For healthcare providers, prior authorization (PA) via fax or telephone is the second most costly medical administrative function. On average, medical staff spend two business days per week on PA. Automating PA while maintaining clinical excellence is essential for better care delivery. With a focus on leveraging digital solutions and fostering data-enabled decisions, Magellan Healthcare is building more provider-friendly approaches to improve care.

Recently Magellan announced a collaboration with Stanson Health, Premier, Inc.’s clinical decision support (CDS) technology division, to deploy DecisionPoint, an industry-leading automated PA solution. Powered by Premier’s CDS technology, DecisionPoint is available at the point of care and supports true automation within the electronic health record (EHR) and the physician workflow, making the PA process easier and more efficient for providers, patients and health plans.

DecisionPoint is built with Magellan Healthcare’s Advanced Imaging Management program clinical guidelines and Premier’s award-winning technology platform. Magellan maintains one of the industry’s most comprehensive evidence-based sets of clinical guidelines. Our clinicians develop our criteria through an extensive process of innovation and refinement. We base these guidelines on the analysis of public, peer-reviewed articles; health plan medical policies; the Centers for Medicare & Medicaid Services (CMS) policies; specialty physician reviews, professional society guideline statements; and other rigorous reviews of scientific documents. We continually monitor peer-reviewed literature, professional society guideline statements, and CMS-covered criteria to update our guidelines regularly, no less than annually. Initially, DecisionPoint will include our suite of the 20 highest-volume advanced imaging studies that make up 85% of all requests.

Working directly in the EHR, DecisionPoint guides provider decisions in real time in response to key workflow events, such as ordering an advanced imaging study. Integrating within the EHR improves efficiency while ensuring safety and quality and reducing undesirable variation in care.

Rules-based programming leverages EHR data, locating all relevant patient clinical information and citing appropriate Magellan clinical guidelines. Requests that satisfy the clinical guidelines are automatically approved and posted in the EHR, and approval IDs are automatically loaded to the record. With a confirmed authorization determination, the member leaves the appointment with a clear plan of action.

Hawai‘i Pacific Health (HPH), one of the largest healthcare providers in Hawai‘i, is leading the way in automating prior authorization by piloting DecisionPoint to help ensure their patients receive real-time, evidence-based decisions at the point of care whenever possible. Administered through HPH’s Accountable Care Organization (ACO) with over 800 physician members, the pilot leverages Magellan’s clinical guidelines and our full panel of clinical experts. We expect DecisionPoint to be available to additional providers in the fourth quarter of 2019 and include additional specialties and tests in the future.

The healthcare industry is in the midst of a significant paradigm shift as it transitions from a fee-for service model to value-based care. As a technology-augmented service backed by the support of providers, DecisionPoint is designed to minimize the industry’s challenges by fully integrating with EHRs at the point of care to enable faster PA and help deliver on the triple aim—improved quality, reduced cost and improved patient/provider experience.

To learn more about DecisionPoint, click here to go to our website, or email ProviderSolutions@MagellanHealth.com.

Prior authorization (PA) goes by many names—preauthorization, preapproval, advance notification, precertification and preadmission, to name a few. All these terms refer to the utilization management (UM) process used by many U.S. health insurance companies to ensure patients receive the right services, equipment and prescriptions at the right time and place. PA requires healthcare providers to request and obtain approval before rendering certain services, equipment or prescriptions in order to receive insurance reimbursement for those services. Not everything requires PA. Typically, authorization is needed for more complex services such as hospital admissions, diagnostic tests, medical equipment and complex prescription medications.

The PA process is intended to act as a safety and cost-saving measure. It can lower costs to the patient, prevent unnecessary or invasive procedures, and reduce the use of unnecessary tests that may expose patients to potentially harmful radiation and/or undue stress. For example, up to half of advanced imaging procedures ordered fail to provide information that improves patients’ welfare.[i] In addition, despite studies demonstrating overuse, rates of advanced imaging procedures continue to rise—increasing costs and exposing consumers to excessive radiation.  Despite its benefits, the prior authorization process needs an upgrade.

According to the 2018 CAQH Index , manual prior authorizations (via fax or telephone) are the second most-costly medical administrative transaction, costing providers $6.61 per submission. Providers estimate their staff members spend up to 30 minutes completing one manual prior authorization. While manual prior authorization is a much-debated topic due to the time and cost it requires, many parties support standardizing and simplifying the process.

Technology can significantly  decrease the need for expensive manual processes.  According to the 2018 CAQH Index, the medical industry could save $417 million annually by transitioning to electronic prior authorizations, which includes $278 million in annual savings for providers and $139 million for health plans.

While many health plans offer web portals to process prior authorizations, this approach requires providers to use different online systems for each health plan. Instead, digital solutions should include automation within the electronic health record (EHR) and the physician’s workflow. Automation is essential to reducing inefficiencies for providers and health plans and enabling authorizations at the point of care while maintaining clinical integrity.

The goal is to make the right decision for each patient—quickly and easily so patients get the care they truly need. Automating prior authorizations will benefit everyone involved.

[i]Beachy, D. (2014, September 8). Defensive medicine driving up wasteful imaging. Retrieved from https://www.healthimaging.com/topics/healthcare-economics-policy/defensive-medicine-driving-wasteful-imaging.

Patient management programs are important for both payers and patients. Successful patient management programs can improve health outcomes and quality, increase member enrollment, and improve member satisfaction, all of which support the health plan. The goal of a successful patient program is to improve the quality of medication use and the overall health and wellness of the patient, and this can be achieved through patient engagement and empowerment.

Knowing all of this, the challenge for a patient management program is often getting patients to participate. Traditionally, this has occurred through live and/or automated telephone calls and mailed letters to the patient, and additional faxes to the patients’ providers. These approaches have varied engagement results, and there are growing concerns that there is a ceiling to how many patients can be engaged through these modalities.

Adults are working longer into life than ever before, making them harder to reach and talk to during traditional business hours. In addition, letter campaigns become more and more costly as postage rates continue to rise, and a growing interest in “going green” makes mass mailings appear wasteful.

Newer technologies and the prevalence of mobile devices present new opportunities to engage patients, particularly the millennial generation that are now becoming patients themselves.

Today’s patient likely has a smart phone and may also have a tablet and/or wearable device, all of which provide a means to communicate with his/her provider(s). With that in mind, here are several ways that patient management programs can evolve using technological advances:

Text Messaging – Text messages have become the go-to method of communication for many people. Responses can typically be received in a matter or minutes, and even “busy” patients can text when a phone conversation may be a non-starter. Beyond one-way alerts and reminders to the patient, two-way exchanges and even live chat features are available.

Video Conferencing – For patients who may be not wish to text, online video capabilities allow for face-to-face counseling between clinicians and patients, even if that consultation isn’t in a conventional setting. As opposed to telephone calls, video chats allow for perception of non-verbal cues, assessment of physical symptoms, and even walkthrough tutorials, like injection training.

Artificial Intelligence (AI) – AI can range from predictive modeling and analysis used to predict potential adherence issues, to apps that can monitor, track, and measure adherence through features like facial recognition, digital pills, and more.

Video on Demand – Consumption of video content via mobile devices is as common as ever, and there are services available which can provide patients with additional drug information that can accessed whenever, wherever. These videos can reinforce talking points covered during consultation and provide a compliment to education provided through patient management programs. It also allows for information to be shared in a paperless way.

Senior Whole Health, a wholly-owned subsidiary of Magellan Health, has a core mission of addressing the social and medical needs of individuals eligible for Medicare and Medicaid, with a special focus on putting services in place to allow elderly individuals to remain safely in their homes for as long as possible.

The average Senior Whole Health member is 76, female, has several chronic illnesses, and takes five or more medications. In spite of the fact that many members have home-based community services and regular nursing visits, a majority of the admissions for hospital and emergency department care are unexpected. While it is not feasible for all high-risk members to have a daily evaluation by a clinician, Senior Whole Health is implementing a program of passive home monitoring for select high-risk members allowing for early detection of changes in behavior that identify when an individual is at risk for hospitalization. With prompt interventions by clinical staff, trips to the Emergency Department and/or Hospital can be averted.

The program being used by Senior Whole Health is called Lively® Home, a GreatCall product offering. With advance permission of the member and their family, a suite of 10 passive sensors is installed in the home. Activities of daily living such as getting into and out of bed, using the toilet and opening the refrigerator are monitored, allowing for a normal pattern of activity for an individual to be modeled. In the event that the individual’s behavior pattern changes (such as staying in bed much longer than usual or using the refrigerator much less than usual), an alert is sent to clinical staff, allowing for a wellness call to the member to check on their status. Often a medical condition can be identified and treated in the outpatient setting, avoiding more serious outcomes including hospitalizations and/or premature nursing home admissions.

Seniors have listed losing independence as among their greatest fears of aging. The use of passive monitoring technology such as Lively® Home along with direct in-person support services is expected to further extend the ability of high-risk Magellan Health members to live safely and independently as long as possible at home.

Is it necessary to explicitly focus and call attention to the obvious fact that I am a woman in technology? You might not think so these days. Women have accomplished so much since the first bra was burned, that it would be understandable if you believed that we have established and gained enough ground to just be people in technology.

The reality is, unfortunately, there remains a staggering degree of inequality. Last month, the New York Times published an article titled “The Top Jobs Where Women are outnumbered by Men Named John.” The article reveals that there are fewer women among Chief Executives of Fortune 500 companies (5%) than there are men named James (5%); fewer female Venture capital investors in the largest tech deals of the last five years (9%) than there are men named David, James and Peter 11%.

You may giggle at first when reading the article, but its conclusion is stunning: it is more likely that the names of the men in charge will change sooner — fewer Johns and Roberts and more Liam’s and Noahs — than the number of women.

This is a reality that we cannot ignore, and one that exists all over our industry. While some of us women may not “feel it” as much as others, we are all still subject to “it.”

The World of Economic Forum’s 2016 Industry Gender Gap report recognizes that in “nearly all industries and geographies there has been a marked shift away from deliberate exclusion of women from the workplace, there continue to be cultural beliefs that lead to unconscious biases. This includes perceptions that successful, competent women are less “nice”; that strong performance by women is due to hard work rather than skills; and assumptions that women are less committed to their careers.”

We women have all felt this. The one woman that can be “tough enough” always gets through, but not all of us. We internally debate with ourselves whether to be more like our male counterpart in order to simply be heard in a meeting. Sometimes it is a question of style, but more often than not, we don’t have a seat at the table. And when we “power through it all” we still struggle to find a lot of role models to look up to.

I personally attribute my success to relentless stubbornness, shameless self-confidence (which often gets mislabeled since I am a woman) and sometimes blunt confrontation. Still, many times throughout my career I was asked to sit on the sidelines. I was encouraged to “focus on my wedding planning activities, rather than worrying about a promotion” which by the way I well deserved and earned.

At Magellan, we have decided that the only way to overcome these inequalities is to take them on proactively. That is why, in 2018, we have formed an internal ‘Women in Technology’ (WIT) change leadership group.

Being at a company that is not only willing to discuss and support a Women In Technology group, but is actually ready to “put their money where their mouth is” is refreshing.

The WIT group we established has taken off and I am so happy to see the responses, the community and the peer (gender agnostic) support we are offering to women across Magellan IT and beyond.

Our group is not exclusive to women, in fact we need everyone involved to truly make a difference, because our goals are critically important:

• We are focused on fostering female employee development and growth across the IT organization.
• We want to see more of us out there – we want our talent pipeline and the recruiting tactics to bring women to the table.
• We aim to encourage young women in the middle and high schools our communities to consider, try and stick with STEAM (Science, technology, engineering, arts and mathematics).
• We want to support each other through peer-mentoring.
• We want to bring role models forward to provide insights into the possibilities.

Ultimately, we want a future where being a woman in technology is not a heroic accomplishment, and super powers are not needed to claim our earned and well-deserved seat at the table.

Our own Seth Feuerstein spoke recently at the APA annual meeting about how Digital Mental Health Care is increasing access and delivering positive outcomes.

“Here’s what’s interesting…subjectively, patients described [the digital program] as by far the most positive experience they have when they go to that center,” said Feuerstein. “Their engagement with it was kind of off the charts.”

You can read about Seth’s comments and more at the American Journal of Manage Care by clicking here

Note: This article originally appeared on LinkedIn, you can read it there by clicking here.

You cannot escape the responsibility of tomorrow by evading it today – Abraham Lincoln

On one of my many cross-country flights, I started to think about how the concept of employment has changed dramatically over the course of my thirty-year career in the US. In this time, information technology and globalization have changed how business is done, increased competition and improved workforce productivity in every industry. These forces have dramatically changed the employer-employee compact*, doing away with stable jobs, lifetime employment, pensions, and predictable career advancement. These have been replaced by a dynamic, ever changing, ever evolving workplace. It’s not a stretch to say the Future of Work is very different, it is emerging and changing right in front of our eyes, and it requires:

• New skills: Students going through school will very likely be in a job that hasn’t been invented yet and more than a third of the job skills that will be needed in 2020 are not considered crucial to the jobs of today
• Curiosity and Continuous learning: These same students are learning core curriculum content that will be out of date by the time they graduate. They need to develop the capabilities to make learning a life-long activity that they enjoy
• Resiliency and Adaptability: Provide the skills required to adapt to careers that have 10-12 job changes in their career and possibly change their career 3 or 4 times, and
• New models of employment: Many individuals with specialized skills will see their career as a series of “Tours of duty”, with a newly defined Employer-Employee compact*. Other employees will expect the flexibility to have more than one gig at the same time enabled by the Gig Economy.

The Workforce of the future is made up of tech savvy digital natives who are always on and always connected. They flow between work activities, personal tasks and gigs that fulfill their need for artistic, financial, security or other needs. These employees are highly adaptable continuous learners, who have a breadth of skills across multiple domains. Organizations need to have a different view of their workforce and talent. They need to plan for employees who:

• Seek a higher purpose and “meaning” to the work they do and balancing that with what they are good at and at the same time enjoying what they do (The Japanese call the “ikigai”)
• Want to pursue multiple jobs/roles/gigs that align with their values and needs
• Prefer to work from anywhere, at anytime through different modalities – work from home, co-working spaces, all-inclusive campuses or traditional workplaces
• Look for the work to come to them as opposed to moving their families to where the work is and spending several unproductive hours commuting in big cities. The nature of work today is increasingly digital, distributed and not constrained by geographical boundaries, it goes to where the skills are
• See work and life as two sides of the same coin. These employees go beyond traditional notions of work-life balance and embrace work-life flow where they work where they want and can handle their personal life when they need to.

At Magellan Health, we believe that communication, collaboration and community are core basic human needs. We believe that collaboration is a highly personal and uniquely human experience that is critical for us to achieve our Massive Transformative Purpose (MTP) of “Leading humanity to healthy, vibrant lives”. Our challenge was to see how we could build a collaboration platform that took advantage of the strengths of this workforce and addressed some of the opportunities and constraints that come with the workforce of the future.

In late 2016, we introduced Magellan Hub, our platform to enable the workforce of the future and make them thrive in the Fourth Industrial Revolution (4IR). Magellan Hub was designed with five foundational principles:

1. It had to be humanized, personal and democratic – the platform needed to be personal in a way that it gave every individual within the organization a unique voice that was their own. It also needed to be representative, self-governing and participatory (collaboration is not a spectator sport). It also should NOT allow for anonymous participation.
2. It had to support emerging modalities of communication – the platform had to go beyond Web 2.0 technologies to include emerging modes of communication including Groups/Communities, Videos, Group Chats, Video and Audio Conferencing, desktop NLP, and Chatbots
3. It had to bridge distance and time – In other words, it had to retain the context of conversations, the history of events and be searchable. In addition, it had to have the flexibility to support real-time and delayed interactions at the same time
4. It had to be everywhere and nowhere – this allowed people to be always connected when they needed to be and completely disconnected when they wanted to be. This enables both pull and push communications where users could opt-in to the content they wanted to see.
5. It had to be future proof – The platform had to be scalable to support our growth and be accessible from anywhere, at any time over no, low and high-bandwidth connections.

We believe in Magellan Hub, we built a platform that supports the workforce of the future to effectively handle the future of work. Here are a four examples:

• When Dana, a new employee joins Magellan, she is instantly connected to the broader community across Magellan. She has the choice to share what she wants to share, develop her unique voice and influence the dialog of her colleagues, her team or the entire company. She can subscribe to the content she wants to see, groups she wants to join, formal and informal leaders she wants to follow. In other words, Dana immediately becomes part of the Magellan Community the minute she gets an ID to access Magellan Hub
• Steve, a long-term Magellan employee, spends most of his time in infrastructure operations and is focused on his day-to-day tactical tasks. With Magellan Hub, Steve can be part of groups that are focused on the projects he is working on to stay in sync with the rest of his team irrespective of where they reside or work from. He can also join special interest groups around technical domains or social domains (such as Magellan Musicians) to connect with others with similar interests. He does all this on his Android smartphone as he is running personal errands working out of his home office.
• Lara, a highly engaged mid-level executive uses Magellan Hub to do a digital management by walking around to check on the pulse of her team that is spread across 12 states and 3 different time zones. She uses HD Videoconferencing and personal chat/video/audio conferencing through to enable these highly personal and humanized experiences without extensive travel. What’s cool is that Lara can have these humanized, high-touch interactions with her team from her home-office, from the indoor gym as she watches her kids play or from an airport as she waits for her flight to take off
• Jeff, who is a product manager developing our next leading edge Cognitive Behavioral Therapy tool can collaborate real-time with his colleagues and team members from different departments across the company to create, edit, comment on shared product specifications in a secure way. At the same time, he uses a closed and private group to discuss and collaborate on these product specifications and coordinate the development of this product across the company.

At Magellan, we are the employer of the future who is fully committed to continuously exceeding the expectations of the workforce of the future. While we may not be there yet, with Magellan Hub, we provide a collaboration platform for employees so that they can do their best work every single day and they become the change that we want to see.

References and Notes:

* Hoffman, R., Casnocha, B., & Yeh, C. (2013, June). Tours of Duty: The New Employer-Employee Compact. Harvard Business Review.

** World Economic Forum. (January 2016). The future of jobs: Employment, skills and workforce strategy for the fourth industrial revolution. http://www.weforum.org/reports/the-future-of-jobs

*** The name Magellan Hub was selected by our employees through a crowd-sourcing contest that was conducted on the platform

I have had the privilege of wearing many hats in a variety of industries throughout my career, including as an entrepreneur, executive, board member, educator, inventor and investor in technology, healthcare, biotechnology and life sciences.

I have seen the development of ideas and innovations that never had the opportunity to come to fruition. There are a number of contributing factors that impact these advancements. However, one of the most frequent causes is that inventors and researchers do not have the proper experiences, training and education to advance their ideas and work from the research setting to the patient or consumer.

In addition to my role as chief innovation officer and chief medical officer of medical and digital innovation at Magellan Healthcare, I also serve as a faculty member at the Yale School of Medicine. It is through my role at Yale that I have the opportunity to lead a unique training program for substance abuse researches from across the country in entrepreneurship starting next spring. The work of these scientists focuses on the prevention and treatment of substance abuse disorders leading to innovative options for improved care. Unfortunately, many of these innovations never reach the market because today’s scientists do not have the training in how to commercialize their ideas.

The training program, called Innovation to Impact: Translation Support and Education, is made possible through the funding of a $1.25 million grant by the NIH National Institute on Drug Abuse (NIDA). Students will participate in a free five-day boot camp on entrepreneurship and product development and will also have access to an extensive network of new venture mentors, seed funding for new ventures and training in how to promote a culture of entrepreneurship locally.  This will also help start what we hope will be an active community hosted virtually as well.

In addition to my work in developing apps and software programs designed to combat substance use disorders, I have also been teaching entrepreneurship for many years. This program is a logical next step to not only advance these innovations, but significantly help people with substance abuse disorders.

Open to researchers across the country who are focused on basic science, epidemiology, prevention, treatment and policy, the program will help advance innovations that impact the substance use field. This work is of the upmost importance as we face a national crisis on substance abuse. I also believe the future innovations of these researchers will soon impact our work at Magellan and the customers and members we serve.

Magellan makes it a priority to advance innovation, as evidenced by its support of my participation in this initiative with the NIH as well as dedicated resources through various innovation initiatives to help develop and commercialize new product ideas or services. It is rare that you find a private sector company like ours that is committed to allowing its executives to undertake educational activities when they fit within our massive transformative purpose of “leading humanity to healthy, vibrant lives.” I’m excited to continue to focus on collective entrepreneurial spirit with an amazing team at Yale to share our lessons with others and bring new ideas to light.