November is recognized as Diabetes Awareness Month, a critical reminder of the pervasive health challenges and associated financial burdens facing every payer. For executives managing provider networks, chronic conditions like diabetes are not just clinical issues; they are the single greatest driver of utilization, cost volatility, and Medical Loss Ratio (MLR) instability.
This is where network intelligence becomes essential. Managing a condition that affects over 37 million Americans requires moving beyond compliance checks and retrospective reports. It demands an in-depth analysis of provider performance and contract efficiency across the entire continuum of diabetes care, from primary care adherence to specialist referrals and inpatient admissions.
Connecting the Dots: Adequacy, Quality, and MLR
For a health plan, an ineffective network management strategy can turn chronic care into a liability in three major ways:
- Access Barriers and Hidden Costs: If members cannot easily access primary care physicians or endocrinologists, routine management fails, leading to costly complications and avoidable emergency department visits. Poor access and adequacy reporting directly translate to higher downstream costs.
- Unmanaged Unit Costs: Networks that lack insights into unit cost variation across diabetic supplies, pharmaceuticals, and ancillary services will inevitably overpay. Cost and contracting intelligence must pinpoint and renegotiate arrangements with high-cost providers that exhibit poor patient outcomes.
- Quality & Performance Gaps: The network must actively steer members toward providers with demonstrated success in HEDIS and STAR metrics for diabetes care, such as A1c control. A lack of quality and performance analytics means clinical resources are being spent without improving outcomes, impacting quality bonuses, and member health.
TOG Network Solutions equips executives with the tools to stabilize these risks. Our integrated platform provides real-time market visualization and financial simulations, allowing plans to design and build networks that reward superior performance and actively guide members toward cost-effective, high-quality diabetic care. This strategic approach ensures your network is actively supporting your financial goals while delivering on your mission of superior member health.