Archive for the ‘Guest Posts’ Category

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 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 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.

Guest Post: Clinical, Quality and Financial Benefits of Incorporating Technology into Healthcare Practices

April 10th, 2018 by Brooke LeVasseur

New technology adoption playing an increasingly vital role in healthcare practices.

Adoption of new technology is playing an increasingly vital role in the future of healthcare practices. Through population health solutions, artificial intelligence and new expanded telehealth offerings, healthcare stakeholders are better able to achieve triple aim goals with increased access to care, reduced readmissions and transfers, improved care coordination and more efficient clinical workflows.

These technological advancements have the potential to improve patient outcomes while significantly decreasing the overall cost of care.

  • According to the Certification Commission of Healthcare Information Technology, it is estimated that about 50 percent of healthcare finances are wasted, due to inefficient processes.
  • Empowering providers with new communications tools can lead to increased efficiency and improved care coordination at a lower cost.
  • New advances in care delivery models such as eConsults allow providers to have immediate access to the necessary information to treat their patients without the constraints of physical location. eConsults allow for providers to connect with specialists to collaborate on treatment plans, all within the primary care setting.

While telehealth can deliver substantial cost savings, it can also deliver clinical advantages.

  • Telemedicine allows for greater access to care for those living in areas where either population congestion or geographic proximity makes gaining access to healthcare more difficult. Providers are also able to have access to more patients per day versus a traditional office visit.
  • Smart Care Platforms are making strides in the senior and Medicaid managed care industries because it allows for the elderly population to receive eConsult specialty care from the comfort of their primary care setting.
  • Prison systems have also taken advantage of Smart Care Platforms to alleviate the extra staff/security and financial costs of transferring an inmate to a hospital or specialty care setting.

About the Author:

Brooke LeVasseur

Brooke LeVasseur, CEO of AristaMD, has over 15 years of leadership experience launching new, innovative healthcare products and solutions to payers and providers. After graduating from Stanford University, she worked in equity research, covering medtech companies for Thomas Weisel Partners. Since then, LeVasseur has worked with numerous start-ups in a variety of capacities, including: corporate and commercial strategy, marketing and new business creation where she has led teams to successfully commercialize new healthcare tools and gain widespread clinician adoption and reimbursement.

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: Outcomes Drive the Evidence-Based Practice Journey

March 29th, 2018 by Michele Farrington and Cindy Dawson

The Institute of Medicine set a goal that 90 percent of all healthcare decisions will be evidence-based by 2020. Executives and nursing leaders, at all levels within organizations, have clear responsibility for making this goal a reality and ensuring consistent, standardized use of evidence-based practice (EBP) in care delivery that will meet patient, family, clinician, and organizational outcomes.

Promoting use of evidence, valuing questioning of clinical and administrative practice, and building organizational capacity, culture, and commitment are pivotal to building a supportive organizational culture related to EBP.

Organizations must meet regulatory requirements, from the Centers for Medicare and Medicaid Services and The Joint Commission, that incorporate EBPs and the need for increasing public accountability and transparency (e.g., use of national benchmarks) for quality and safety. Financial incentives associated with pay-for-performance are also directly linked to EBP. Despite these outside forces in today’s healthcare environment, clinicians and executives cannot forget about the need to provide individualized patient care, which includes patient engagement strategies aimed at improving the overall patient experience.

EBP is a continuous journey for individual clinicians and organizations alike and starts with building organizational capacity.

Organizational Capacity

EBP capacity is built using a strategic, systematic approach to create a solid foundation and infrastructure to support the work. Before EBP work can be successful at the unit or clinic level, EBP must be integrated at the organizational level and a culture for change must exist.

The organization’s mission, vision, and strategic plan must include EBP language to ensure evidence-based healthcare is clearly portrayed as the organizational norm. Creating a culture valuing inquiry and innovation must start during orientation for new hires and continue during competency review for current employees and through ongoing training and professional development opportunities for both clinicians and executive leaders.

An infrastructure that directly integrates EBP work into the organizational governance structure is needed to support the mission, vision, and strategic plan. A crucial organizational decision is determining what group will hold primary accountability or functional responsibility for EBP to ensure it is integrated into practice processes, policies, and documentation.

Recruiting and hiring clinicians and executives with experience and/or interest in EBP will help build the desired culture and capacity. EBP mentors are developed from successful projects and are used to nurture the next generation.

A well-defined path for EBP includes adoption of an EBP-process model to guide implementation and sustained organizational change across disciplines. There are a number of EBP process models: The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Health Care; Johns Hopkins Nursing Evidence-Based Practice Model; Stetler Model of Evidence-Based Practice; and Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model. Each model follows a step-by-step problem-solving process suitable for concurrent use with the organization’s quality improvement processes.


The governance structure must clearly outline the process and channels for communicating EBP work and obtaining necessary approvals from applicable committees. EBP discussions should be a regular agenda item for all shared governance committees.

Project results should be reported internally through the organization’s shared governance and quality improvement structures to promote practice change adoption, share learning, garner continued support (e.g., time, resources), and as a platform to recognize success for the institution’s EBP program.

Successful EBP work takes time and effort, so successes should be celebrated and rewarded throughout the process. Celebrations are an opportunity to spotlight clinicians for doing this work and helps build a pervasive culture that supports and expects use of evidence in practice. These strategies promote organizational buy-in and commitment for the EBP process and set higher standards as a foundation for future efforts.

Expected behaviors from clinicians across all job classifications at every level must clearly demonstrate the value of EBP. Behavioral expectations regarding EBP are easily set if they are built into every job description and can be quickly reviewed annually during the performance appraisal process. Utilizing documents and mechanisms that already occur is an easy and efficient way to promote positive reinforcement and priority setting in busy work environments with many ongoing and competing demands for clinicians’ and leaders’ time and attention.


EBP is value-added with a strong return on investment and responds to current priorities. A single project may improve patient and clinician safety, improve clinical outcomes, improve patient/family satisfaction, promote innovate care, and/or reduce costs.

Clinicians, nurses, and leaders all influence an organization’s capacity for EBP. Leaders who demonstrate and expect EBP will promote its use in clinical and operational decision-making at the unit or clinic and organizational levels. Building on the organization’s mission, vision, capacity, and value for delivery of reliable, safe, high quality care provides a foundation for success.

About the Authors:

Michele Farrington, BSN, RN, CPHON, is a clinical healthcare research associate at the University of Iowa Hospitals and Clinics. She is certified in pediatric hematology/oncology nursing and received her BSN from the University of Iowa. She has been leading, co-leading, or mentoring EBP initiatives since 2003, and her work has been awarded extramural funding, validating the strength of the projects and impact on nursing care. She is widely published and has given multiple local, regional, national, and international presentations.

Cindy Dawson, MSN, RN, CORLN, is the chief nurse executive and associate director of the University of Iowa Hospitals and Clinics. She received her BSN from the University of Iowa, MSN from the University of Phoenix, and is a Certified Otorhinolaryngology Nurse. Over the course of her career, she has published extensively on EBP, nurse triage, nursing management/leadership, and clinical practice guidelines and has given numerous local, regional, national, and international presentations on these topics.

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: Three Benefits to Using Virtual Care Services During Seasonal Epidemics

March 27th, 2018 by Dr. Delanor Doyle

Virtual Care

Virtual care benefits providers and patients.

This year, the flu epidemic reached an all-time high with 39 states experiencing high patient traffic and marking it as the most hectic season for hospitals since 2009. It seems every day in the news we heard about another state or city breaking a record for the most local flu cases of all time. It’s no wonder then that anyone, even medical professionals, were wary about coming into contact with others and being susceptible to the illness.

When a true epidemic breaks out, like this flu season, it is critical that healthcare providers encourage the use of virtual care services. This is important not only from a health perspective for themselves, but also because it benefits the patient in more ways than simply not having to get out of bed to go to the doctor’s office.

#1: Provides a Personalized, Holistic Care Approach

In the past, physicians would travel to the homes of their patients so the sick did not have to travel. With virtual care, physicians can actually return to this level of personalization. Now, physicians can talk with their patients one-on-one to relate to them on a deeper level—as if they were coming into their home—through the use of video conferencing capabilities. People want to relate to people so providing a face-to-face interaction virtually ensures the patient feels cared for and valued.

Additionally, there are many benefits to seeing the patient’s home or work environment that can help provide health advice that goes beyond a traditional visit. By seeing their surroundings, a physician may recognize triggers or red flags in the background that can help further diagnose a problem that wouldn’t otherwise be known from an office visit. This allows physicians to truly be care providers, as opposed to simply treating an illness.

#2: Improves Satisfaction in Level of Care Provided

We’ve all seen the emergency room that is full to the brim with patients waiting to be seen and feeling the level of stress rise in needing to get to every one of them as quickly as possible. During an epidemic like the flu, the ER is going to be packed and physicians will need to move from patient to patient quickly. However, they can actually do so just as fast, if not more so, virtually. Patients no longer have to become frustrated waiting hours in the ER intake room waiting to be seen. Instead, they receive more immediate care with less coordination and hassle at the office.

By using virtual care services, physicians are simplifying the process while also being able to scale faster. A dedicated virtual staff can answer patient questions efficiently while not losing the personal touch so they don’t feel rushed out of the office. Virtual care service removes the lag time between patients walking in and out of the office, allowing more time for care and the visit and the volume of those needing assistance decreases faster.

#3: Lower Out-of-Pocket costs While Increasing Retention Rates

It seems a patient’s immediate first step when they feel they are coming down with the flu or another quickly-spreading illness is to go to the ER or an urgent clinic because they want immediate care and do not want to wait to schedule an appointment with their primary care physician. Unfortunately, some of those types of visits are not covered by a patient’s insurance plan or they must pay an extremely high co-pay for it. As physicians, it is critical we better educate patients about virtual care services that can give them that immediate return that doesn’t cost them extra.

By reminding patients of these services and then providing quality care when they do utilize them, physician groups and healthcare organizations can build loyalty and begin shifting potential negative perceptions a patient might have about their provider. This allows providers to establish a true relationship with patients and be seen as a key resource for all health-related issues, which increases retention for reoccurring visits.

About the Author

Dr. Delanor Doyle

Dr. Delanor Doyle

Dr. Delanor Doyle is the chief medical officer of Texas Health Aetna, the jointly owned health plan focused on improving quality, affordability and overall member experience between Texas Health and Aetna. The company represents two leading healthcare organizations coming together to fundamentally transform the health care experience for members through technology-enabled, data-driven analytics and enhanced local care management. For more information, please visit

Guest Post: How U.S. Healthcare Mega-Mergers Hurt Patients

March 14th, 2018 by Robert E. Grant, Founder/CEO, CONCIERGE KEY Health

From the National Economic Council to the healthcare public policy experts at Harvard University, leading medical advisors and economists alike continue to invoke the words of Adam Smith, the eighteenth century British political economist and author of The Wealth of Nations who stated some 300 years ago, “Seldom do businessmen (companies) of the same trade get together but that it results in some detriment to the general public.”

Take the colossal U.S. financial collapse in 2008, for example, which followed an all-time mergers-and-acquisitions (M&A) high of $4.3 trillion in deals. Not more than five years passed before companies were willing to hedge their bets again—especially in the healthcare sector—but with markedly higher stakes. The same year the Journal of the American Medical Association released a thoughtful examination of hospital consolidation, penned by leading medical authorities from the Harvard School of Public Health who opposed the notion of mega-mergers, Teva Pharmaceuticals announced its plan to acquire Allergan’s generics business, Actavis Generics, for $66 billion.

According to data from the financial information firm Dealogic, that was just the tip of the iceberg. The close of 2017 bore witness to the consolidation of private practices, private equity funds and pharmaceutical companies at the current and future expense of the American healthcare patient, who in turn, experiences fewer choices and a decreased quality of care—all for a higher price.

Healthcare’s Merger Epidemic

In 2015, global M&As skyrocketed and set new records by exceeding $5 trillion. It was no surprise that the healthcare sector emerged a frontrunner, leading the charge that year with a total of $723.7 billion in deals. Gaining even more momentum with Abbott Laboratories announcing its definitive agreement to acquire St. Jude Medical for $25 billion in 2016, and a 2017 announcement by CVS to acquire the health insurance giant, Aetna, for roughly $70 billion, the industry innocuously sent a clear message that there was no longer a sky—or an effective governing body—to set any limits.

As the world heads toward the fourth industrial revolution, where artificial intelligence and automation are taking organizations to new heights, health systems and hospitals are falling in line to compete and retain a market share. In 2017 alone, consulting firm Kaufman Hall and Associates reported 115 hospital and health system mergers, which represented a 13 percent increase from 2016. Many experts believe part of the consolidation epidemic stems from the enactment of the Affordable Care Act (Obamacare) in 2010. Even Bob Kocher—the only medical doctor on the National Economic Council advising President Obama—recanted his support of consolidating hospitals, health systems and doctors into larger groups in an effort he believed could drastically improve the delivery of patient care. In 2016, he laid bare his soul in a Wall Street Journal op-ed titled, How I Was Wrong About ObamaCare.

But it’s not just the architects of Obamacare that have failed to heed the words of economists who, like Adam Smith, understand how fewer market participants and less competition are very likely to result in higher prices for consumers, without an improvement in quality.

Not All Mergers are Alike

It is important to note that not all mergers are considered equal. Consolidation driven by organic and natural forces of the market can undoubtedly decrease costs for consumers while improving the quality of a product or service. But if escalating healthcare costs and insurance premiums—along with a flawed system where seeing a specialist requires a referral protocol that can delay a visit by weeks or months—are any indication of the manic consolidations taking place today, it should be proof enough that we are headed for a reckoning.

Demanding More for Less

Even in a growing on-demand, digital economy where consumers can influence the decisions of others through multiple channels and social media platforms, the patient experience has yet to be addressed. In addition to soaring healthcare insurance premiums, in just three years the average new patient doctor appointment wait times in the U.S. increased by 30 percent, according to a 2017 Merritt Hawkins survey. In large markets, the average wait time to see a doctor was 24.1 days (up 30 percent from 2014), with average wait times to see a family medicine doctor up 50 percent. That may not mean much to a healthy individual relocating and searching for a new doctor, but for someone facing a potentially life-threatening illness, it could become a matter of life and death. Furthermore, prior studies such as the 2004 analysis of the 1996 Aetna acquisition of U.S. Healthcare put forth by University of California, Berkeley health economist, James C. Robinson, offer solid evidence that hospital and insurance mergers, in particular, almost always lead to higher costs, less efficiency and less innovation. Why? Because, as Adam Smith warned, mergers reduce competition, which is the driving factor of a free market.

Perhaps the greatest irony in all of human healthcare is that organizations came into existence for the very purpose of helping people get and stay well, yet it seems the survival of the organization has taken priority over the patient and obscured who the consumer actually is. Never before have health consumers been asked to pay so much for so little. It’s time to allow the invisible hand of the U.S. economy to operate as intended. It’s time to look past the bottom line and look to new business models that put patients at the center of the healthcare experience.

Robert E. Grant, Founder/CEO of CONCIERGE KEY Health

About the Author: Robert E. Grant is founder and chief executive officer of CONCIERGE KEY Health, the world’s first mobile app for on-demand access to elite doctors, including specialists and care facilities. An entrepreneur, inventor and investor, he has played a pivotal role for more than 20 years in successful technology and business development in pharmaceutical, medical device and healthcare markets. In addition to founding CONCIERGE KEY, Grant is founder and vice chairman of ALPHAEON Corporation, as well as founder, chairman and managing partner of its parent company, Strathspey Crown Holdings, LLC.

Most recently, Grant was CEO and president of Bausch+Lomb Surgical, leading the significant growth of its product portfolio. From 2006 to 2010, he served as president of Allergan Medical; Grant also served as director, board chairman, CEO, president, COO and CFO of Biolase Technology from 2003 to 2006.

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: Real-Time Data Analytics Key to Decreasing Denial Rates, Saving Time and Lowering Costs

February 22nd, 2018 by Jonathan Farr, Senior Vice President, North America, EFFY

For hospital and health system leaders, financial challenges pose some of the most insurmountable hurdles, with claim denials a significant contributor. Consider the numbers: annual losses from denial write-offs average 5 percent, and up to 15 to 20 percent of initial denials occur with the first billing. The burden of reworking denials not only impedes the revenue cycle process, but can also compromise care quality.

Furthermore, the number of hospital mergers and acquisitions surged by 15 percent between 2016 and 2017. This has generated massive sets of disparate data that must be reconciled and reviewed, creating an environment where the revenue cycle management (RCM) process can be fraught with missteps. As a result, today’s hospital leaders seek new opportunities for maximizing revenue, and identifying solutions that enhance both financial and clinical performance.

Optimizing Revenue Cycle Management

Issues that lead to denials occur throughout the revenue cycle. Certain best practices are helpful for hospitals of every kind and size, such as taking steps to minimize denials up front, managing them through efficient workflows and processes, and analyzing denials after the fact to identify common causes.

Perhaps the most important step hospitals can take is to find the right RCM solution to optimize financial performance—one that doesn’t require replacing an existing and often expensive operating system (OS). The best option is to find a partner that offers an actionable real-time or near real-time data analytics platform that overlays or integrates with the current installations.

Actionable Real-Time Data Analytics

An actionable real-time data analytics platform, especially one powered by an RCM optimization tool that has been proven effective across leading healthcare systems, telecom companies, utilities, retail and other complex industries, can help hospitals significantly minimize denials, and save time and money.

How does an RCM optimization tool work? It can audit and trigger efficiency actions in a way that is non-intrusive to the day-to-day work of the revenue cycle clerical staff. What’s more, this type of solution offers an efficiency platform that overlays an existing system to help healthcare organizations compare massive amounts of data across their total enterprise, detect exceptions and problems, and guide actions and interventions to improve efficiency.

An actionable RCM solution has the reconciliation and analytical tools that help organizations gather and compare data enterprise-wide, detect deviations, issue alerts and offer an integrated workflow to guide the ‘fixes’ they need.

With this solution, hospitals do not have to discard their OS because the RCM solution overlays the current installation, provides the necessary analytics and drives the corrective actions needed. Even better news for hospital leaders, this type of innovative RCM solution eliminates the need for large up-front acquisition costs, representing a financial transaction that does not compromise the bottom line.

Impressive Returns

An RCM solution that uses actionable real-time data analytics and powerful action-driven analytic tools has seen proven results: for one not-for-profit hospital, savings related to denials and write-offs continued to accrue and reached upwards of $800,000 in the first six months of operation.

Furthermore, back-end processes were streamlined, relieving stress and time constraints imposed on the clinical staff. Inadequate documentation of medical necessity was addressed, allowing the hospital to transition charges to patient self-pay or to initiate a change in the course of treatment.

This type of RCM solution represents the future of data analytics, helping hospitals increase net revenue by 3 to 4 percent, with ROI multiples of between eight and ten. It also allows a hospital to use any data from any OS to set up sophisticated validations to detect issues immediately.

By simply overlaying an actionable real-time data analytics system, RCM managers can quickly gain control of aggregated data, and detect/resolve issues that impact revenue integrity, as well as clinical and operational performance, in a way that is truly cost-effective.

About the Author: Jonathan Farr, MHA, is Senior Vice President, North America, for EFFY. Jon has prior experience managing general acute hospitals, surgical hospitals, emergency centric hospitals, behavior health hospitals, and a large physician practice, both for-profit and not for profit, urban and rural, domestic and international. He is highly respected for his ability to work with physicians, boards, committees, regulatory agencies, third party payors, vendors, patients and all levels of personnel. Jon earned a Master’s in hospital administration from the Medical College of Virginia and is a member of the American College of Healthcare Executives.

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.