You are using an older browser that might negatively affect how this site is displayed. Please update to a modern browser to have a better experience. Sorry for the inconvenience!

Value-Based Care, New Business Models Demand Healthcare CRM


By: Santhosh

For most industries, Customer Relationship Management (CRM) platforms are consider core systems, powering Sales and Customer Service and other key functions.  For Healthcare providers, however, investments in CRM have been comparatively limited (overshadowed by massive EHR implementations backed by Meaningful Use incentives).  As major CRM players such as Salesforce have come to the table with Healthcare-specific solutions, leading provider organizations have begun to adopt CRM under the banner of Patient Experience.   However, motivations for the adoption of this enabling technology are more foundational in nature.  The accelerating proliferation of Value-Based Care and emergence of new, innovative business models demand CRM as a means to enable what are now requisite provider capabilities.

Value-Based Care. Though it has taken some time to develop traction since the passage of the Affordable Care Act in 2009, the transition to Value-Cased Care is real and accelerating.  Health and Human Services estimates that 59% of all Healthcare payments will be associated with a Value-Based model by 2020.  Most providers are very familiar with CMS programs driving Value-Based models.  A survey by the Healthcare Financial Management Association (HFMA) indicates 21% of regular Medicare payments are made via Value-Based agreements.  26% of Medicare Advantage agreements are Value-Based.  Commercial payers are aggressively driving the movement as well.  Aetna, as highlighted in their 2018 Health Care Trends report, has entered into Value-Based partnerships with several major integrated health systems.  On April 25th, 2018, Humana announced the launch of their Hospital Incentive Program, a Value-Based model aimed driving improved inpatient experience and improved health outcomes.  Members – major industry players, both provider and payer – of the Health Care Transformation Task Force have committed to having 75% of their businesses in Value-Based payment arrangements by 2020.

Business Model Innovation.  Another approach to fighting the rising tide of Healthcare costs is changing traditional business models.  Vertically Integrated Health Systems – organizations that encompass all tiers of care and are their own payer – are on the rise.   Pioneered by Kaiser Permanente, this approach is seeing increasing adoption in recent years.  Payers are acquiring hospitals and employing clinicians (insurer United Healthcare Group (aka Optum) recently became the nation’s largest employer of physicians with its acquisition of Davita Medical Group).  Providers are buying payers or launching joint ventures with insurers such as Banner|Aetna. These moves create economies by changing the fundamentally adversarial relationship between payer and provider to one of cooperation.

Other models, such as a subscription-based Primary Care, are taking new, larger forms.  Start-up Redirect Health, for example, offers subscription-style primary care, labs, and other services for a monthly fee, a model which it terms as “self-insurance”.  In essence, businesses and individuals pay a subscription fee for access to services (unlimited) delivered within the company’s network of providers – an expression of the Direct Primary Care model.

So, what does this have to do with Healthcare CRM?  To be successful adapting to these changes, provider practices require new or improved information capabilities.  As seen in so many other industries, automation and access to timely, germane information enables new and/or more efficient ways of doing business.  The trends in Healthcare today mean that thriving practices will require:

Comprehensive Patient Visibility.  EMR/EHR systems provide good visibility to medical records for clinicians but lack the true “360-degree” perspective.  Access to notes, history of interactions with the provider organization (not just clinical encounters), and patient-generated information are notably weak.  Flexible and user-friendly view of that data (such as a timeline perspective) are also lacking.  As Value-Based Care models focus on holistic perspective views of the patient, measuring Patient Experience, Safety, and most importantly, overall health outcomes.  Similarly, new provider models require complete views of members.  Practices need their information systems to align to these perspectives and provide a comprehensive perspective.

Access to Patient Health Records Across Organizations.  Even Vertically-Integrated Health Systems cannot insure that everyone of their patient’s health events will occur within their network, or even with their direct line of sight.  Travel or any number of circumstances can require the patient to seek care outside the network.  Gaining visibility to this data is critical to having a complete picture of the patient’s health.  Providers involved in Value-Based Care agreements must understand clinical encounters outside their purview to achieve the best outcomes (for which they are compensated).  Health Information Exchanges (HIE) exist to facilitate access to this data.  However, practical access to the data can be complex and costly with existing EMR/EHR systems.  Providers need a flexible, low-cost way to achieve the same visibility.

Improved Patient Service, Care Plans, and Follow-up.  Traditional or alternative model, All providers want to delivery the best possible care and Patient Experience.  Value-Based Care is linking compensation directly to quality measures.  More effective and efficient delivery is more important than ever.  Providers need flexible automation of processes that ensure idealized patient journeys can be delivered consistently, at relatively low cost.

Patient Population Analytics.  Clinicians and Practice Administrators must be able to understand their patients as a collective.  They must make quick and accurate assessments of risks and patient behaviors to make key practice decisions such as when/how to submit RFP responses for risk-based CMS contracts or change processes to improve health outcomes – and they must be able to do it quickly and flexibly in dynamic regulatory and payer policy environment.  Providers need systems that take the massive volumes of data that complete patient information represents and perform quick analyses and visualization.

Better Ways to Get Patients Engaged in Their Own Health.  Without the certainty of fee-for-service, providers want as much control over patient health outcomes as possible.  The one wildcard is always patient behavior – or as often labeled, Patient Engagement.  In a Value-Base Care agreement, the impact is felt directly in bottom line.  Subscription providers and Vertically-Integrated Health Systems (which incorporate the payer) lose cost-efficiency which is likewise felt on the bottom line.  Unfortunately, the provider never has direct control over what the patient does.   The best diagnoses and care plan can still fall short if the patient acts in manner detrimental to their own health.  Accordingly, any ability for the provider to influence patient behavior and participation in their own care plan issue invaluable.  Education, access to their health records, and interaction (e.g. Engagement) are the key mechanisms available.  Providers need better, more efficient ways to influence Patient Engagement.

OK.  But, again, what does that have to do with Healthcare CRM?  Healthcare CRM delivers exactly these capabilities that providers require today.  In fact, this functionality is really the heart of what CRM does.

  • The notion of the “360-degree” view of the customer (i.e. Patient) was born with CRM.  Flexible views accommodate different user types (clinicians vs. customer service, for example).
  • Modern CRM systems are built to aggregate data and can more easily integrate with external sources to access information such as HIE data.
  • Flexible Workflow and Case Management capabilities that are table stake for CRM platforms, combined with recent derivations such Salesforce Health Cloud’s Care Plan drive automation that improves care and follow-up delivery.  Patient follow-up and just about any other process can be quickly modeled and automated on CRM platforms.
  • As centralized keepers of data, CRM systems have also evolved to be ideal reporting and lightweight analytics platforms.
  • Most CRM platforms today also build in marketing automation features that offer new ways to engage patients.  Automated patient communication journeys educate and remind.  CRM Portals provide a means for the patient to access information and interact.

Point-by-point, Healthcare CRM enables each of the key capabilities providers adapting to Value-Based Care or exploring new care delivery models require.  Once a peripheral system for only large provider organizations, CRM is now a foundational need for all providers.

MST Solutions has successfully partnered with Healthcare providers to deliver integrated, interoperable Healthcare CRM solutions.  We are excited to be part of the evolving Healthcare environment and are ready to help position our partners to thrive in the changing environment.

Contact MST Solutions on this site to find out how we can help.