The strategic imperative
It is estimated that up to one-third of all U.S. health spending is unwarranted, amounting to hundreds of billions of dollars every year. Ensuring appropriate use of procedures and diagnostic tests is a strategic imperative for healthcare providers and payers who want to improve clinical outcomes while reducing costs.
Payers have traditionally managed the use of costly procedures by requiring prior authorization. Increasingly, providers in risk-sharing contracts, and those whose compensation is tied to quality, have additional incentive to reduce costs and be vigilant about appropriate use. In these value-based arrangements, providers want solutions that are integrated into the clinician workflow; take full advantage of the information already logged in the EHR; and support evidence-based decisions at the point of order.
eviCore healthcare provides clinical decision support solutions that apply evidence-based decision criteria to the patient’s clinical profile to produce an optimal procedure score. These solutions:
- Spare patients the risk of inappropriate care and drive better outcomes
- Lower medical costs by eliminating unnecessary procedures
- Reduce the administrative burden and operational costs by 50%
Decision support promotes appropriate, cost-effective care
With eviCore’s clinical decision support (CDS), you can fulfill the Centers for Medicare & Medicaid Services (CMS) mandate to use CDS for advanced imaging while supporting enterprise-wide initiatives for utilization management. eviCore’s tool is among only seven clinical decision support mechanisms (CDSMs) that have received full qualification from CMS for use under the mandate, which goes into effect in 2019. The tool incorporates Appropriate Use Criteria (AUC) from Medical Guidelines Institute (MGI), which received approval from CMS as a qualified provider-led entity (PLE).
Developed by leaders in the CDS industry from HealthFortis, now part of eviCore healthcare, eviCore CDS follows a logical diagnosis-driven approach that fits easily into clinical workflows. Ordering physicians enter the patient’s indications and symptoms and the system presents the most relevant clinical scenarios, making it easy to quickly select the correct and most accurate study for the patient’s condition. Once a procedure is ordered, automated prior authorization can be initiated within the EHR workflow, eliminating administrative hassle and cost.
In addition to AUC from MGI, the tool can be implemented with eviCore’s own comprehensive clinical guidelines. Developed and clinician-proven in over 25 years of medical benefit management, these comprehensive guidelines meet requirements for prior authorization for many payers. In addition, eviCore CDS is easily configured to incorporate guidelines from specialty societies such as the National Cancer Care Network (NCCN) as well as site-specific medical policy.
A leading midwestern IDN consisting of hospitals, clinics and a provider-owned health plan has implemented eviCore CDS to manage use of imaging resources. Because eviCore CDS is integrated directly into the payer’s prior authorization process, the solution delivers immediate pre-approvals when procedures match guidelines. First pass approval rates, which were in the 40% range, jumped to 70% in the first month alone, and then grew to 92% over the next 7 months. Further, the IDN has experienced a 15% drop in utilization of unnecessary imaging procedures from implementation of CDS with automated prior authorization.