Community Health Network Development

A rural health network or community health network is a local, facility-based, preferred provider network that is used to provide a platform for direct-to-employer contracting and deployment of locally directed narrow networks with the various carriers.  As the Affordable Care Act makes self-funding an attractive option and consequent explosion of carrier-developed narrow network plans, more health systems across the country are developing their own network options for both business development and ‘revenue stream protection’ purposes.  Creating a strategy, infrastructure, and execution of a Community Health Network that best-suits your community is where we come in.

SHP’s involvement in the development can be as follows:

  • Overall strategy development
  • Provider solicitation
  • Network infrastructure development: From developing provider demographic data base to acting as a conduit to share payer issues and resolve claims issues
  • Network contracting: Modeling, language review and negotiation, and rate negotiation

However, before moving forward with such a strategy, the operations and network management capabilities must be thoroughly assessed. Key questions to ask that SHP can assess as well as implement and manage:

  • Is there a provider database in place to maintain required demographic information?
  • Are proper credentialing policies and procedures in place?
  • Are there sufficient reporting capabilities to supply monthly downloads to third-party administrators as required?
  • Do claims resolution capabilities, skill sets, and process exist?
  • Is there a help desk function for network member questions and issues?

First, we look at how we can assist in determining market uses for such a strategy.  Feasibility and local conditions for:

  • Direct agreements with large employers
  • Carrier agreements for fully insured products
  • Health exchange products
  • Medicaid Care Management Organization products

While assessing such external conditions, we evaluate internal feasibility as well:

  • Evaluate CIN market strategy in line with overall growth strategy of Health System
  • Determine other health plan ancillary relationships necessary to effective reach market with single stop approach
    • Third party administrator(s)
    • Disease management/high cost case management
    • Stop loss carriers

We then move forward to contract execution:

  • Contract with payers to deploy relevant market products
  • Negotiate agreements as appropriate with selected payers (both direct and carrier agreements)
  • Model rates to support negotiations, for both hospital and physicians

Developing a Community oriented network strategy is a very smart, financially sound, and patient focused initiative.  Going down the due diligence path will force your organization to review internal processes that will only benefit all involved.  It’s certainly a worthwhile endeavor and one SHP is prepared to assist.