Today, specialty care drives the majority of cost and complexity in healthcare. The focus on return on investment (ROI) of medical solution investments will be fundamental to benefits selection moving forward, yet many healthcare platforms use outdated, trend-based methods to calculate ROI. It is apparent that a new ROI methodology—rigorous, robust, and resilient to scrutiny is needed.
Virtual specialty care affords people the opportunity to receive personalized clinical guidance that helps them make well-informed decisions about their health. Readied with education and information can alter the trajectory of a person’s health journey through a change in diagnosis or procedure—or in avoiding unnecessary in person visits to specialists, emergency departments, and urgent care centers, which also has an impact on productivity. These adjustments can drive significant medical cost savings, both in the short- and long-term, and can improve health outcomes and quality of life for patients.
At ViVE 2024, Panelists Share Prior Authorization Progress and Frustration in Payer Insights Program
At the Payer Insights sessions on Day 1 of ViVE 2024, a panel on prior authorization offered compelling insights from speakers who shared the positive developments in this area after years of mounting frustration. Speakers also shared challenges as they work with providers to figure out how policy developments and technology will work in practice.
Data integrity is achievable
In healthcare, we need honest methodologies that accurately capture both the cost and complexity of specialty care and deliver a reliable ROI calculation. Only this sort of replicable, high-integrity ROI calculation can truly associate accessing high quality specialists with lower cost and better outcomes amidst today’s healthcare access and affordability crisis. Such an approach requires us to:
- Capture all types of patient healthcare experiences. The use of robust data sets that reflect all types of patient journeys at multiple points along those journeys is a must.
- Interpret the data based on specific conditions. The cost of healthcare varies dramatically based on condition and treatment. Chemotherapy treatments cost significantly more than an allergy test, and the cost of well child visits pale in comparison to the cost of an emergency room visit. Focusing on a specific condition, rather than an aggregate of conditions, increases accuracy of ROI calculations.
- Address episodes of care. By isolating individual episodes of care, instead of tracking long term trend, it is possible to discern cost savings of a particular program or service—filtering out extraneous factors such as provider price changes or expenses over time that are unrelated to the initial concern.
- Localize the data. Prices vary by location, and healthcare is no exception. Instead of using national averages, location-specific cost data provides greater accuracy and transparency in ROI calculations—especially when using data with zip code-level granularity.
- Use cohorts. Using cohorts of like groups of people—age, gender, location, and condition—is valuable in determining how a given program or service performs. Cohorts are a powerful tool for identifying pre- and post-intervention differences, effectively highlighting cost savings from changes in diagnosis, treatment path, or both.
- Continuously refresh the data. Current, episodic data ensures that ROI calculations can be responsive to fluctuations in the marketplace and reflect more than just a moment in time.
It is the rare ROI calculation methodology that unifies the above elements. Such a methodology brings an integrity that employers and payers can count on to support decisions and identify benefits that have demonstrable value.
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Honesty is the best policy
ROI is top of mind for all human resources and benefits leaders, especially with today’s healthcare access, affordability, and clinician shortage challenges. A strong ROI proposition with a proven methodology can accurately identify which healthcare solutions deli
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Mary Mulcare, MD, FACEP, is the Chief Medical Officer at Summus and oversees all clinical aspects of operations. Mary also serves as a Clinical Assistant Professor of Emergency Medicine at NewYork-Presbyterian/Weill Cornell Medicine, and has held several leadership roles at Weill Cornell, including Director of Undergraduate Medical Education in the Department of Emergency Medicine and Assistant Director of the Margaret and Ian Smith Clinical Skills Center. She continues to make significant academic contributions to the fields of medical education and Geriatric Emergency Medicine. Mary completed her undergraduate education at Princeton University and obtained her medical degree from Columbia University College of Physicians and Surgeons, graduating with honors from the AOA Medical Honor Society and the Gold Humanism Society. She served as Chief Resident of the Emergency Medicine residency program at NewYork-Presbyterian Hospital and completed a fellowship in Geriatric Emergency Medicine at Weill Cornell Medical Center.
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