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Post-Acute Care Preferred Provider Networks

The development, implementation and management of Post-Acute Care Preferred Provider Networks is beginning to resemble contracting in the Pharmacy benefit world working for the Status of Preferred or Tier 2. It was always the goal as a prior Managed Care Director to get our products covered in that coveted position of "preferred".

Narrow networks or formularies are one way that Plan Providers can help to contain and control costs, maintain a level of quality to meet their required outcomes and metrics and offer incentives related to rebates based on market share percentages. Several different Pharmacy Benefit designs, dependent on the positioning, tier, step edit with a PBM and/or MCO can become very complicated and overwhelming in calculating rebates based off of Wholesale Acquisition Costs.

Where are we headed with the narrowed networks of Post Acute Care Preferred Providers and will we eventually get to a place that in order to participate in this network, Health systems may involve additional models for increasing revenue by market share percentages? Will someone manage that for them? Similar to the gain in power of PBM's within the Healthplan world, who offer not only the ability to provide tighter network control but also analytics back to the plan related to the Pharmacy benefit. There will be incentives down the road related to the providers in the network for gain sharing, however is there opportunity for the Health Systems to explore getting more creative?

Out of change and challenge, comes opportunity for new companies, programs or organizations to help systems unaccustomed to managing network providers with an outsourced solution. Help them get the job done within an Alternate Payment Model including avoiding costly penalties. Analyzing data, predicting risk and predicting patient response related to care transitions associated with Bundled Payments is not yet the expertise of many large Health Systems. CMS is serious with an aggressive timeline, rolling out Cardiac Bundling Demonstrations in 2017, their timelines march on. Large systems are just beginning to get their arms around their own assets including bridging gaps with their internal processes and departments. Who will show up as the Knight in shining armor to help get them successfully to the finish line and take this large burden off?

Large Health Systems are notorious for silos, not oversight and connection between departments and integration of post-acute care providers. Is this a challenge we need to be concerned about, yes however it is a reality that everyone in the business of Healthcare today must do a deep soul search and recognize what they do well and where they need help. Transparency is more critical than ever before as well as knowing who and what you need to fill in those gaps, make you successful and transition you to the next phase of Healthcare reform. All Board retreats really should include an outside strategist that helps the system and/or provider "get real" as they say, so you can identify where you are today, where you need to be tomorrow and how you plan to get there.


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