Hello, everyone. This is Erica Spice Mason with the Becker Healthcare care podcast series. Thank you so much for tuning in. Today, I'm thrilled to be joined by 2 guests from Quest Analytics to talk about the benefits to payers of network benchmarking. We have with us Sub S, the Senior vice President of Network at Quest Analytics and Bob Tavern, the sales solution executive at Quest Analytics. Sub ba and Bob, welcome to the podcast performance Thank you so much for being here
today. Thanks, Erica. Thank you. Yeah. Thrilled to have you both. And before we get into our discussion, I was hoping you both might share just a little bit more about yourselves, give our listeners some context. So Ba, maybe we can have you get us started. Sure. Yeah. And, eric, thanks again for, having us, on the podcast here. So this is Sub sebastian Seal I've been in the healthcare space health and data space. I should say for the... For a little of 20 years now.
Last 12 years, I spend time at adopt, and then try to that I've work for another health care data company that is no part of, Iq. And the common thread across all, my tenure in these 2 companies is data analytics product and basically telling a story with with data that's kind of where, I spend most of. Okay? Well. Thank you, Sebastian. And thank you again, Erica for the opportunity. This is Bob Kevin harris. Sales solution executive at Quest Analytics.
I'd come from Healthcare Service Corporation where I have the privilege and opportunity to serve across 4 major divisions for 25 years. Super excited to join quest analytics and bring my health care experience forward in supporting our network performance and benchmarking area of healthcare care. Fantastic. I really appreciate the intros from me both, and it sounds like you've definitely got the expertise to drill down a little bit more into this topic of
health plans and their network performance. So Sub ba, I was hoping you could get us started and just kind of give us a bit of a broad idea of this topic area, how do health plan networks currently measure performance. And what metrics are most critical for evaluating the efficacy of these networks, Sure. What great way to kick off this this topic or this discussion here. So help plans should typically have about 5 or 6 major areas that they would measure themselves on.
And in the list I'm gonna talk about is in no particular order, they're all equally important. So first, it comes
to mind is clinical related measures. Like, outcomes, which is, like, he measure that's a measure of care and service, then, quality measures and patient safety, hospital like, required conditions come this this bucket and then, population, health management, which is, how are they managing their chronic condition of the prop of the population and preventive care, early detection, things like that. So that's the first... That's the
first 1. And then the second area of measurement here is utilization, like, how is the utilization across, like, say, resource management and the services management going on? So meaning, what is the geometric mean length of stay of my, set of my members when the encounter sepsis. Like... So, the utilization is a big, component of measurement for for help... Plans and also, like, how many tests are done, prevent you or diagnostic and things like that.
The third area of measurement is plans cost management, which is mostly, like, medical expenses, what's their medical loss ratio? What's the total cost of care, again, a big measurement area for health plans. Then the the fourth 1 will be, wanna say member satisfaction. Like, this is an important, piece of measurement because they want their members to be happy.
They want, I mean, a member retention is a is a big measure for them, and it comes out through age gaps and that can impact their ratings with Cms and also that will indirectly kind of impact the payment. So... And then the fifth the 1 is operational efficiencies, again, timelines of care, claims processing efficiencies, these come to mind in that. And then last but not least, at least, from
a measurement standpoint regulatory and compliance related. These are and say, are they meeting in Secure standards or, they are they in line with, compliant with state and federal regulators agencies. So those are kind of broad candidates. There's a lot more under of them that they measure. But I think in every other measure they make can roll up into 1 of these 6 buckets that I just mentioned. Each And that's fantastic. Thanks so much, Sub
ba. So it sounds like we're looking at clinical measures, utilization, cost management. Member satisfaction, operational efficiencies and compliance, you know, it's a pretty wide range of measures that payers are looking at to measure their overall performance. So I wanted to take that just a little bit further and considering all of those elements, can you kind of discuss the role that benchmarking plays in and how this helps payers really improve their network performance as well?
Yeah. I mean, the the 6 measurements that I talked about. So let me extend that, into your next yep, the question around benchmarking. These 6 measures are not mutually exclusive. The age measure kind of, like, leads into the others, or so your cost management can be a function of utilization and clinical outcome. So they're they have very good relationship between each other. So benchmarking can create real measurable goals for these health plans.
They reveal performance gaps in these areas for health plans. And, they also can highlight areas of improvement. They also can highlight best practices, and they create awareness around, what the industry standards, are, etcetera, etcetera. So I'll give you a couple of examples here. So if I'm a health plan, Like, I wanna know what is the risk adjusted 30 day mortality rate for chest pain, patients, chest pain period. For my members with provide us in my network.
Versus those in my competitors network. Right? And if the rate is comparatively higher I will... I as a health plan will ally align in sign incentives to improve this outcome or are just provider composition in my network. So members have access. To higher quality providers. So that's can that's an example where benchmark can come handy. The other thing is it's not only about clinical outcomes. As I mentioned earlier benchmarks can also help with cost management initiatives.
Like, for example, care coordination. How often my members that I've been through a surgery post discharge, end up in an un scheduled Event. Versus my competitors. Right? Because that is an expensive, affair for, work from from emotional standpoint from dollar standpoint everywhere. Right? So if my number is higher than market average, I need to take action to, like, increase care coordination. So there's a flow.
There's there's there's a follow, call with, with the Pcp post discharged within 5 days or something like that. And the other important thing that Benchmarks can provide is, do I have more low value care providers compared to my... To the market median? Right? It's not always comparison against your competitor or the next next health plan. But what is the market median? Meaning, these are providers that have increased utilization with no evidence of improved clinical outcome.
So do my... For example, do my antibiotics go directly to any knee surgery without trying physical therapy like that because that's I mean, that can increase the cost of care without trying everything before going to the next 1. Next big item, which is. So benchmarks can really be critical to our gaps subsequently diagnose the problem and measure the impact of any corrective
action. So again, I know, Bob, you you probably have dealt with this directly, I mean, in your in your time during your time and the payer. Anything you would add for the roll of benchmarks here? Absolutely Sub ash. Benchmark and services are really several roles and helping the how plan, evaluate network performance. A few examples would be helping to service baseline plans for health plans.
Through which network performance can be measured, compared against utilize and evaluating network performance of the physicians and facilities, in the cases of network contract affecting, rate adjustments, negotiations and renewal, also supporting, the provider and vendor contracts, acting, with contracts that are based to its Sla and performance guarantees, pay for performance, fee for service models, And also look looking for, like for, like, comparisons against
provider specialists for member satisfaction. Additionally, they they can also be utilized, within payer organizations for achieving marketplace differentiator. So for example, on C qa to, the point you mentioned earlier a population how how could health equity initiatives. They're also used by regulators to help to establish the standards or which payers are required to achieve, for example, state departments of insurance, Medicaid Rfp.
And then lastly, really focusing more around the quality lens. Of those providers and how do we ultimately steer members into higher quality providers and helping them with their health care decisions? Yeah, Bob S, these are such great insights, and I think it really... Everything you've shared really speaks to how benchmarking can provide a lot of insights in so many areas of the business. I think we've touched on patient or member satisfaction.
We've talked about clinical quality, we've talked about the quality of specialists and how providers are performing against market performance and I can only imagine that these measurements, while helpful. They're probably rather complex to not just track and measure, but also to monitors. So, Sub, I was hoping you could shed a little bit of light on the role of third party benchmarking services. You know, what role do they play in helping payers evaluate
network performance. And if you could share any examples of how those services have provided actionable insights for network improvements that would be fantastic. Yeah. I mean, I think benchmarking as a topic in itself is is pretty complicated. Like, even you could you could have benchmarking in in a better idea of ways. Right? So 1... The first 1 is, like, you you compare against yourself. That's still, like, I mean, how did I do as as a health plan,
last year compared to this year. Right? So that's fundamental that's foundation and everyone should be doing And that's a bare meeting. Right? You compare against yourself year over year and and are you trending in the right direction. Right? And and this is not super complicated and doesn't necessarily need a third party resource. So, like, because you got all the data, you crunch the numbers. Again, you need some analytics talent in in house we kind of
do that. But you crunch the numbers, and you see how you're trying and most help plans do this. Like, not not rocket science. Right? The the challenge comes in, like I mean, knowing what the market capacity is I think that's where things start to get tricky and and complex. Right? If if my... Again, I'll I'll go back to, like, say, if my members when they end in the hospital for pneumonia, they're in the hospital for, say, 4.3 geometric millions, as zinc inpatient stays.
Is that good bad? Like, I mean, okay. Last year, I was 4.2 and 4.3 and going up. But... I mean, So knowing in what the market is, I think is is very important and that's what Benchmarks will do. Right? And so there... There's a lot more I can go deeper into into, like, the third party services. But again, I, I love to get it here from Bob his point of view because, Bob, you were in leadership role at health plan and and you...
You dealt with this, like, first hand? Like, did you do, like, homegrown benchmarking or did you go outside and and and source it from outside? Like, and what are the pros and cons of each approach? Should light on that. Absolutely. There... There definitely is some homegrown benchmarking, but it's also limited. Typically line of business level. So we... We've noticed different levels of benchmarking when you're looking at a commercial population versus a government population.
You know, the other thing that we're we're thinking more about is, you know, just the health equity lens and how do you, know, ultimately, deliver guidance on actual insights from paying attention to race ethnicity, language, cultural competency, inclusive programs for, diverse member populations and ultimately how do you deliver a network that's gonna help to meet that member population where they are in close proximity to what they need and based on the type of care that they're looking for.
Yeah. I mean, going back to your question, Eric around, like, I mean, third party, benchmarking service actually, they they assume... They are in this in this space for a, from a very long period of time, they have a lot of data understand the nuances of it. So there are advantages to the third party sources where they have a data infrastructure talent pool and to
maintain this on an ongoing basis. Right? And then, the other advantage is they have a very broad, holistic and, like, global view of the problem. At hand. Because it's like, because of that 10000 hour role, if you if you know, on a given. If when you do this over and over, again, you you tend to get better and better and
your experience kind of speaks very clearly. Like, that's what when somebody is, like, doing this purely on a day in day out basis, So they can identify patents very very quickly, and they have the ability to layer additional data on top of the simple comparison. Like claims data, for example, they can take claims data on top of network data and provide much deeper insights, which is critical because sometimes your
superficial, just comparing counts getting misleading. I I might have 25 percent of my provide an network in really high efficient bucket, but are you really getting activity for this from this 25 percent... This 25 percent drive only 3 percent of your activity. That's not good. Right? So that level of detailed analysis, can be possible when somebody is, like, really doing it on on a day to day basis. Mh.
Yeah. I really appreciate those add ons. S and and Bob, especially your perspectives from all of your time at a payroll organization. This
has been a great discussion. Our time has come to a close so quickly, but I just wanted to thank you both again for for joining this discussion and also Sub sebastian highlighting some of the capabilities and and really the capacity that third party services can really help organizations with in terms of understanding, having access to the benchmarking data, understanding the nuances and analytics as well. So again, thank you both for for being on the podcast today. Yeah. Thank you very
opportunity in. Definitely enjoyed the the conversation. Thank you, Eric. Great opportunity. Appreciate it. Oh, thank you both again, and we'd also like to thank Quest Analytics for sponsoring this episode today. Listeners, please be sure to check out other Becker healthcare podcasts at becker hospital review dot com.