Network Value

Partner with your providers to successfully shift from volume to value

The facts

Each year, $600 billion in U.S. healthcare spending goes to unnecessary care and other inappropriate payments, driving up overall costs without returning real value to the system. To create meaningful change, payers and providers must collaborate in the definition and pursuit of high-value care, in which providers make the most efficient and judicious clinical choices that deliver the best patient outcomes and save systemic costs. In exchange, providers should be rewarded for their efforts. 

Cotiviti’s Network Value solution helps payers and providers collaborate to create and manage value-based healthcare delivery and payment. We enable an innovative new approach to medical economics that helps clients recognize and reward high-value care while eliminating low-value care and other unnecessary payments from the healthcare system. We take payers through the high-value journey, socializing and educating providers about value. Then, we put data into action and incentivize change.

Benefits

Drive down the total cost of care

Increase revenue through more informed market expansion and network optimization

Enable payer and provider collaboration in high-value care programs executed through multiple payment structures

Identify and reduce low-value care from inefficient and unnecessary services

Encourage members to make wise caregiver choices

Set the right goals

To begin the high-value journey, clients must first understand what “value” really means. Cotiviti offers a proprietary methodology for calculating what is considered to be high-value care, using the Dartmouth Atlas, Choosing Wisely, and other academic research as well as Medicare claims data (Parts A, B, and C).

We then benchmark providers across their geographic and specialty peers to identify those who are most likely to succeed in risk-based arrangements. Clients can recognize and reward high-value care while eliminating low-value care, allowing them to build and optimize high-performing networks, enable provider collaboration, transition from volume to value, and drive down the total cost of care.

The power of perspective

Cotiviti combines more than 100 different publicly available data sources with our own data to create powerful benchmarks that payers can use to encourage high-value care. Our data sources come from:

  • Government health data: Cotiviti takes traditional government health data, such as Medicare Advantage bid data or Exchange Enrollments by ZIP code, and identifies insights so business users can understand and react quickly to market changes.
  • Academic health data: Cotiviti layers on a level of analysis to academic datasets that have traditionally been undecipherable or inaccessible to business leaders and their teams, including the Dartmouth Atlas.
  • Socio-economic, behavioral health, and demographic data: Cotiviti incorporates a variety of census datasets that have not traditionally been used by healthcare organizations, such as Behavioral Risk Factor Surveillance System datasets.
  • Cotiviti’s proprietary sentiment data: Cotiviti collects a variety of sentiment data on health behaviors and consumer views of healthcare organizations across the United States using multi-year Google Analytics surveys.

Cotiviti examines and grades each provider, then compares him or her with others in the client’s network. With the data assembled, clients can tier and sculpt their networks, share this information with members, and create strategies to steer them toward higher value providers—which has a significant and positive impact on value and cost for everyone.

 

Inspire behavior change

Network providers tend to operate on a bell curve. Through education and data, Cotiviti reveals their practice patterns. How do they practice, how do they refer, and how can we give them better data to make better choices? Cotiviti spends the time to educate clients so they better understand their current networks and where their value lies.

Next, we help payers collaborate with their providers to create lasting change. We educate and inform providers, showing them how their practice patterns compare with their peers’ and what they can do to become a high-value performer. We reduce the administrative burden for high-value providers with tools such as gold-star programs, audit exclusion, or no prior authorizations. In addition, we build high-value referral pathways to direct more members to high-value providers.

Transparency accelerates provider buy-in

Cotiviti uses open data and open methods to create its scores. Because we use public data, we can obtain data for 90 percent of physicians in a given geographic area.

  • We use an algorithmic approach to identify specialties and create peer cohorts based on specialty and geography.
  • We use specialty-specific metrics to measure clinical quality and medical economic outcomes.
  • Measures are risk-adjusted based on the provider’s patient panel using traditional Medicare HCC risk-adjustment methodologies.
  • Providers are scored in each measure based on their relative performance within their peer cohorts. We use a simple red or green scoring system: Red denotes low-value providers whose practice patterns may be clinically appropriate but are optimized for a fee-for-service model; green denotes high-value providers whose practice patterns align with value-based care models. 

Reward value, not volume

Payment must be tied to value or change will not occur. Cotiviti helps clients think through and implement payment programs at scale, in real time, and virtually on a claim-by-claim basis.

Through policy-driven payment programs, we incentivize high-value care by shifting payment from low-value to high-value providers. Through the development of specialist programs, we incentivize high-value care across providers that often exhibit significant unwarranted practice pattern variation. And through the development of primary care programs, we incentivize high-value care within existing programs.

 

Bring members along on the journey

With providers ranked by value, clients can influence choice of providers. This information can be highlighted in provider directories and benefit design. Cotiviti enables organizations to generate data-driven awareness campaigns and offer shared decision-making to help guide informed choices.

RowdMap Risk-Readiness® Platform

Payers can use this platform to access RowdMap analytics, benchmarks, and reports.
 

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RowdMap U

Our interactive learning center offers trips, tricks, tutorials, and functionally oriented resources to help healthcare payers and providers understand and interpret information about RowdMap healthcare value scores.

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