Project Management
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
Communications
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.
Knowledge Management
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.
Measuring Results
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 technology investments.
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.
Reporting
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 claims.
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.
Managing Risk
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
Managing Deliverables
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.
Summary
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.
