a lot of Herculean effort there that can be solved by technologies like workflow automation, rules orchestration and the creation of a provider source of truth for the enterprise.” These capabilities typically lead to a 20-30% reduction in administrative costs for the health plan. At the same time, they reduces the administrative burden on providers.

The third solution suite, Collaboration, involves the simplification of engaging providers and members, while offering tools to improve decision support. “Within this suite, we offer health plans solutions such as provider self service, provider directories, clinical tools, and assets to support the management of Patient Centered Medical Homes. As we see the healthcare market mature with care models such as ACOs and PCMH initiatives, it is important for health plans to offer tools to providers and members that make it easier for information to be shared among all stakeholders. Additionally, as the new care model initiatives transform from pilot to full scale operations, the ability for care coordination, performance management and streamlined reimbursement will be critical for their ongoing success.”

The Value Based Reimbursement (VBR) solution suite focuses on addressing the performance and payment reform initiatives facing health plans and providers. In order for the healthcare system to evolve from a fee-for-service model, health plans and providers are engaging in new care arrangements that promote performance and quality of care. Capobianco explains that this transformation is not easy because it affects many processes between health plans and its providers such as, provider contracting, provider selection, provider reimbursement and how this information interacts with claims processing. The value of this solution suite is that it reduces the administrative and medical costs for health plans through the orchestration of relationships that focus on performance and care, while promoting increased transparency to providers.

Portico has completed a number of return-on-investment assessments with its clients. Note that improvement levels depend on the initial environment, including level of automation, process consistency, process integration, and workflow. A sample of client benefits are:

• Credentialing time frame reduced by 82% (from 120 days to 22 days)
• Provider updates reduced by 86% (from 35 days to 5 days)
• Online directory refresh reduced from weeks to every 5 minutes
• Provider enrollment (credentialing, contracting, setup) reduced by 40% [from 70 days to 42 days]
• Reduction of provider management FTEs by 25-35%
• Improving provider data quality by 15-20%
• A 50% reduction on contract rework
• Identified impact on MLR — 2% opportunity based on reductions to contract-claims gap and increased auto adjudication

According to a Commonwealth Fund report (2011), “Plan leaders identified several factors they believe contribute to being a high performing plan: building a physician–plan partnership, establishing the plan as a resource for physician practices, providing physician quality and cost data on performance, and emphasizing a local area orientation.”

Capobianco said, “at the end of the day, that is what our software and services are enabling for our health plan customers. We are supporting the need for health plans to build a stronger physician-plan relationship that optimizes how networks/care teams are organized, how provider contracts are created to incent performance and to orchestrate value-based provider payments.”

Portico recently announced the launch of its Portico 9.0 IPM platform.