Controlling costs and operating efficiently while ensuring fair payment to provider employees are challenges faced by many payers, including Grand Valley Health Plan (GVHP). Located in Grand Rapids, Mich., and established in 1982, GVHP owns six primary care practices, an obstetrics center, an urgent care center, a radiology facility, a holistic health center and two full-service pharmacies. All of our physicians are employees of the plan, which covers 10,000 lives.

As a staff-model health maintenance organization (HMO), GVHP needed solutions that would make claims easier to process, hasten provider reimbursement and provide coding support that accurately reflects the level of service delivered. Our ultimate goals were to improve workflow processes from patient check-in through charge capture, claims submission and remittance processing that allows GVHP to extract critical information about utilization and performance to improve productivity and determine appropriate pricing for its products.

Problem

When GVHP was founded, we relied upon paper-based processes throughout the enterprise. In 1994, we converted to a single software solution, which was intended to support both the patient care and insurance components of the business. This was an improvement over manual processes, but not an ideal solution. Because it was a middle-of-the-road hybrid, the system did not offer “best practices” for care delivery or insurance processes. In addition, since the software did not completely fulfill needs on either side of the business, neither our providers nor our insurance staff felt any ownership of the system and, therefore, were not invested in maximizing its value.

With the implementation of an EMR system with the PM system, documentation of care and coding has improved, allowing us to collect accurate quality data, enhance risk management efforts, and allow better reporting on Health Plan Employer Data and Information Set (HEDIS) measures that are necessary for the plan’s National Committee for Quality Assurance (NCQA) accreditation.

Once implemented, the system was static. We were unable to reconfigure processes or make any changes to content as GVHP grew and as the healthcare market evolved. Likewise, we found it difficult to obtain reports and analysis from the system. Leadership was unable to extract scheduling information, encounter data or even demographic detail about special patient populations. With no access to vital business intelligence, we were handcuffed as we attempted to make decisions in a dynamic and constantly changing environment.

Solution

Leadership at GVHP determined we needed to implement a practice management (PM) system as well as a separate, more sophisticated insurance system throughout the organization. In 2002, we hired a consultant to gather information on available options. A committee representing various internal stakeholders then began to evaluate options, narrowing the list to three vendors for each system. Committee members included group practice managers, nurses, medical assistants and IT staff from Grand Valley Technology Services, as well as representatives from central billing, claims processing and contracting.

Following demonstrations and extensive reference checking, GVHP representatives attended each candidate’s user-group meeting to solicit candid feedback from current users. We later discussed what we learned from the user group meetings — the good, bad and ugly — and reviewed the strengths and weaknesses of each system.

Implementation

We found implementation of the PM system in 2004 to be relatively painless. At the heart of our efforts was the formation of an implementation work group, with representation from each practice. The work group’s first assignment was to review all of our current processes, and determine what was working well and what could be improved. The work group also looked at the functionality of the PM system so we could modify procedures and work habits in order to make best use of this new technology. Documentation of the modified work processes and use of the system was distributed to all users for ongoing training and support.

The work group then attended vendor-sponsored training and was subsequently awarded the daunting task of determining the best way to roll out the PM system among all of our providers and locations. Our solution was to install the system in one practice at a time. When the first practice was up and running, staff members from the second practice visited the first, and observed the system in use. Observational staff members then returned to their own site and helped drive adoption. This leapfrog process was followed at all locations, until implementation was complete by the end of the year.

Challenges

The biggest hurdle took the form of human resistance to change. While we wanted to complete the transition as quickly as possible, GVHP leadership also recognized that if we pushed too hard, we might create additional barriers. Instead, we made an effort to ensure that users understood the “whys” and “what fors” of the new PM system, not just the “whos” and “whats.”

The only significant problem we encountered related to hardware. We had initially installed a wireless platform that proved unreliable — users would become aggravated because they lost connectivity on a regular basis. The only solution was to remove the initial hardware and install a better system, which delayed rollout by approximately a month.

With no access to vital business intelligence, we were handcuffed as we attempted to make decisions in a dynamic and constantly changing environment.

Of course, we subsequently took on an even bigger project: the adoption of the EMR. Our success with implementing the PM system smoothed the path and reassured our clinical staff that their efforts would pay off during this period of change. They recognized the benefits that integration of the two systems would offer. Better documentation increases coding accuracy, which facilitates our efforts to report quality and business data. This, in turn, impacts compensation and performance bonuses.

Results

Since converting to the new PM system, both the health plan and our providers have realized a number of benefits. Among the most significant is improved scheduling and timely response to patient requests for appointments. To determine performance in this area, GVHP measures the “days to appointment” for planned encounters and for urgent visits, and conducts analysis of each practice and category of patient to measure compliance. GVHP has decreased average days to appointment for preventive and routine care from 15 days to 10 days. Likewise, when patients call for urgent appointments, the days to appointment rate is 0.3 days, whereas prior to implementation it was 0.89 days.

We also generate automated reminders to patients regarding scheduled appointments. Besides being viewed as a valuable customer service, this functionality has also caused our no-show rate to drop, which saves the plan money and decreases provider frustration when patients fail to arrive for visits.

With the implementation of an EMR system with the PM system, documentation of care and coding has improved, allowing us to collect accurate quality data. This, in turn, enhances risk management efforts and allows better reporting on HEDIS measures that are necessary for the plan’s NCQA accreditation.

Leadership is likewise able to generate reports with information vital to the health plan’s business stability; improved utilization and quality data helps GVHP better understand costs. We, therefore, are able to more effectively price our products and appropriately determine rates the insurance company must charge.

We have also been able to decrease referrals to non-plan specialty providers. Quality data reporting allows the health plan to identify which of our own staff provides superior care in specific areas (e.g., diabetes). We have set up a hold in the system giving all GVHP providers a consultation time window from 2:00 p.m. to 2:30 p.m. daily, when no appointments are scheduled. Whenever possible and appropriate, plan physicians consult with one another instead of referring patients elsewhere. This has generated a reduction in specialty care costs of 14.52 percent.

A New Attitude

GVHP providers have maximized their use of workflow tasking and appreciate the convenience it provides. Fewer details fall through the cracks since assignments are forwarded electronically and then monitored automatically. This is especially convenient for several of our providers who practice from multiple locations, as they are able to forward work assignments to any staff member from any location. Workflow tasking likewise supports the GVHP preceptor program. Mentors oversee new providers for six months. Chart and documentation review can be completed in real-time, thanks to automation.

With virtually no exceptions, our staff members are delighted with the benefits of our PM system. It has improved efficiency and productivity, and made everyone’s job easier. Because it provides easy access to a wealth of data, we have been able to improve business and clinical operations, as well as respond to changes in the healthcare and insurance marketplace.

Pamela Lea Silva is vice president of operations for Grand Valley Health Plan. Contact her at [email protected].

April 2008