Those accountable for a system of care have an interest in managing services to maximize the potential for wellness in community settings. Promoting care in the least-restrictive environment possible is more recovery oriented than providing avoidable inpatient care, and it has been enshrined into law by the U.S. Supreme Court’s Olmstead decision. Community-based care is also less costly than higher levels of care. Thus payers and clinicians have aligned incentives for reducing possible excessive use of acute care services, such as emergency and inpatient care.
Payers have developed many sophisticated data-driven methods for monitoring network performance; however, these analyses are often based on financial claims data, which may lag behind the services provided by as much as 90 days. This delay makes it difficult to address problems early. Furthermore, such efforts may not fully realize the potential for providers at ground level to contribute additional context and ideas...
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