How to build better relationships with health plan and payer communities

Dr. Jessica Badichek, Chief Informatics and Compliance Officer, MediTelecare

Modern healthcare is a complex dance between quality and quantity.

Payers and insurers want to improve patient outcomes because poor health is expensive. Healthcare providers, on the other hand, want to ensure that patients are not overlooked and receive appropriate care.

To understand how to meet the needs of both patients and payers, we need to take a step back and consider the relationship between payer communities and telemedicine services.

Behavioral telemedicine takes hold

the concept of telemedicine It’s been around for a while, but it wasn’t until the pandemic hit that it became the pillar we know today. Very few insurance companies did. So even if it seemed compelling, it was just too bold. Most likely.

In other words, telemedicine will continue to take hold. However, several hurdles need to be addressed to provide quality care to patients while reducing healthcare costs for insurers.

One of the key elements of quality healthcare is the balance between quality and quantity. Telemedicine providers need to see many patients each day, but with increasing numbers of patients, they must implement quality measures to ensure each patient receives the best possible care.

For example, it can be difficult to quantify behavioral health conditions. However, with quality surgical procedures in place, each patient can receive more extensive and comprehensive care that reduces the use of drugs such as antipsychotics and benzodiazepines. High-risk psychotropic drugs pose the greatest threat, potentially leading to more negative outcomes and ultimately higher costs to insurers and the payer community.

Is behavioral telemedicine really worth it?

Telemedicine has many advantages. One is to exponentially reduce costs for patients, families, facilities, and insurance companies. Patients can see both general and specialist clinicians without leaving their homes. Seeing specialists remotely reduces gas, time and on-site labor costs, and allows patients to receive specialized care nationwide.

Not only does telemedicine help reduce costs, it also helps us see more patients more often. Frequent virtual medical triage greatly reduces the chances of a patient being sent to the hospital. This is often costly for insurance companies. In addition, by expanding the reach of care by trained health care providers and through a patient-centered approach using clinical protocols, behavioral problems can be properly diagnosed and individuals with mental health conditions can be treated. increase.

Older people and those with behavioral health problems have higher rates of mental health problems, including mood disorders such as depression and bipolar disorder, anxiety disorders, post-traumatic stress disorder (PTSD) and psychotic disorders. You may experience the states and behaviors of However, these patients are often misdiagnosed with a mental health condition due to the wrong causes of their symptoms and behavior. These misdiagnoses can lead to inappropriate medications, including over-prescription of risky antipsychotics. Regular visits to behavioral patients via telehealth ensure patients receive appropriate and safe medications, increasing revenue for each facility.

The healthcare system is also plagued by a shortage of providers and care. So it’s no wonder they are leveraging more digital tools and teletechnology services to provide care and extend their reach to underserved groups.

So is telemedicine worth it? Providing accessible, patient-centered, high-quality virtual care is the perfect solution for patients, their families, facilities, and insurance companies. As a result, payers welcome telemedicine and related practices because they benefit patients by increasing access to care, managing misdiagnoses and avoiding unnecessary complications, thereby reducing premiums. increase.

Usually not always optimal.

In most situations where telemedicine is used, the patient visits a clinician/specialist, the clinician creates a clinical note that triggers a claim code, and the insurance company covers the costs. Efficient, but still has drawbacks. Quality is up to clinicians and clinicians only. Nothing else protects patient care.

Telemedicine clinicians are often sent to see patients with little or no support, with costly and sometimes dangerous health consequences. Steps can be taken to ensure access to quality care. Implementing high-quality operational procedures into telemedicine practices ensures that clinicians are supported and well-equipped to tackle individual behavioral medicine.

This begins with the manual selection of clinicians during recruitment/onboarding and continues through a qualification process that ends with a rigorous internal approval. To provide the best care, clinicians must be supported, trained and undergo continuing education.

With quality standard operating procedures, insurers no longer have to worry about the quality of care for each patient or whether a patient is sent to the hospital due to misdiagnosis or use of unsafe medications.

Policies and Procedures Upfront and Center

How can structures be implemented to ensure standardized, high-quality, and accessible telemedicine services? First, let’s talk about URAC accreditation. URAC is the organization responsible for developing quality standards for the entire healthcare industry. The accreditation process is used to set high standards for health care organizational systems, procedures, and techniques that organizations must uniquely meet.

Insurers and insurers typically consider partnering with URAC accredited organizations. Because this is synonymous with quality care. This is a testament to healthcare differentiation and demonstrates the company’s commitment to quality, which means improved patient health outcomes. There are also two economic benefits of accreditation. Increased patient numbers lead to increased revenues, and Medicare payments to qualified facilities are maintained through appropriate patient status placement.

While being URAC accredited is very important, it also allows facilities to continuously check and enforce their policies and procedures to ensure their practices are within laws and regulations. Procedures enforce quality standards. For example, screening patients for behavioral problems is a common method that can be used to analyze and monitor patients. In addition, telemedicine services help care facilities manage and monitor patients who often have high-volume polypharmacy, where patients may be on multiple medications.

Screening and patient analysis are often an afterthought, but they are good indicators of how well patients are adapting to medications, treatments, and other interventions.

Behavioral telemedicine cuts costs

Virtual healthcare has grown significantly over the last few years, but the payer community and insurers have yet to capitalize on its benefits. Healthy patients benefit from having trained providers who can adequately diagnose and treat behavioral problems through a patient-centered approach using defined clinical protocols. This ensures that patients receive appropriate and safe medications, even non-pharmacological options when possible, and reduces the risk of adverse outcomes such as hospitalization and side effects of medications.

Telemedicine is the perfect starting point for payer communities and insurers looking to engage with high volumes of patients while implementing quality care techniques. Financial burden on payers and insurers in the healthcare system by enabling proactive/frequent clinical visits, taking steps towards URAC accreditation, and using telemedicine to implement quality procedures and policies is greatly reduced.

About Dr. Jessica Badichek, PharmD, BCGP

Dr. Buddicek holds a BA from Fairfield University in Connecticut and a Ph.D. in Pharmacy from the College of Science in Philadelphia. She is currently the Chief Informatics and Compliance Officer. MeditelecareShe previously worked with ComprecareRx Pharmacy (PursueCare) with opioid use disorders and Arrow/Partners Long Term Care Pharmacy with hospice and geriatric patients. She has significant experience and knowledge in all aspects of psychopharmacology and the use of psychotropic drugs in the elderly population.

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