Boost Your Personal Brand and Professional Growth Through a Role in a Managed Care Organization

This article is part of a series detailing the opportunities and entry into a nontraditional health information management sector: managed care organizations (MCOs). The series began with a big-picture approach, understanding the impact of MCOs on the modern healthcare environment. It continued into the direct connections between MCO operations and the health information professional’s skill set. In this third and final article, the focus is on how to transition to a MCO role and the professional benefits.

There is one thing certain about the current state and future of healthcare: It demands better integration and partnerships between providers and payers. This is starting to happen because it must happen. Those that continue to be agitators in separation by blaming the other side will not be seen as the problem solvers the healthcare system needs, and thus will not be a leader in the future of healthcare. Those changing the rhetoric and proving what can be possible will emerge as national leaders.

Executive-level leaders who have worked on both the provider and payer side all have the same view on transitioning, and their diverse experience brings immense value to multiple facets of their organization. Having the experience of working on the provider side, for example, allows leaders to give insight and reason to their colleagues on the payer side.

As a health information (HI) professional, the breadth of the value you bring to a managed care organization (MCO) is immense. On the provider side, the concept of the health information management department is familiar: Direct oversight of a diverse set of operations and skills from revenue cycle, technical, privacy, operational, clinical documentation, and so on. In addition, HI professionals have knowledge of most other operations in the provider setting.

When these professionals enter the MCO space, they have a knowledge set that is of value to every team — a sought after, go-to resource. This is where the notion of an “interpreter” transforms into being the “bridge.” Knowledge becomes actionable. The HI professional becomes a utility for every aspect of the company.

All this fits into standard leadership models. The progression through leadership is marked by two main transitions: Task expertise into providing value to the company; and operational subject matter expert into broader strategist.

The healthcare payer sector is at a pivotal point because of pressures from legislation, consumers, and the financial climate. To respond and prepare for the future, payers have pivoted their strategies to main themes and roadmaps that call for HI professionals’ involvement. Those themes are:

• Provider–payer partnerships
• Data to drive holistic well-being and consumer experience
• Product and service diversification

All three have a common denominator: collaboration with providers across process, alignment, and technology. While conversations between provider and payer may be happening to progress these strategies, a key player that is often missing is someone who knows the provider side.

Even before cross-table conversations occur, the general understanding of the provider side allows for creation of partnership frameworks. Injecting business partner knowledge into the approach before the conversation will only ensure success and good relations from the start by showing understanding and value.

As we think about healthcare in the context of revenue cycle, patient access, value outcomes, and consumer experience, it is a continuous loop that crosses back and forth between provider and payer multiple times. Knowing the touchpoints and impacts of each part of the cycle enables you to be the architect who enables a cross sector cohesive flow that strives for the Quintuple Aim: improved care experience, healthier populations, reduced costs, clinician experience, and health equity.

Provider-Payer Relationships

To be successful and competitive, payers need to be good partners. To be good partners, there needs to be provider consideration engravement into operating models; business models between partners need to align to support the healthcare system. The greater the alignment on business and operational models, the more seamless the consumer experience becomes, as well as higher levels of service delivery and coordinated care. A major part of being a good partner requires helping providers be successful. Provider satisfaction scores are often directly impacted by the interaction or lack of interaction between payer and provider. Non-clinical interactions with providers are equally important to consumers.

The other major factor is provider contracting, specifically value-based care. While value-based care is a standard model for MCOs, it is still not overly favorable to providers. Naturally so, due to circumstances of revenue based on variable factors all within in a new payment model. All MCOs have programs set up to help their provider network be successful. Captured data through mechanisms like the Healthcare Effectiveness Data and Information Set (HEDIS) is shared back to providers. Additionally, dashboards are provided with value metrics to help providers target improvement efforts. All of this — the resources, data, and analytics — won’t elicit use or interest by provider partners; it needs an understood value proposition.

The HI professional is the right person to ensure that value. Again, the role of interpreter comes in. Data points or dashboards alone don’t always ensure mutual understanding or even provide needed information. Being able to know and predetermine what provides value to provider organizations only enhances the provider-payer relationship and consumer experience.

Take a look at recent headlines related to combatting the most complicated healthcare issues such as health equity and social determinants of health. Most likely, that headline involves collaboration among a payer, provider, and community organization. Be the change agent that flips the script on the combative rhetoric through realized value outcomes and you will elevate your professional and personal brand quickly. The future of healthcare is more cross sector collaboration centric, and being a leader in this future requires professionals with cross sector experience and track record.

The Role of Viable Data Steward

The healthcare data ecosystem is complicated. Even before you get to the technical make up, you have the regulatory and ethical questions of: Can I use this data? How can I use it to make a personal experience between provider and payer?

The traditional sense of healthcare was episodic, where patients would only interact with their provider and insurer when they needed something or were sick. That model is changing, and data is essential to enable that change. Payers are striving to be the trusted source of data to drive healthcare delivery innovation. If a healthcare professional can improve someone’s health and well-being, then they become a trusted partner with loyal advocates.

For data to equate to impact, there need to be viable data stewards. This can be the HI professional. There is a dynamic when it comes to how payers position themselves as reputable data sources.

First, the data needed and used by payers is ingested from a variety of external sources, as well as internally created, each with a different data scheme makeup. This data then must be aggregated in a way that its useable for internal and external goals. Finally, the aggregate must be able to be packaged in an output that is usable and relevant to providers, consumers, and the government.

There must be consistent governance of data from all sources to be used in a global manner to aid internal operations, cross-sector processes, and customer relevant output. The ability to push data consistently and accurately through its quality layers requires an experienced and informed HI professional who understands the purpose, definition, use, and need for data within the health information management domains. There is a commonality in data definitions and need across the healthcare system, but that commonality is usually not widely realized.

Data still tends to be defined and structured for internal or industry-specific use. When that commonality is known and embedded, cross-sector partnerships become easier and more amicable. The missing component to this is usually an AHIMA-credentialed HI professional.

Being that missing component does not necessarily mean an expert-level technical skill of database and query, but rather the ability to lead and guide those teams to structure and govern data in a manner that aids the Quintuple Aim. In fact, the Centers for Medicare and Medicaid Services Medicaid Integrity Institute Medicaid Data Analytics Working Group released a report on how to assess data analytics programs, and the report calls out the understanding and use of provider data and diagnosis coding practices.

Product and Service Diversification

Just as stand-alone hospitals, research institutes, and practices have evolved into the geographical and specialty spanning health systems we know today, payers and MCOs are also on a similar strategy path.

Yes, collaboration across sectors is key to achieving the Quintuple Aim; but from an organizational strategy to compete in the current market and meet the demands of the healthcare system and needs of consumers, direct control over all patient, revenue, and data lifecycle touchpoints is sometimes favorable.

If you keep the pulse of industry business news, you will see constant acquisitions of specialty and innovative provider and technology companies by the payer sector. The American Hospital Association published a study that examines physician acquisitions from 2019-2023. This study revealed that insurers are a larger driver than hospitals in physician acquisitions. In fact, hospitals aren’t the nation’s largest single employer of doctors — payers are.

In another approach, we also see that provider-owned plans are expanding as their provider arm expands geographically. Provider-owned or -sponsored plans cover millions of people. The distinct lines between payer and provider have already started to blur. For these growth strategies to be successful, payers need leaders who thoroughly understand the provider settings they are acquiring.

According to Harvard Business Review, 70-90 percent of business acquisitions fail, and the catalyst is usually issues related to integration of the acquiring and acquired companies. HI professionals are already a trusted, integral part of the provider landscape; it only makes sense to have them routinely be part of the landscape that employs the most providers: payers.

Stephen A. Young, RHIA, MBA, MSS, is director of records management organization for the enterprise risk management division of the AmeriHealth Caritas Family of Companies.

Statements of law, fact, and views expressed are those of the author individually and are not the opinion or position of AmeriHealth Caritas Family of Companies, its parent organizations, or its affiliates. The AmeriHealth Caritas Family of Companies does not endorse or approve, and assumes no responsibility for, the content, accuracy, or completeness of the information presented.