The Unique Role of Project Management In Payer-Provider Collaboration
Because a payer-provider collaboration project may spawn a large number of
separate initiatives, there must be an established ground zero to synchronize
planning, reporting, monitoring, and knowledge sharing. Project management provides
this framework. Project management helps control the project on a microlevel
to coordinate sub-teams or workgroups. It also helps manage the project on a
high level to ensure that all the teams are successfully collaborating.
The application of proven project management methodologies and standards helps
ensure the requisite level of consistency, accountability, and compliance. Project
management is especially helpful to encourage communication between payers and
providers, whose previous exposure to each other is typically during contract
negotiations and through provider service representatives (not direct to management).
Project management helps the two groups come together to discuss business process
issues and to create mutual solutions.
In some payer-provider collaborations, a project management office (PMO) is
established to act as a centralized clearinghouse to direct, control, and monitor
all project initiatives. The PMO consists of personnel, tools, technologies,
and standards that enable and facilitate the project management process. The
PMO is responsible for coordination, implementation, and transition of project
management methods and tools, as well as project resourcing (see Figure 1).
Figure 1. The Scope and Approach of a Project Management Office
Whether functioning in the capacity of mediator, conciliator, or interpreter,
project managers are critical to ensure that effective communication occurs
within a payer-provider collaboration environment.
Effective project management ensures clear, consistent, and timely communication,
especially in large collaborative projects. For example, Capgemini worked with
the seven largest health systems in southeast Michigan to collaborate with Blue
Cross and Blue Shield of Michigan (BCBSM), the largest nongovernmental payer
in Michigan. The project had hundreds of constituents involved across the eight
organizations. Constant communication was imperative to ensure consistent messaging
across all the involved organizations. This level of communication also facilitated
critical buy-in, support, and coordination from all stakeholders.
Because both payers and providers tend to speak their own industry language,
it may be desirable to have a third-party consultant present to translate industry-specific
jargon and help all parties share a common frame of reference. The independent
third party can also offer objective opinions regarding issues that have significant
impact on either party.
One of the biggest areas of miscommunication between payers and providers occurs
when neither understands how their actions affect the other group. Project management
and its associated tools ensure that the impact of proposed workflow solutions
on both parties is known, validated, and fully addressed prior to implementation.
By encouraging group communications, project management plays a key role in
helping the two parties to agree on needed changes.
Project managers use knowledge management as an effective tool to capture and
share information throughout the collaborative process. The primary objective
is to facilitate the identification, acquisition, screening, packaging, and
distribution of information from various knowledge sources to the project team.
In a payer-provider collaboration environment, this allows participants to leverage
knowledge across various initiatives to continually build and re-use best practices
as the project unfolds.
Knowledge management is particularly appropriate for collaboration efforts
because communication across the traditional payer-provider boundaries is so
important, and there are too many players to involve in every meeting. It is
also inefficient to include every person involved in the collaboration, as project
participants are usually high level staff. One of the key elements of knowledge
management is that it allows individual participants to benefit from a workgroups
collective experiences while encouraging and promoting individual learning.
For example, the Michigan collaboration involved seven hospital groups. The
workgroups were established so that every group did not require representation
from each hospital. Instead, all the hospitals received the benefits and knowledge
resulting from the efforts of all workgroups, without having to send someone
to each group to help create the solution.
Project managers usually establish knowledge-sharing sessions at the end of
each project phase. In the Michigan project, two teams created a set of solutions
that addressed eligibility issues. A half-day session was organized in which
those two teams reported to a group that included representatives from all the
facilities. Each attendee received a copy of the deliverables and a CD with
project tools. The teams conducted the presentations, but the project management
team facilitated the knowledgesharing effort.
Project managers play a tremendous role in managing the output of multiple
teams to ensure that all collaborative participants benefit from shared knowledge.
The knowledge output can then be leveraged to other business areas to improve
processes throughout the organization (see Figure 2).
Figure 2. Project managers ensure that all collaborative participants benefit
from shared knowledge.
Measurement is critical for collaborations to succeed. Measuring the business
impact of collaboration initiatives adds instant credibility and brings both
payer and provider groups together to celebrate early project wins.
Proof of early success is critical to engage stakeholders and keep them on
board. Tracking and reporting key project deliverables is the necessary lifeblood
that keeps a payer-provider collaboration alive and moving forward. With detailed
information, both groups can act strategically to negotiate terms or implement
policy or procedural changes that improve performance.
When measuring the impact of a payer-provider collaboration, some benefits
are less easily quantified. Financial gains for example, a decrease in bad
debt are considered hard benefits and are easy to measure. Other benefits,
however, such as provider satisfaction, are less easy to gauge. Although sometimes
difficult to track, these so-called soft benefits make important contributions
to an organizations overall performance and must be factored into any critical
assessment of a collaboration project.
Capgemini promotes a balanced approach where a variety of different measurement
criteria are used. Payers, for example, seek to lower administrative and medical
care costs. Providers try to reduce AR and bad debt, and try to streamline paper
shuffling to cut administrative costs. Organizations should pick the specific
measures that are right for them, given their respective business strategies
and priorities. Payers and providers need to agree on the measures that will
be used to gauge the collaboration. Consistent definition is extremely important,
to ensure that they are tracking apples and apples, versus apples and oranges.
Though there is a nearly infinite number of specific metrics, there are three
basic categories that can be measured to indicate the success of a payer-provider
collaboration project: quality of care, financial and operational measurements,
and service level ratings or customer satisfaction.
Measuring Quality of Care
As payers and providers work together to improve clinical pathways to gather
patient information, providers can use this information to improve patient care.
For example, a hospitals risk assessment department can use data resulting
from the collaborative effort to target patients who have early risk factors
for certain diseases. By measuring the success of these riskbased programs,
providers can tell if quality-of-care outcomes have been favorable.
Measuring Financials and Operations
Financial measures mark any change in a payers or providers financial health.
Increased revenues and productivity, or reductions in costs or waste, all signal
a measurable improvement in the financial strength of an institution. Since
an institutions financial health is most frequently expressed in numbers, it
is often the most straightforward measure.
For example, providers track financial outcomes by measuring reductions in
accounts receivable. This is directly related to the length of time required
for bills to be paid by insurers. Providers can also track bad debt rates, measuring
how many claims must be written off as uncollectable.
Both payers and providers can track the cost to process claims. By looking
at measurements such as clean claim rates and rejection rates, both groups can
evaluate how long it takes for a claim to be paid, which directly correlates
to AR levels. An integral part of payerprovider collaboration is measuring the
results of improved operational processes. Several methodologies can be used
to determine whether the new processes are running smoothly. One example is
measuring auto adjudication rates to pinpoint the percentage of claims that
are resolved in a completely automated environment. The greater the rate of
automation, the less manual intervention required and the higher the adjudication
rates, translating to reduced administrative costs and a better leverage of
Measuring Service Levels Or Customer Satisfaction
Both payers and providers measure the success of a collaboration project using
customer satisfaction ratings. For example, when providers poll patients using
satisfaction surveys based upon care received at a hospital or at a physicians
office, they can include questions related to overall satisfaction with billing
issues or payment. Providers can also measure how many times a patient has to
call before a claim is resolved. This is often a direct measure of customer
satisfaction fewer calls equal a higher level of satisfaction, increasing
loyalty, and improving retention.
Payers can also measure satisfaction both from members and from providers.
In some cases, providers may refuse to participate in the payers network, or
they may demand higher reimbursement rates in retaliation for perceived service
problems. This is an informal but telling measurement of provider dissatisfaction.
Member satisfaction can also be measured by call volume. Decreasing call volume
indicates that problems are either not occurring or are being resolved early
on, reducing the number of follow-up calls needed to resolve issues.
Project management is responsible for setting up the reporting function in
a payer-provider collaboration. Timely, accurate reports are required from each
workgroup to determine project status and performance with respect to milestones,
schedule, cost, quality, and risk (see Figure 3).
Figure 3. An Example of a Project Management Status Update
In a collaborative environment, reporting is critical to ensure that project
managers are capturing the concerns of both sides in an unbiased way. By requiring
the same reports from all parties, project management ensures that equal attention
is given to issues concerning both payers and providers
For example, as a result of the Michigan project, a quarterly newsletter was
generated to communicate the results of the first five project teams and to
outline the next phases of work being considered. The newsletter is oriented
primarily toward CFOs and BCBSM executives and describes, among other things,
how the group will be expanding the collaboration project to include physician
In a large-scale collaboration project, reporting is not a one-time event.
It is an ongoing process that communicates project achievements to keep all
parties motivated. Because of the large number of constituents and because a
great deal of time lapses between meetings, reporting is critical to ensure
that tasks do not fall off the radar screen.
Unique risks are associated with payer-provider collaboration projects. One
of the inherent risks is that the workgroups will develop a solution that is
a win for one side and a loss for the other. Or, a team might develop a win-win
solution, but it will require an investment from only one of the players. Risk
management identifies these kinds of risk so they can be avoided or lessened
to ensure that deliverables produce expected benefits.
For example, perhaps a workgroup proposes a programming change to claims-processing
logic that must be made by the payer, but the benefit will accrue to both the
payer and the provider. Project management helps the two parties see the impact
on both sides and work collaboratively to minimize risk.
Ongoing risk assessment communicates the progress of each initiative to highlight
problem areas. Because many initiatives are interrelated, risk assessment facilitates
a project managers early intervention, thus preventing a domino effect through
other project initiatives.
In a payer-provider collaboration setting, risks are magnified because any
incurred risk transcends an organizations own four walls, affecting other organizations,
patients, and subscribers. For example, if a workgroup proposes collecting copays
at the time of service, the provider may experience greater impact because hospital
staff must now explain the new process to patients and must be responsible for
cash collection. In addition, this process change has an effect on subscribers
that the payer will need to understand and address.
As part of project management, many teams maintain a log that tracks major
issues, assumptions, changes, and risks that impact payers and providers at
a program level. This helps project managers ease risk by identifying and mitigating
risk up-front (see Figure 4).
Figure 4. An Executive Scoreboard
Depending upon a workgroups assignment, a deliverable might be a policy change
on either the payer or the provider side. Project management outlines the exact
requirements of a deliverable and how it impacts all players.
A process change is also a deliverable. Project management ensures that when
a process change occurs, all other parts of that process are changed accordingly.
For example, if a collaboration workgroup develops a new process to request
online precertification, the deliverable outlines the new process, how it will
be implemented, how the process will be communicated to staff, and how staff
will be trained to handle the new process. The deliverable must address both
the payer and the provider side of the process. Project management ensures that
all these items are addressed in the deliverable so that the process change
can be successfully launched through both organizations.
Maintenance and Ongoing Monitoring
Project management is ongoing. Once the framework is in place, project management
occurs during the rest of the project lifecycle. Along the way, project managers
periodically re-evaluate goals and progress and make the appropriate adjustments
to keep a collaboration project on track. Project management also delivers value
to both payers and providers by creating a template to manage future collaborative
efforts after the initial project is completed. Project management is an investment
in the mutual success of both payers and providers, since it communicates the
appropriate tools and techniques needed to maintain ongoing collaborative efforts.
Project management provides an organizational framework for both payers and
providers to address mutual issues and communicate throughout a collaboration
project using a common language. Project management integrates performance improvement
measurements with traditional project monitoring and reporting to create a culture
of accountability that is critical to collaborative success. The role of project
management also involves identification and mitigation of risk to keep the project
progressing smoothly. In addition, deliverables management keeps all parties
accountable so that new policies and processes are accurately documented and
can be shared with other groups. Finally, project management is an ongoing process
and ensures that information sharing and problem solving between payers and
providers lives on beyond the initial collaboration project.