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 high-cost surgical procedures and advanced imaging 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.
QPID Health and our parent company eviCore healthcare offer utilization management 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 and automated approvals for diagnostic imaging
With eviCore clinical decision support (CDS), you can fulfill the CMS mandate to use CDS for advanced imaging procedures while supporting enterprise-wide initiatives for quality improvement and variation management. Unlike some CDS tools that frustrate users with content for only a limited set of clinical scenarios, eviCore CDS supports the referring physician via comprehensive guidelines. Clinicians 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 their patient’s condition. Once a procedure is ordered, automated prior authorization can be initiated directly from eviCore CDS within the EHR workflow, eliminating administrative hassle and cost.
eviCore CDS incorporates industry-approved clinical guidelines from the American College of Radiology (ACR Select), the American College of Cardiology (ACC) and the National Cancer Care Network (NCCN). The solution also integrates eviCore healthcare’s comprehensive clinical guidelines, developed and clinician-proven in over nearly 25 years of medical benefit management. Further, with the guidelines editor, you can easily incorporate site-specific medical policy.
A leading midwestern IDN consisting of hospitals, clinics and a provider-owned health plan implemented eviCore CDS to manage use of imaging resources more cost-effectively. eviCore CDS is integrated directly into the payer’s prior authorization process, delivering immediate 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.
Ensuring appropriate use of high-cost surgical procedures
- QPID’s decision support solution for high-cost, high-volume surgical procedures was first implemented at Massachusetts General Hospital (MGH) when Partners HealthCare became a Pioneer ACO. In addition to their commitment to 100% appropriate care, the hospital now had an additional financial incentive to control costs. In the first year of use, MGH documented dramatically lower rates of inappropriate use of diagnostic catheterization for suspected coronary artery disease than national averages: 1% compared to over 28%.
- The program has now been rolled out across the entire Partners Healthcare network for 20 high-cost and high-volume cardiac/vascular, orthopedic, GI/GU, and surgical oncology procedures. Clinicians are enthusiastic about the software, which makes them feel confident that their decisions are evidence-based, and helps them communicate personalized risks and benefits to patients.
- Focusing on the pre-operative planning of the most costly surgical procedures, the application applies sophisticated guidelines-based decision criteria to patient medical profiles to produce an optimal procedure recommendation. QPID utilizes natural language processing (NLP) to pull relevant patient data from the Epic electronic health record. Clinical summaries showing relevant indications, symptoms, co-morbidities, medical therapies, lab results, imaging and other diagnostics are displayed to assist with appropriate care decisions. The system also calculates patient-specific risks and appropriateness scores and compiles them into a customized patient consent form, for shared decision making between doctor and patient.
- Payers including Neighborhood Health Plan and Blue Cross Blue Shield of Massachusetts accept the QPID solution for review of appropriateness. This represents a step toward a dramatically improved prior authorization experience.