Beyond the Status Quo

We have been conditioned to expect that “best” equates to positive, desired results. Whether in sports, business or healthcare – we strive beyond good or better and desire the “best.”  But implementing accepted status quo best practices doesn’t guarantee optimum results. History is scattered with epic examples of “best” induced stagnation or worse outcomes.

President George Washington’s 1799 treatment led by his personal physician James Craik for a throat infection (acute bacterial epiglottitis) was tragic. Our country’s first leader had the best clinicians, received the best accepted treatments, resulting in the worst avoidable outcome. He was first given the clinically accepted concoction of molasses, butter and vinegar, which choked him as he struggled to swallow. Then over 40% of his blood volume was excruciatingly drained from his body. We now know this would have driven his body into hypovolemic shock. As he quickly deteriorated, cantharidin (which causes chemical burns) was applied to his throat, further hampering his ability to breath. Clinical norms having been correctly applied and facing a failing patient, his doctors gave George Washington an enema – and he died. The sad takeaway is that if he would have received no treatment and had been allowed to simply rest, he would have recovered.

Don’t be smug thinking, ya well that was over 200 years ago and we clearly would never settle for practices causing harm or at the least which are mediocre. After all, we are much more enlightened. But now more than ever, with multiple forces impacting healthcare, we need to fracture accepted processes to think differently. We should be like Will Smith’s character in Hitch, who cries out with searching heart felt pain, “what if best just isn’t good enough?”

At Coventry, we’ve felt compelled to move beyond the complacent status quo to shoot for implementing, “Wouldn’t it be cool if we…” Our leadership team empowers us to think differently and be willing to fail in the pursuit of breakthroughs, but fail fast, learn and move on to innovative breakthroughs which will benefit our customers. Coventry has been emboldened to inject pragmatized realignment into the healthcare ecosystem leading to enhanced value outcomes. A transformative mindset has specifically altered Coventry’s look at provider demographic currency (think directories), data use, and client service support functions. Although the industry status quo had been successful for Coventry in the past, there has been a push to pivot toward disruptive opportunities to further enhance quantifiable deliverables for our customers.

Previous industry models for achieving accurate channeling directories involved: provider self-reporting, many outreach calls to provider offices, accessing available data sources, emailing medical offices and physical mailings to confirm demographic updates. The highly transitory nature of medical practices led to an industry mindset that to be the “best” with provider directories, you just had to do “more and more often.” But you could never scale up enough to fully impact accuracy. You simply would be “less bad.” And increased outreach has the unintended consequence of provider abrasion, similar to annoying telemarketer phone calls during.

Coventry has pivoted to a different model of provider data innovation to support adjusters, nurses and injured workers. This approach aggregates data currency from all of Aetna’s businesses (and data inputs), as well as all the historic networks we’ve combined into what is now known as the Coventry Integrated Network®. The combined provider data is then injected into machine learning to integrate vetted external sources to derive better search outcomes. Our expanded relationships with third parties have been folded into the process to further enhance the accuracy of the provider directory information. An ongoing evaluation of HIPAA compliant block chain opportunities is also under way. The expansive approach has been reflected in a current audit showing an increase to 90% accuracy. Improving provider data currency has led to decreased administrative costs and improved user satisfaction.

In conjunction with a modified approach to provider demographic currency, Coventry has coupled its massive data warehouse and machine learning toward predictive models which can quickly detect inappropriate prescribing patterns or at-risk patients. Application artificial intelligence (AI) is coupled with Coventry’s data models to enhance the monitoring of our network and medical claim outcomes. We use machine learning tools to identify previously undetected patterns or potential waste, fraud or abuse. Coventry’s data capabilities assist in pointing claims toward case managers early in the episode to prevent claims from “sneaking up” with adverse surprises and allowing time for early interventions.  In addition to a claims’ focus, the combined enhanced data is being used to identify providers who consistently demonstrate excellent outcomes for client channeling to maximize patient outcomes.

Focusing on client needs, clarifications or requests is managed by a service team whose metrics aren’t driven by the length of calls, the number of interactions or solely deferring to automation as a “fix all” (what the industry may view as the “best”). The team’s philosophy is to “be the solution.” They are mindful to uncover root causes whereby preventing downstream issues from materializing. Clients are assigned a dedicated e-mail address and are supported by client-based teams. The team members are specifically trained for nuances unique to their assigned client. Each team member is tasked with the responsibility of being, “the last stop for gas over a long bridge, the last chance to get it right.”

The philosophy of owned responsibility for interactions is in contrast to an industry perspective driven by both automation and episodic issue interactions. Coventry’s service team members are encouraged to look for anything which may seem odd in their provider interactions beyond the initially stated issue and pursue the expanded matters to resolution. The broader perspective builds in a holistic approach and supports proactive demographic data accuracy. A more comprehensive outcome approach advanced the team’s Coventry Connect capabilities allowing adjusters to directly submit requests and updates, thus facilitating self-service transparencies. The capability saves clients’ time and supports quicker access to information. Open communication extends to the service team’s leadership participating in inclusive provider network meetings to ensure a broader client support perspective and prevent the dreaded knowledge “silos.”

As both a client and provider facing company, Coventry continues to embrace opportunities to perform beyond the industry’s status quo.

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