Archive for the ‘Guest Posts’ Category

Guest Post: The Provider’s Responsibility for Building Patient Relationships

July 31st, 2018 by Dr. Delanor Doyle

A foundational element of healthcare is the relationship between a patient and their PCP.

One of the foundational elements of healthcare is, or at least should be, the relationship between a patient and their primary care physician (PCP). And yet, it seems many Americans are not fully utilizing their PCP and instead are turning to emergency rooms or urgent care clinics for non-urgent conditions and illnesses. In fact, only 9 percent of emergency department visits result in a hospital admission. This means it is likely that many of these cases could have been avoided by seeking the care of a PCP.

Emergency department visits not only result in hefty costs to the patient and their employer, but also create wastes of time and resources in the healthcare system. The impact in terms of costs, for the patients can have many down-stream consequences. In fact, a recent report by the U.S. Federal Reserve found that four out of 10 adults in the United States could not cover an unexpected $400 expense. In some cases, this amount can easily be reached for a single emergency room visit between out-of-pocket costs for the visit, medications and laboratory services —especially when dealing with out-of-network issues. Providers should work to keep patients out of emergency rooms and urgent care facilities and to emphasize the importance and purpose of the PCP in the patient’s healthcare journey.

Until the 1940s, about 40 percent of all physician visits were house calls and while today patients don’t have this same expectation, providers should treat patients with that same level of personalized, individual care that builds a strong relationship. Providers can consider implementing the following best practices with their patients:

Every Discharge Deserves a Follow-Up

In many cases the PCP is not the provider who admitted or cared for the patient while in the hospital. However, it is imperative that the PCP insist on receiving information about the patient’s admission, so that he or she can be a part of the discharge plan. The patient should be seen back in the practice within three to five days after discharge —even if they were seen just prior to going into the hospital. In fact, this should be scheduled for the patient prior to hospital discharge. Timely follow-up appointments have been associated with a decreased risk of readmission. A converse association also exists. A study published in Clinical Interventions of Aging found only half of patients discharged following heart failure had a follow-up appointment scheduled and the readmission rate was significantly higher in those that had no follow-up scheduled.

Follow-up appointments allow for the provider to engage or re-engage the patient and ensures the patient is aware of any care transition recommendations. Concerns regarding disease process, expectations and convalescence should be addressed at this time. Working to schedule all patients for timely follow-up post discharge eliminates the risk of the patient forgetting to schedule the appointments themselves. Many patients report a higher sense of satisfaction with the communication between themselves and their provider and with their overall care.

Encourage Virtual Care Options

For after-hours needs, do your patients know there are virtual care options they can use in lieu of going to the emergency room or urgent care clinics for non-urgent concerns? Many patients are simply unaware of these services or aren’t sure how to use them so they don’t consider it as an option. According to the National Business Group on Health, only 8 percent of employees utilize telemedicine services, yet the cost of healthcare benefits is expected to increase an average of 5 percent due in part to pharmaceutical costs but also to site of service issues as well. Spend a few minutes during the visit to educate patients on the services available as well as when to use them.

Promote Health Plan Resources

Unfortunately, many patients are also not familiar with the services or programs offered by their health plans. These materials are good resources for preventative care measures and offer proactive suggestions for patients. For example, their insurance provider might offer diabetes educational materials and resources. Most health plans have programs for diabetes and other chronic conditions. If members are encouraged to access the materials available online, telephonically and in print they might be more likely to seek out that information and if contacted by the health plan they will be much more likely to engage. It is important that patients begin to get a sense that the health plan and the providers are collaborating for the patient’s benefit.

We are still in a fee-for-service world but moving toward fee-for-value. This is being driven by the Centers for Medicare and Medicaid Services (CMS) and all the major health plans. To be successful in this new world, improved patient outcomes should be a major focus for providers. Strategies that engage the patient and simplify the healthcare experience when and where it is needed most are going to be produce the winners in this new era. The literature is replete with strategies that can produce population health success, but few are shown to be consistently correlated to economic success combined with improved patient satisfaction and outcomes. The exceptions have been those that employ heavy care coordination in a face-to-face venue and that address the social determinants of disease.

Fully leveraging these strategies is going to require the development of trust between the patient and provider so that patients know we are not just treating a disease but caring for the whole person. When that level of trust is reached it becomes easier to influence utilization of the PCP practice and other more appropriate levels of care instead of the ED. Similarly, it becomes easier to impact the readmission rate in one’s own panel of patients.

About the Author:

Dr. Delanor Doyle

Dr. Delanor Doyle

Dr. Delanor Doyle is the chief medical officer of Texas Health Aetna. Leveraging the strengths of two leading organizations, Texas Health Aetna is blurring the lines of traditional health care plans and health systems to create a truly integrated solution that’s simple to navigate and puts the member’s experience first. The local health plan is committed to providing affordable, high-quality health care services and delivering customized care to members throughout the Dallas-Fort Worth metroplex. For more information about Texas Health Aetna, visit www.texashealthaetna.com.

Guest Post: A Report on Healthcare Data Security & Privacy Compliance

July 26th, 2018 by Gary Palgon

Privacy and security regulations for enterprise data in healthcare organizations are complex and current efforts to bolster enterprise data compliance among all organizations, including those in healthcare, are immature and ineffective, according to a recent study conducted by Aberdeen, an industry analyst firm.

In fact, 86 percent of 112 hospitals and hospital groups in the study are dealing with multiple types of data and data-related processes that are subject to compliance requirements. This is not surprising because healthcare organizations generate, collect, store and manage financial transactions, personally identifiable information, protected health information, employee records and confidential or intellectual property records such as partnership agreements and contracts.

When asked if their organizations were compliant with 11 common regulations and frameworks for data privacy and security, only 65 percent reported achievement. PHI has the highest percentage of compliance reported—85 percent. The lowest compliance rates were reported for ISO 27001 and the General Data Protection Regulation at 63 percent and 48 percent respectively.

To measure the maturity of healthcare organizations’ efforts to comply with privacy and security requirements for data, Aberdeen developed a Net Maturity Index across six key elements of an enterprise data lifecycle. An index score above 50 percent indicates strong maturity in compliance activities and below 50 percent indicates immaturity.

Managing data, which includes normalizing, cleansing, validating and correlating data, earned a 66.6 percent score for healthcare respondents, the only element that indicated maturity. Scores for other key elements were:

  • 49 percent for storing data—persistent, on-demand, self-service access to data;
  • 41.2 percent for protecting data—encryption, tokenization;
  • 33.4 percent for syndicating data between any two applications—including mobile, connected devices, on-premises or cloud;
  • 25.4 percent for ingesting data into a common repository—cloud-based, data lakes; and
  • 3.9 percent for integrating data from multiple sources—disparate sources, formats and protocols

The immaturity of the data lifecycle and associated enterprise data compliance efforts has real-world consequences for healthcare entities. Four out of five (81 percent) study participants reported at least one data privacy and non-compliance issue in the past year, and two out of three (66 percent) reported at least one data breach in the past year.

Investment in data compliance efforts is not lacking. A median of 37 percent of the overall IT budget of healthcare survey respondents is allocated to data compliance activities. This is a significant amount of funding to still experience data breaches, data compliance issues and low percentage of achievement of compliance with multiple enterprise data security and privacy regulations. When compared to respondents from life science and other industries, healthcare respondents reported the highest percentage of the IT budget devoted to data compliance.

The survey also indicated that healthcare organizations are more likely than organizations in other industries to have instituted compliance-specific governance processes and appointed specialized leadership such as data protection officers, compliance officers or chief risk officers, to oversee enterprise data compliance initiatives. While these are often considered to be best practices for achieving data compliance, still less than half of all healthcare organizations have instituted these approaches. Having specialized leadership is one of the most likely ways to effectively address enterprise data security and privacy compliance issues but it may also present further complications. Although the role may be assigned to an individual, the task of ensuring compliance with multiple regulations that evolve and change along with new technology and the addition of new data sources, requires an expertise that is difficult to achieve and oversee by one person who probably wears multiple hats in the organization.

One solution to the complex, challenging task of achieving data security and privacy compliance is the use of third-party providers who can address the healthcare organization’s need to enhance integration, management and storage of data. Providers who are experts at data management and integration but also provide the added value of the expertise needed to ensure compliance with regulatory requirements affecting data will offset some of the burden on hospital staff. The solution is not a simple application or a one-off project. Achieving and sustaining compliance with data privacy and security rules as they evolve is an ongoing effort.

The study also points to the need to better manage financial investment in compliance strategies. One option for healthcare organizations is managed services agreements with data management and integration providers. Switching to a predictable, monthly fee versus periodic capital investment or ongoing efforts that are ineffective frees IT funds to be used to advance other hospital goals.

Although many healthcare organizations do not consider outsourcing some of their data management, integration and compliance challenges, but choosing a partner wisely—one with expertise in healthcare as well as other data-centric industries with multiple privacy and security requirements—can reduce the compliance burden on an already overworked hospital IT staff and make funds available to continue digital transformation or other strategic initiatives.

Read the overall survey report here: Enterprise Data in 2018: The State of Privacy and Security Compliance

Read the brief on results for healthcare organizations here: Enterprise Data in 2018: The State of Privacy and Security Compliance in Healthcare

About the Author:

Gary Palgon

Gary Palgon

Gary Palgon is vice president of healthcare and life sciences solutions at Liaison Technologies. In this role, Gary leverages more than two decades of product management, sales, and marketing experience to develop and expand Liaison’s data-inspired solutions for the healthcare and life sciences. His unique blend of expertise bridges the gap between the technical and business aspects of healthcare, data security, and electronic commerce.

Guest Post: Increase HCAHPS Scores Through Healthcare Design

July 10th, 2018 by Rebecca Donner

Improving HCAHPS scores from an interior design perspective.

The Centers for Medicare & Medicaid Services’ (CMS) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was established as a way to measure patients’ perspectives on healthcare and make comparisons across hospitals based on the patient experience. Receiving a high score can boost hospitals’ Medicare/Medicaid reimbursement, while a low score can decrease funding by as much as 2 percent. Because HCAHPS scores can affect a hospital’s bottom line, it provides an incentive for them to place a greater focus on patient experience to receive a high score.

There a number of ways to increase a HCAHPS score, including patient communication and respect, speediness, cleanliness and even pain management procedures. But one way that may be overlooked is how to raise that score through interior design. There are a number of ways to approach HCAHPS scores from a design perspective.

Noise Reduction

With so much commotion in hospitals, it can be difficult for patients to rest, which is a key component to the healing process. Standard noise levels should be 35 dB(A) during the day and 30 d(B)A at night, but peak noise levels in hospitals often exceed 85 to 90 db(A), according to the Center for Health Design.

Aside from limiting overhead announcements and machine beeping, hospitals can reduce noise by focusing on the materials they use inside their facility. Carpet tiles or rubber flooring, as opposed to tile, can reduce the noise of foot traffic outside patient rooms. In addition, acoustic wall coverings and ceiling tiles act as giant sonic sponges, soaking up unwanted noise and echo. This can prevent any loud conversations or unwanted noises from traveling down hallways.

Privacy

Privacy and comfort rank high in ways to improve patient experience. According to the 2016 Hospital Construction Survey, many hospitals are now converting semi-private rooms into private rooms to increase patient privacy. After all, no one wants to share a room with a stranger during what can be one of the scariest times in someone’s life. Plus, two patients in a room can increase the chance of infection.

Many hospitals are also increasing the square footage of patient rooms. This way, even if two patients are sharing a room, they each have plenty of private space.

Personal Controls

To make the hospital feel like home as much as possible, many facilities are now offering patients greater control over the lighting, temperature and window shades in their rooms. Everyone has different preferences when it comes to how warm or cool, or how dark or bright, they want a room to be. Personal dimming controls allow patients to adjust the lighting depending on their activity, whether they are trying to sleep or need extra light for reading or examinations. Giving patients control over these variables can lead to higher patient satisfaction.

Mobility

Hospitals with high mobility and accessibility receive higher HCAHPS scores. Installing handrails makes it easier for patients to get to the bathroom, and wide bathrooms give patients the space they need when using the facilities.

About the Author:

Rebecca Donner

Rebecca Donner

Rebecca Donner is the owner and founder of Nashville-based healthcare interior design firm Inner Design Studio. For more information.

Guest Post: Staying HIPAA Compliant When Using Smartphones

July 5th, 2018 by Brad Spannbauer

Smartphones in Healthcare

Introducing smartphones into a healthcare environment also brings new security risks, especially when devices are used to create, receive, maintain or transmit ePHI.

Smartphones are becoming increasingly ubiquitous in clinical settings. When compared with the likes of pagers, smartphones offer many benefits, such as improved communication and collaboration, increased mobility, and more advanced security and privacy features. However, despite these benefits, introducing smartphones into a healthcare environment also brings new security risks, especially when devices are used to create, receive, maintain or transmit electronic protected health information (ePHI).

The compact size and portability of smartphones is what makes them so convenient for on-the-go healthcare professionals, but it is also this which makes them particularly susceptible to loss or theft, which can lead to data breaches.

According to a Ponemon study, 90 percent of healthcare organizations have been affected by at least one data breach, and nearly half have had more than five data breaches. While malicious activity continues to be the leading cause of these attacks, employee negligence and lost or stolen devices are the primary instigators.

Eliminating the security and privacy threats introduced by smartphones isn’t easy, but by addressing the following key areas, HIPAA (Health Insurance Portability and Accountability Act of 1996) covered entities can mitigate the risks and significantly reduce the likelihood of a data breach occurring.

Put a stop to non-secure communication

In today’s cyber crime ridden world, organizations must be proactive in guarding every aspect of their digital infrastructure, and maintaining secure communications is a key part of this process. Non-secure applications such as email or native text messaging apps are inherently risky due to a lack of security features and privacy controls, which ultimately render them non-compliant under the rules of HIPAA. Instead of using unsecure tools, healthcare providers should invest in secure communication solutions that are designed to withstand the rigors and regulations of healthcare.

Educate your workforce

Research by IBM suggests that 95 percent of all security incidents in 2016 involved human error—misaddressed emails, weak passwords and falling prey to phishing schemes are prime examples of how data breaches can occur due to carelessness or lack of proper education. Additionally, the rise in BYOD (Bring Your Own Device) means employees are more frequently using devices both inside and outside the office, which naturally increases the risks of a device being lost, stolen, or accessed by an unauthorized third party. Regular staff training should therefore be a top priority for any organization that allows its employees to use a mobile device for work purposes. Ultimately the onus is on employers to ensure employees understand their responsibilities, and to provide the tools to allow them to carry out their jobs effectively and securely.

Follow OCR’s advice

In recognition of the risks associated with increased usage of smartphones in clinical settings, the Department of Health and Human Services (HHS) and Office for Civil Rights (OCR) has issued guidance for HIPAA covered entities who use mobile devices to create, access or store ePHI. The guide offers the following tips:

  • Implement policies and procedures regarding the use of mobile devices in the workplace—especially when used to create, receive, maintain, or transmit ePHI.
  • Consider using Mobile Device Management (MDM) software to manage and secure mobile devices.
  • Install or enable automatic lock/logoff functionality.
  • Require authentication to use or unlock mobile devices.
  • Regularly install security patches and updates.
  • Install or enable encryption, anti-virus/anti-malware software, and remote wipe capabilities.
  • Use a privacy screen to prevent people close by from reading information on your screen.
  • Use only secure Wi-Fi connections.
  • Use a secure Virtual Private Network (VPN).
  • Reduce risks posed by third-party apps by prohibiting the downloading of third-party apps, using whitelisting to allow installation of only approved apps, securely separating ePHI from apps, and verifying that apps only have the minimum necessary permissions required.
  • Securely delete all PHI stored on a mobile device before discarding or reusing the mobile device.
  • Include training on how to securely use mobile devices in workforce training programs.

Remember, at the end of the day, if you allow ePHI to be stored on mobile devices, some of those devices inevitably will be lost or stolen. And if that ePHI is not adequately protected through strong encryption along with robust access controls as described above, you will have a reportable data breach on your hands. So plan accordingly.

As devices and applications become more technically advanced, and as more and more healthcare organizations leverage the advantages of smartphones over traditional tools, smartphone usage is only set to increase. To realize the benefits, however, it is critical that the security of mobile devices is reviewed and updated regularly, and policies are modified when necessary. Convenience should never come before compliance.

About the Author:

Brad Spannbauer

Brad Spannbauer

A 20 year industry veteran, Brad Spannbauer currently oversees product strategy and planning, and provides direction and market leadership for j2 Cloud Connect’s worldwide business as their Senior Director of Product Management. His focus in the healthcare and legal verticals led to Brad’s involvement with the j2 Cloud Services™ compliance team, where he leads the team as the company’s HIPAA Privacy and Compliance Officer. Learn more about our HIPAA Compliant Fax Solutions.

Guest Post: 5 Steps To Prepare for Real-Time Enterprise Healthcare Data

July 2nd, 2018 by Melanie Matthews

The right real-time enterprise data infrastructure allows the information to be routed to a data lake where enterprises can employ modern business intelligence solutions to derive actionable insights.

Recent trends and emerging technologies are converging and a truly real-time enterprise will soon be an achievable possibility. As we move beyond traditional batch data to include streaming data, healthcare systems are seeing an unlimited and unyielding flow of data. This constant flow gives enterprises the ability to act on the information as it originates. Additionally, the right infrastructure allows the information to be routed to a data lake where enterprises can employ modern business intelligence solutions to derive actionable insights.

Of course, not every organization will need to be able to utilize truly real-time data, all organizations need to consider how they can best manage the increasing flow of data. Following are five steps to consider as you develop your enterprise information management (EIM) strategy:

  1. Define/identify business objectives – Is real-time data needed?: While the use cases are innumerable, real-time applications of data by their nature require a much higher level of network resources than data that is sent every hour or every day, as batch processes often are. Consider this: do you need data immediately or is once per hour sufficient? Organizations must first consider how frequently information is needed and then set the strategy.

  2. Find your edge and manage devices: Advancements in integration, messaging software, and Internet of Things (IoT) are building a new edge of the network. Mobile devices in the modern context can be virtually anywhere. To have success organizations need a data and device strategy to ensure that they can “read” the data they need, when they need it. Asset management strategies are also necessary for these devices to ensure that the information on them is controlled, secured, and properly maintained. An increasingly common example of device management at the edge is in healthcare, where tablets and mobile phones are increasingly used at the point of care.

  3. Let Data Streams Flow into Lakes: As organizations gather and use different kinds of often completely unrelated data forms, it makes a lot of sense to create a data lake. Whether this is required goes back to the context of use and the business objective, but in all cases, it is crucial to develop a strategy to consolidate, store, protect and back up the data.

  4. How Do Users Consume the Data?: Information for the sake of information can be distracting. Real-time data is no exception. Again, it is critical that its use be considered in the development of strategy. Let’s use monitoring again as an example. Do users need to know what is happening all of the time, or just when something is wrong, or some other key milestone? If they only need to know at certain points (problem detected, report generated, etc.), what is the best way to relay that information—an alert, a color-coded dashboard? The possibilities are limitless but should reflect a keen understanding of how the information will be used when needed most.

  5. Build in Analytics to Mine That Gold: Information is dynamic and so are the use cases that motivate different users to seek and apply it. For many, the information they gain is descriptive, for some it’s diagnostic in nature, and for others it’s predictive. An example can be found in the predictive analytics used to proactively identify equipment failure and to guide the resulting maintenance and repairs. For others it is prescriptive and informs what is happening currently to help define what should be happening. Regardless, the enormous range of use demands that organizations seeking to benefit from real-time data first establish the infrastructure necessary to run analytics in a way that pulls out actionable, relevant information.

A move to real-time enterprise will require changes to virtually every part of an organization. It will take a great deal of time, attention and hard work; however, the benefits will be significant. The five steps discussed here can help healthcare organizations find and stay on the right path to becoming a real-time enterprise.

About the Author:

Jennifer Schwartz

Jennifer Schwartz is an accomplished professional with special expertise in enterprise information programs, consulting, strategic planning, and mobile solution architecture. She has 18 years of experience with improving operational efficiency, reducing costs, and formulating strategic plans for her clients. As the Enterprise Information Management solution lead for CTG, Ms. Schwartz focuses on business process management and automation, providing best practice guidance, and executing special projects that help transform data into action. Jennifer works across industries, advising clients on the execution of projects to realize efficiencies.

Guest Post: Three Steps To Controlling Healthcare Costs with Data

June 21st, 2018 by Will Herold

Three Steps To Controlling Healthcare Costs with Data

Data analytics is key to reaching the goal of controlling healthcare costs.

Data analysis plays a key role controlling and potentially lowering healthcare costs, according to DHS Group.

DHS Group, an employer and health plan solutions provider based in Houston and Cleveland, provides three steps to reach the goal of controlling healthcare costs:

  1. Invest in your partners: If data, and the information you gather from accessing, reading and interpreting it, is important to you, then the company you work for to get the job done should be too. Don’t underestimate the value of investing in a partner that will go above and beyond in making sure the money you’re investing is put to good use and you’re able to access and understand the information you’re looking to gain.

  2. See data as actionable information: If you’re taking the time, and spending the money, to gain access to your data, consider the idea that the “data” is more meaningful when viewed as a place where actionable information resides. Look for partners that will translate your data into “Key Health Metrics” or information that you can make real decisions with based on your goals and benchmarks.

  3. Integrate your systems: Use the actionable information you have gained from your data to make informed decisions on the health and wellbeing of your employees – expanding programs to include areas like mental health and financial wellbeing. Data-driven benefits programs work best alongside health and wellbeing programs that are being driven by the same numbers and facts.

“Most people don’t realize all that can be done with regular access to claims data,” Jim Pritchett, DHS Group CEO, said. “Better plan design, discovery of preventative initiatives, empowering your members to better manage their health, identifying hard-dollar pharmacy savings, improving engagement and measuring ROI.”

Will Herold

About the Author: With years of experience in HR and benefits industries, Will Herold leads DHS Group’s Business Development team with a strong understanding of the HR and benefits marketplace. As a sales leader, he is responsible for managing DHS Group’s revenue and working with other professionals to assist corporations in establishing clear, aligned strategies for impactful, cost-effective benefit and wellbeing program outcomes.

Guest Post: Lab Data is the Missing Link in Healthcare Risk Adjustment

June 19th, 2018 by Jason Bhan, MD

Data informing risk adjustment programs is critical under value-based healthcare reimbursement models.

For health plans, value-based care means a continuous need to innovate and improve their risk adjustment, clinical quality, and care management programs. Unless payers identify and receive the correct amount of reimbursement, it is difficult for them to invest appropriately into member care programs for better outcomes while remaining financially successful.

The data informing risk adjustment programs are critical, as they build the foundation for accurate member risk stratification. In that respect, those data sources are directly related to the correct amount of reimbursement payers receive and can invest in proactive care management. In other words, high-quality clinical data delivered quickly enough for a plan to get a member into a care management program early enough is important to the health of the member and the business. The approach leads to improved clinical outcomes and reduced costs in emergency room visits, hospitalizations and chronic condition management.

Lab Data: An Untapped Resource

To achieve such clinical granularity, at scale, plans can turn to diagnostics—or lab—data. Lab data drives approximately 70 percent of medical decisions and, unlike claims data, is available in near real-time. It also provides an unrivaled level of specificity for clinical conditions. When lab data is integrated into plans’ claims- and chart-based programs, it enables earlier, more comprehensive and accurate clinical insights to benefit care management of both existing and new members. Utilizing the same information that clinicians use to make decisions, within the same timeframe, provides a powerful and unique opportunity to intervene and impact a patient’s health.

What Can Lab Data Do for You?

Expanding and improving their clinical data supply with diagnostics data can help health plans to:

  • Provide historical insights on members where claims are unavailable to improve risk adjustment. For new enrollees, this enables the health plan to get new members into the appropriate care/disease management programs from day one.
  • Serve as an early detection system for care management of all enrollees. Plans can identify patients in need of additional or alternative therapy from lab data earlier than from any other data source. For existing members, the detailed results uncover needs that may have been overlooked based on a claims analysis alone.
  • Identify high-risk members for case management and provider interventions from lab data. Optimized risk adjustment aligns reimbursements to health status, enabling the plan to more heavily invest in member care programs.

Applying AI Solutions

When it comes to gaining actionable insights from diagnostics data, plans can benefit from partnering with healthcare artificial intelligence (AI) specialists in the field. Healthcare AI organizations use techniques such as machine learning and natural language processing—coupled with massive computational power—on big data sets, to make sense out of non-standard, complex, and heterogeneous data.

Healthcare AI, when applied to diagnostics clinical lab data, improves risk stratification by identifying diagnoses earlier in the year versus waiting for the claim or searching charts. Rich in clinical details, it presents a more complete picture of the member’s health. Better risk stratification leads to better care management programs; and successful programs have been shown to reduce costs by targeting those most likely to benefit and keeping intervention costs low.

Dr. Jason Bhan

About the Author: Jason Bhan, MD, is co-founder and Chief Medical Officer at Prognos, an innovator in applying AI to clinical lab diagnostics. More than half of the Prognos team is made of engineers, data scientists, and clinicians. Prognos aims to increase the usefulness of disparate healthcare data to better inform clinical decisions and ultimately improve patient outcomes.

Guest Post: As Mergers Continue, Healthcare Industry Faces New Data Consolidation Realities

June 12th, 2018 by Christian Puff

As if the healthcare system wasn’t confusing enough, construction signs are now popping for consolidations.

As if navigating the twists and turns of the U.S. healthcare system highway wasn’t confusing enough, construction signs are now popping up all over the place in the form of consolidations. Why is this happening? What does this mean for consumers? And, how will this change the way consumers receive care?

The United State’s annual medical spend has risen to over $3.4 trillion and is only projected to grow. This spend accounts for roughly 18 percent of the U.S. GDP. Some want a piece of the incredibly large pie, while others are focused on reducing its size. Then, there are those who have accepted the need for a smaller pie but want the biggest piece possible. It’s in this third group where we’re seeing many of the industry consolidations. From Aetna and CVS to Cigna and Express Scripts and, most recently, Walmart and Humana, these big-name players are intent on controlling the largest portion of the multi-trillion dollar industry they can.

If these consolidations are successful, the way insurers and healthcare providers interact will change because of one word: data. Data is king, and many believe it is the key to reducing healthcare costs in this country.

Aetna is one of the largest health insurers. Its plan to merge with CVS, the largest national retail pharmacy chain that also happens to own the largest pharmacy benefit manager, Caremark, will give the consolidated healthcare giant access to an incredible amount of member, patient and provider data. The same is true for Cigna and Express Scripts, although to a slightly lesser extent. While this consolidated entity would not, at this time, have brick-and-mortar pharmacies, together, they will reap the benefits of combining member, patient and provider data. However, the proposed Walmart and Humana merger could prove the most impressive in terms of data consolidation, followed by Aetna and CVS. Not only will the newly combined company know whether their members and patients fill their prescriptions, they’ll know what those same members and patients purchased while waiting for their prescriptions. Did the depressed, hypertensive diabetic buy ice cream, red meat and cigarettes? They will now have those answers.

So why is this important? According to the Centers for Disease Control and Prevention (CDC), over 86 percent of the healthcare spend is due to those suffering from chronic disease. More importantly, however, is over 50 percent of these costs are attributable to patient behavior. As a result, having access to both medical and behavioral data allows the depressed, hypertensive diabetic purchasing ice cream, red meat and cigarettes to become an opportunity for outreach and case management.

These companies will attempt to capitalize on the data available to them to help manage the cost of care. Perhaps it will be in the form of a letter or phone call to the member. Perhaps it will come in the form of a highly personalized clinical program where the member receives access to nicotine replacement therapy, a gym membership and nutritionist services.

These organizations alone cannot and will not be able to force patients and members into participating in programs designed to improve health and reduce the cost of care.

Okay, so now what? Let’s assume for an instant all of this data conglomeration works to drive down the cost of care to a more reasonable $2.5 trillion. Will consumers benefit from the savings? This is yet to be determined. In reviewing the proposed consolidations, the federal antitrust enforcers will attempt to discern the impact on the consumers. Undoubtedly, these entities will argue the proposed mergers will reduce costs by increasing efficiencies and allowing them to positively affect the medical spend trend. Critics, however, predict individual consumers will never see the savings projected by these organizations. Who’s right? That’s a question that can only be answered with time.

This article is educational in nature and is not intended as legal advice. Always consult your legal counsel with specific legal matters.

Christian Puff

Christian Puff

About the Author:

Christian Puff is an attorney with Hall, Render, Killian, Heath & Lyman, P.C., the largest healthcare-focused law firm in the country. Please visit the Hall Render Blog at http://blogs.hallrender.com/ for more information on topics related to healthcare law.

HIN Disclaimer: The opinions, representations and statements made within this guest article are those of the author and not of the Healthcare Intelligence Network as a whole. Any copyright remains with the author and any liability with regard to infringement of intellectual property rights remains with them. The company accepts no liability for any errors, omissions or representations.

Guest Post: Is the Future of Value-based Healthcare Payments at Risk?

May 31st, 2018 by Erin Weber

CAQH CORE report highlights how value-based payment may encounter the challenges fee-for-service faced 20 years ago.

There is an old adage that anyone who doesn’t learn from the past is doomed to repeat it. For those of us in healthcare, it is time to review our history, so we can avoid repeating some of the operational headaches that emerged almost two decades ago.

Beginning in the 1990s, when electronic transactions were first being implemented to administer fee-for-service payment models, organizations began using many different, often proprietary approaches. Although HIPAA standards were in place, there were no agreed-upon expectations for exchanging data, and the content of transactions varied from one organization to another. This slowed automation and resulted in an inefficient, costly and frustrating experience for all parties.

If wireless companies, for example, did not use common approaches for exchanging data, you would need to carry different phones to call people on other networks. This is what health systems started to face with fee-for-service models. Instead of having to connect with four or five different carriers, however, they had to exchange electronic data with every health plan with which they contracted, often a dozen or more.

To help address this challenge, stakeholders across healthcare came together to form CAQH CORE®, a nonprofit collaboration of health plans, health systems, and vendors. Members worked together to develop common rules, many of which have been codified as part of the Affordable Care Act.

Because of these and other industry efforts, more fee-for-service administrative information flows electronically and securely today. Health plans, providers, and clearinghouses have sharply reduced the use of costlier manual phone, fax, and mail processes.

CAQH CORE is starting to see signs that value-based payment operations are following a similar path. Today, as adoption of value-based payment is growing, health plans and providers are developing new approaches to measure, manage, and pay for care. While innovation is needed, a common foundation for basic administrative operations is lacking. Absent this foundation, value-based payment is being managed, in part, using approaches designed for fee-for-service. This is not likely to yield the fluid, reliable, and trusted exchanges of data needed for long-term value-based payment model success.

Given that experience, CAQH CORE began to study the matter in depth by interviewing stakeholders and reviewing the literature. Last month, CAQH CORE published these findings in a report, All Together Now: Applying the Lessons of Fee-for-Service to Streamline Adoption of Value-Based Payments. In it, they identified five areas where greater uniformity can help the value-based healthcare economy thrive: data quality, interoperability, patient risk stratification, provider attribution, and quality measurement. The report also details specific strategies to address each of these areas.

For example, today there are many issues with data quality, particularly involving provider identification. In the value-based payment world, inaccurate information about the provider can yield a cascading series of problems, such as misplaced accountability, erroneous risk-based payments, inappropriate referrals, and higher patient costs. The report recommends more universal and consistent use of the National Provider Identifier as one way to improve data quality and mitigate many of these problems.

This is just one example, but it highlights how acting now, before operational variances can become entrenched in value-based payment models, will help avoid needless costs, inefficiencies, and frustration. Others in the industry are looking at these challenges as well. By working together to apply the lessons learned during the fee-for-service transition, CAQH CORE hopes to energize an effort to ease the pain points in value-based payment and avoid reliving challenges of the past.

Erin Weber

Erin Weber

About the Author:

Erin Weber is director of CAQH CORE, a nonprofit collaboration of over 130 public and private health plans, hospitals and health systems, vendors and others that helps stakeholders uniformly adopt electronic transactions and exchange data efficiently.

HIN Disclaimer: The opinions, representations and statements made within this guest article are those of the author and not of the Healthcare Intelligence Network as a whole. Any copyright remains with the author and any liability with regard to infringement of intellectual property rights remains with them. The company accepts no liability for any errors, omissions or representations.

Guest Post: Demonstrating High Quality Care Becomes Paramount in the Bundled Payment Models

April 24th, 2018 by Shane Wolverton

Optimizing bundled payment model opportunities.

The Centers for Medicare and Medicaid Services’ (CMS) cancellation of the mandatory payment bundles for cardiac care, surgical hip and femur fracture treatment in late 2017 is expected to be replaced in 2018 with a voluntary program, called the Bundled Payments for Care Improvement Advanced (BPCI).

CMS also cancelled the cardiac rehabilitation incentive payment model and switched participation requirements in the Comprehensive Care for Joint Replacement (CJR) model from mandatory to voluntary while reducing the selected geographic areas from 67 to 33.

In the BPCI Advanced model, providers will be expected to share in the financial risk and redesign of care delivery to reduce expenditures while maintaining or improving performance on specific quality measures.

CMS’ decision regarding payment under the CJR model that allows total knee arthroplasty to be performed in outpatient settings has caused considerable concern for providers in the acute care setting due to potential loss of revenue to lower cost care settings. Despite these uncertainties, some hospitals under the CJR model have reduced spend per episode and implant costs by over 20 percent.

Regardless of the programs offered by CMS in 2018, providers should focus on finding ways to optimize the bundled payment opportunity with self-funded employers or other plan sponsors as they look to bundles for lowering spend and improving quality. Many of these arrangements require providers to implement stop-loss that assumes risk for utilization beyond the bundled rate. With bundles now offered by ambulatory surgery centers consistent utilization and quality performance becomes paramount. There are numerous organizations scaling to meet increasing demand for this type of value-based care ushering in greater competition.

Maximizing the Benefits of Bundled Payments

The key to success depends on the ability of the organization to foster multi-disciplinary teamwork organized around more refined episodic analysis looking at structure, process indicators and outcomes. These advanced analytics serve as the roadmap to thrive with this payment model. It is vital that the analytics be clinically focused and risk adjusted to determine whether variation is manageable or due to the clinical and demographics of the patients.

Four Steps

First, identify physician leaders to guide the study of current practice patterns, patient throughput and post-acute care. While the physicians facilitate this process, it is recommended that nursing, supply chain, pharmacy and other stakeholders be included.

Second, develop the analytic tools to assess care across the continuum using claims, EMR, and process and patient reported outcomes. Organizations should look for analytics that allow stakeholders to see severity-adjusted episode of illness across the entire continuum of patient care. Accurately comparing the total cost and utilization of medical services against peer groups, national norms, and best practices is important as the trend in bundles is to cover post procedural spend for as long as 90 days. It is essential to compile analytics refined enough to define the current performance and model the expected bundled rates and outcomes. If this step is not performed rigorously, the organization faces considerable risk and discontentment by stakeholders.

Third, determine how the bundles rate will be distributed to the physicians and facilities. This must include incentives for improvement for all stakeholders as margins improve and quality increases.

Fourth, educate the patients and families, as key stakeholders to empower them to work as part of a coordinated team. Providing clear information about the episode can reduce anxiety and improve adherence to recommended therapies and medications pre and post-surgery. Using navigators is a proven approach to help patients through the episode of care.

Patient Selection

As the journey into bundled care begins with the selection of patients best suited for this type of care, it is advantageous to build a repeatable and evidence-based approach to delivering this care. More variability in the clinical and demographic attributes of the patient leads to greater potential variance in treatment. It is vital that the teams develop a consistent care path especially early into the program. This fosters the knowledge required to set utilization and quality outcomes firmly in alignment with the bundled rate. Even the slightest inconsistencies can have significant impact on the programs performance.

Healthcare Performance Management & Analytics

With bundled payments, providers and healthcare delivery organizations benefit from the savings, provided the outcomes of the patient meet expectations. There are some arrangements where quality performance guarantees are included as part of the agreement. For instance, one of the most comprehensive arrangements is the inclusion of a lifetime guarantee for hip arthroplasty. As more care moves from the acute care setting into ambulatory surgery centers or hospital outpatient departments the price of bundles will be commoditized and attractive margins harder to maintain. Patients may also believe that lower cost settings of care may also translate to the delivery of lower quality of care. This puts tremendous pressure on hospitals to begin diligent work on bundles knowing they have a cost disadvantage compared to outpatient settings. Demonstrating high quality care to patients regardless of setting will foster greater trust with employers and payers and reduce the reluctance for patients to seek treatment in the outpatient setting.

Assessment of risk adjusted mortality, complications and unanticipated readmissions along with Agency Healthcare Research and Quality patient safety indicators is essential in building and maintaining a bundled program. These indicators must be risk adjusted properly to validate performance, remediate poor outcomes, credential providers and market the program. The use of statistical process control techniques is also required to discern random versus special cause variation in utilization or outcomes. It would be desirable to use methods published in peer reviewed journals for integrity with the medical staff.

As plan sponsors look for lower cost settings, the quality of care delivered becomes even more important since partnering with a low quality facility may impact the success of this program and their bottom line. Providers that can share their level of safety and performance measures based on reliable and comprehensive analytics will be in a far better position to attract patient volume with better outcomes.

About the Author:

Shane Wolverton

Shane Wolverton is SVP Corporate Development at Quantros. He is responsible for establishing business partnerships for the company and is a sought after speaker on a wide range topics around value-based healthcare delivery.

With over 25 years of deep domain expertise in the use of clinically and risk-adjusted medical analytics he works with many stakeholders in healthcare including employers, brokers, benefits consultants, vendors & providers. He is currently working with numerous organizations leading the movement toward value-based care through high performance networks, COEs, transparency, consumer navigation, bundles of care and network optimization. In addition, he advises hospitals, and physicians, in the use of advanced analytics to drive clinical performance improvement, clinical documentation improvement and performance based marketing communications.

Prior to joining Quantros, Mr. Wolverton served as senior vice president of corporate development at Comparion Medical Analytics. He also served as a management consultant with Health Care Investment Analysts (now IBM Truven Health Analytics) and the McGraw-Hill Healthcare Management Group. He received his undergraduate degree from Auburn University.

HIN Disclaimer: The opinions, representations and statements made within this guest article are those of the author and not of the Healthcare Intelligence Network as a whole. Any copyright remains with the author and any liability with regard to infringement of intellectual property rights remains with them. The company accepts no liability for any errors, omissions or representations.