Providing patients access to innovative medical devices
We had a virtual meeting with Mike Simon, founder and CEO of PRIA Healthcare, to discuss his company’s business model and how Salesforce Health Cloud has been central to efficient and scalable operations.
How the Affordable Care Act changed the landscape
Prior to the ACA, insurance companies mitigated their risk by selecting healthy patients. Thus, when a provider asked for coverage on a medical device, it was almost always granted. There was only a 4% denial rate of prescribed treatments.
In other words, providers almost always received in-demand medical devices when they asked for them. Payers complied with the needs of providers and patients, and innovation thrived within the healthcare industry, to the benefit of millions of patients.
Since the ACA, many more patients have had access to affordable healthcare. However, insurance companies have been much more selective about risk. The denial rate for prescribed treatments has skyrocketed—all the way up to the current 32%. This form of risk management is known as utilization management.
The process for appealing on behalf of a patient is complex and can require a high volume of clinical data. A number of parties are involved.
In 2012, Mike Simon recognized that there was an opportunity to help the three parties involved in an appeal of denied care:
- The patient, who is appealing the denied care
- The provider, who submits the information about the patient and the product or procedure needed
- The device manufacturer, which is looking for greater adoption of their innovation(s)
The business began as a paper and fax based system. As part of the appeal process, they had to gather a lot of clinical data—sometimes hundreds of pages.
After a year and a half, it became apparent that the business model would not be scalable with manual systems in place. For example, it became increasingly difficult to keep patients apprised of where their case stood in the appeal process as PRIA’s client base grew from hundreds to thousands.
Mike and his team realized that they had to put a database along with process automation in place—a solution that they could tailor to PRIA’s unique needs. The team looked toward CRM products, and after researching vendors, PRIA decided on Salesforce Health Cloud for the company’s operational platform.
PRIA’s Salesforce Health Cloud based solution
The first order of business was to create a structure for managing and linking information about all involved parties—including payers—within Salesforce. Next was making the transition from a high volume of paper to data records and electronic file management.
With Salesforce Community Cloud, PRIA was able to centralize the flow of messaging among physicians, patients, and medical device manufacturers. Providers were now able to submit cases through a Community Cloud portal.
Using Salesforce’s outbound functionality, PRIA could also send updates to different parties as email alerts.
The benefits to a device manufacturer working with PRIA now included:
- Avoiding exposure to HIPAA regulations, which are now covered by PRIA
- Shifting the appeals process to PRIA
- Access to highly efficient process management
- Integration of a direct data feed that populates the device manufacturer’s systems with updated status
While Salesforce-to-Salesforce is the easiest form of integration to set up, J2 has built integrations between Salesforce and other systems as well.
Ongoing Development & Support
As PRIA’s requirements evolved, Mike and his team realized that they needed to find a partner with a deep understanding of both the healthcare industry and of Salesforce. They also needed a partner with the developer skills and experience to protect health data with Salesforce Shield.
PRIA chose to partner with J2 Interactive.
– Michael Simon, Founder & CEO, PRIA Healthcare
Today, PRIA has two in-house program managers but works with J2 for all their development needs. J2 has helped with integrating their clients’platforms, whether they are on Salesforce or another application.
The system continues to evolve, and we’re building new integrations with device manufacturers on a regular basis.