How Evidence-based Solutions Are Optimizing Healthcare Quality and Efficiency

The obstacles faced by health plans, ACOs, and other payer organizations today come on many fronts:

  • Compliance with government mandates/regulations
  • Implementing value-based reimbursement and encouraging provider collaboration
  • Better leveraging of internal data to improve the quality of care and lower costs

Cobbling together solutions to address each of these issues involves time-consuming research and often requires creating a patchwork of tools which neither speak the same technological language (or which are difficult to integrate with existing IT systems). Eight of the largest U.S. health plans have turned to MCG Health and its portfolio of evidence-based solutions to help navigate toward optimized care delivery which focuses on compliance, quality, and efficiency. The positive results of improved outcomes using MCG are both concrete and measurable; many MCG clients regularly attend the company’s annual Client Forum event to report on the extraordinary success they’ve achieved by incorporating MCG into different aspects of their organizations such as utilization management, case management, and financial analysis.

Clinical Content Should Support Compliance and Quality: Utilizing medical necessity criteria can give health plans, ACOs, and other payer entities a powerful documentation tool to justify the appropriateness of member treatment. Updated annually, MCG care guidelines are available in robust, evidence-based content volumes for virtually every healthcare setting including but not limited to Inpatient and Surgical, Ambulatory, Behavioral Health, Recovery Facility, and Home Care. MCG also has unique care plans such as Chronic Care (long-term care support) and Transitions of Care (support for moving members between various levels and settings of care). All MCG content volumes are developed with consideration to U.S. government regulations such as the Mental Health Parity Act (MHPA) and can be used to support efforts to achieve accreditation/certification through NCQA, URAC, and the Joint Commission. MCG has also been conscious to layer in tools guidance around opioid management across all content volumes to better support payers and government services as they struggle with addressing the Opioid Epidemic.

One of the goals of evidence-based guidance is to reduce avoidable hospital readmission, and many MCG clients who leveraged these offerings saw metrics improve within six months. MCG also added all appropriate NCDs (National Coverage Determinations) with convenient search logic to allow quick access to Medicare determinations as the aging population increases and health plan staff must accomplish more within allocated resources.

Software Integration to Improve Communication and Collaboration: Once you have the criteria, you need quick and easy accessibility for staff to leverage this content. A suite of software solutions exclusively for payers called MCG Cite allows interactive access to guideline content via Cite CareWebQI and leverages the same content to automate the prior authorization process via Cite AutoAuth. Medical determinations can be customized to auto-approve or pend for a Medical Director’s review allowing a health plan to maximize the efficiency of its employees. In addition, the MCG Cite suite can integrate into nearly all of the leading UM software and workflow management platforms giving health plan employees a simplified process which reduces the need for phone calls and faxes. Special integration solutions such as Informed by MCG for Disease Management (designed specifically for chronic care treatment) and Informed by MCG for Behavioral Health have been offered as standalone solutions for health plans needing more targeted criteria that is a seamless part of their workflow. Having the ability to communicate medical necessity decisions to providers in a timely fashion can help encourage collaboration and relieve potential abrasion.

Unlocking Insights in Your Data to Reveal Areas of Focus: Last year, MCG partnered with the widely respected Milliman actuarial firm’s MedInsight division to produce a new solution called Guideline Analytics. With its unique grouper identification technology, Guideline Analytics can filter an ACO or health plan’s claims data to identify areas of opportunity for cost and quality improvement. MCG also offers benchmarking data for commercial and Medicare populations to allow a health plan, ACO, or payer entity to access length of stay benchmarks of other regions to identify areas of unexplained clinical variation for specific procedures. MCG also offers a software solution, Interrater Reliability (IRR), which allows an organization to monitor and test employees ensuring MCG criteria is being applied consistently. IRR also supports meeting URAC and NCQA requirements by documenting the consistent and appropriate use of nationally recognized guidelines through rigorous testing of the staff’s ability to find the right guideline sections and apply them appropriately to a clinician-written case study.

The arc of member care is complex and challenging, but having the proper solutions to apply at vital points along that journey can be an effective means of cost control, regulatory compliance, and quality improvement. MCG is continually developing new solutions to help health plans, ACOs, and payer organizations meet the demands of today’s market and increase member satisfaction. To learn more about MCG, visit www.mcg.com.

Article image courtesy Shutterstock/Uber Images


MCG Health, part of the Hearst Health network, supports payer organizations and government contracted entities with evidence-based criteria, analytics, and software solutions that proactively and efficiently move patients toward health. MCG’s transparent assessment of the latest research and scholarly articles – along with data analysis – gives our clients the vetted information they need to feel confident in their care management decisions. Eight of the largest U.S. health plans and more than 1,700 hospitals use our evidence-based guidelines and software. Learn more at MCG.com.

This article was created in collaboration with the sponsoring company and our sales and marketing team. The editorial team does not contribute.