Archive for the ‘Healthcare Administration’ Category

Infographic: The Reality of Healthcare Claims Denials

August 12th, 2016 by Melanie Matthews

Some 90 percent of healthcare claims denials are avoidable and two out of three denials are recoverable, according to a new infographic by ZirMed.

The infographic looks at the rates of claims denials, the cost of appealing denials and provides a timeline for working a denial.

Innovative Plan-Provider Ventures: Case Studies From Anthem and AetnaInnovative Plan-Provider Ventures: Case Studies From Anthem and Aetna provides the details of two case studies of plans and providers that are collaborating on value-based care models:

* Vivity, a collaboration between seven prestigious California health systems and Anthem Blue Cross of California, promises to improve quality and share cost savings among the participating entities.

* Innovation Health, the northern Virginia health plan owned 50-50 by Aetna Inc. and Inova Health System, represents a great example of an "alignment" structure, with the new health plan allowing the provider and carrier to tap into each other's expertise to lower costs, grow market share and move to value-based payment.

Innovative Plan-Provider Ventures: Case Studies From Anthem and Aetna provides strategies to reduce coverage costs and improve outcomes.

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Are You MACRA-Ready? Physician Groups Prep Members for Medicare Payment Modernization

May 16th, 2016 by Patricia Donovan

Physician groups digested the 962-page MACRA notice of proposed rule-making in order to distill the notice for their members.

As they digest the HHS's momentous proposal to modernize how Medicare provider payments are tied to the cost and quality of patient care, physician organizations are assembling arsenals of educational tools to de-mystify MACRA.

The federal government's first step in implementing certain provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was detailed in an April 2016 announcement.

Just nine days after that bulletin, the AAFP arranged a town hall meeting for its members with two high-ranking CMS officials to discuss the law that will greatly influence how physicians are paid. Comments provided by CMS Acting Administrator Andy Slavitt via conference call are detailed here.

While the HHS window to receive feedback on the proposal remains open through June 27, 2016, the AMA has created an extensive set of online resources to support physician preparations for a post-MACRA Medicare. The resources include a guide to physician-focused payment models, key points of the Merit-based Incentive Payment System (MIPS), and five things providers can do now to prepare for the legislation, among other resources, according to a May 2016 press release.

“The core policy elements in MACRA are surfacing in other public and private insurance programs, so understanding these policies will be essential for most physician practices,” said AMA President Steven J. Stack, MD.

The AMA's MACRA support tools were announced in conjunction with the release of its new interactive module on practicing value-based care authored by Grace Terrell, MD, an internal medicine physician and president of Cornerstone Health Care, who shares the proven steps her clinic used to focus on patients at the center of care.

The value-based care module is the latest in the AMA’s STEPS Forward™ collection of physician-developed practice improvement strategies.

Also readying its membership for MACRA is the AAFP, which last week launched a comprehensive member communication and education effort related to the proposed legislation. The AAFP's MACRA Ready site is a one-stop shop filled with resources family physicians can use right now such as the following:

  • A timeline of important MACRA dates;
  • A list of acronyms to help digest the alphabet soup associated with MACRA's complicated regulations;
  • A "MACRA in a Minute" 60-second overview video;
  • A deep-dive review of what value-based payment means to family physicians;
  • and much more.

In announcing the MACRA tools, AAFP President Wanda Filer, MD, MB, told family physicians that the academy's MACRA communication plan "is designed to help simplify the transition and provide the guidance that you will need to realize the benefits of MACRA and value-based payments."

A recent AAFP survey indicated that some 40 percent of family physicians already were involved in some kind of value-based payment system, she noted.

As she related the history of MACRA, Dr. Filer reminded members that the legislation not only repealed the sustainable growth rate (SGR) but also established an annual positive or flat-fee payment for the next 10 years as well as a two-track program (the MIPS, and Alternative Payment Models, referred to as APMs) for calculating Medicare payments beginning in 2019.

Infographic: 6 Healthcare Performance Management Trends

May 9th, 2016 by Melanie Matthews

The healthcare industry's transformation to a value-based system has placed even greater importance on performance management, according to a new infographic by Perficient. Healthcare Enterprise Performance Management creates visibility and accountability throughout the organization to identify financial performance gaps continuously and quickly change course when needed.

The infographic identifies 6 strategies and solutions that will help you succeed in a data-driven, cost-management culture.

Healthcare Trends & Forecasts in 2016: Performance Expectations for the Healthcare IndustryFrom cost pressures, consumerism and consolidation to a proliferation of patient-centered, value-based delivery and payment models, the state of healthcare continues to challenge organizations in the industry.

Healthcare Trends & Forecasts in 2016: Performance Expectations for the Healthcare Industry, HIN's 12th annual business forecast, pins down the trends destined to impact the industry in the year to come and proposes tactics C-suite executives can employ to distinguish their operations in a dynamic marketplace. Click here for more information.

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MACRA Transition Bolstered by CMS Quality Measure Development Plan

May 9th, 2016 by Patricia Donovan

payment bundling shared savings

Partnerships are key to the final Quality Measure Development Plan by CMS.

The final Quality Measure Development Plan by CMS is an essential aspect of its transition to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), according to last week's blog post by Kate Goodrich, MD, MHS, director of CMS's Center for Clinical Standards & Quality.

The Quality Measure Development Plan is a strategic framework for clinician quality measurement development to support the new Merit-based Incentive Payment System (MIPS) and advanced alternative payment models (APMs), stated Dr. Goodrich.

CMS recently rolled out a proposed rule outlining MACRA's payment incentives for physicians and other clinicians based on quality rather than quantity of care.

The final Quality Measure Development Plan will provide the foundation for building and implementing a measure portfolio to support the quality payment programs under MACRA, Dr. Goodrich said.

After considering comments and suggestions for the plan, CMS finalized the Quality Measure Development Plan to include the following:

  • Identification of known measurement and performance gaps and prioritization of approaches to close those gaps by developing, adopting and refining quality measures, including measures in each of the six quality domains:
    • Clinical care;

    • Safety;

    • Care coordination;

    • Patient and caregiver experience;

    • Population health and prevention;

    • Affordable care.
  • CMS actions to promote and improve alignment of measures, including the Core Quality Measures Collaborative, a work group convened by America’s Health Insurance Plans (AHIP). On February 16, 2016, CMS and the collaborative announced the selection of seven core measure sets that will support multi-payor and cross-setting quality improvement and reporting across our nation’s healthcare systems.
  • Partnering with frontline clinicians and professional societies as a key consideration to reduce the administrative burden of quality measurement and ensure its relevance to clinical practices.
  • Partnering with patients and caregivers as a key consideration for having the voice of the patient, family, and/or caregiver incorporated throughout measure development.
  • Increased focus and coordination with federal agencies and other stakeholders to lessen duplication of effort and promote person-centered healthcare.

Yale New Haven’s High-Risk Care Management Commences with Its Employees

January 14th, 2016 by Patricia Donovan

A care management pilot by YNHHS for employees and their dependents with diabetes was a template for future embedded care management efforts.

Disenchanted with vendors it engaged to provide care management for its workforce, Yale New Haven Health System (YNHHS) launched an initial care management pilot for its high-risk employee populations. The pilot went on to become a very robust program and served as a training ground for two more embedded on-site care management initiatives. Here, Amanda Skinner, YNHHS's executive director for clinical integration and population health, provides details from on-site face-to-face care management for YNHHS employees and their dependents.

We have an RN care coordinator based on each of the four main hospital campuses of our health system: one in Greenwich, one in Bridgeport and two in New Haven. All of the RN care coordinators in this program are trained in motivational interviewing. The intent is for them to work with our high-risk, high-cost employees who have chronic diseases, and with their adult dependents that also fall into that population.

The care coordinators work with these employees across the entire system to help them access the care they need, identify their goals of care, get under the surface a little to determine barriers to their being as healthy as they can be, and manage them over time. We did create some incentives for employee participation in this program, including waived co-pays on a number of medications (for example, any oral anti-diabetics).

When we initially launched the program, we limited it to employees and dependents that had diabetes, because that was the population for which we had very robust data. We also knew that diabetes was generally a condition that lent itself well to the benefit of care coordination; that there were a lot of gaps in care. When we looked at our data, we saw that ED utilization was very high for this population; that their past trend was rising, that utilization of their primary care provider was actually below what you would expect. This meant that they were under-utilizing primary care, over-utilizing hospital services, and were not particularly compliant with care.

With that population, we saw a lot of opportunity that a care management program could help address. In general, diabetes is a condition that lends itself to accepting a helping hand, to help people understand their condition and address the medical and social issues so they can manage that condition more effectively.

The program has been tremendously successful. We expanded it this year to include wellness coaches based at all of our delivery networks’ main campuses as well. These coaches work with a lower risk population and are available to any health system employee that wants to work with a coach to set care goals and then meet with the coach monthly or quarterly to track improvements against those goals. This expansion is because we’ve seen such positive results from this program.

Source: 3 Embedded Care Coordination Models to Manage Diverse High-Risk, High-Cost Patients across the Continuum examines YNHHS's three models of embedded care coordination that deliver value while managing care across time, across people, and across the entire continuum of care. In this 30-page resource, Amanda Skinner, executive director for clinical integration and population health at Yale New Haven Health System, and Dr. Vivian Argento, executive director for geriatric and palliative care services at Bridgeport Hospital, present a trio of on-site care models crafted by YNHHS to manage three distinct populations.

Guest Post: Delivering Value-Based Healthcare Starts at the Top

January 7th, 2016 by Nicholas Christiano, National Managing Partner, Healthcare, Tatum

The healthcare industry has long been characterized by change and evolution. Yet, new requirements introduced by the Affordable Care Act (ACA), as well as changing demands and expectations among patients, have created new pressures for today’s healthcare organizations. Healthcare providers that fail to address this new reality and meet the call for more value-based healthcare that focuses on the patient will struggle to remain sustainable in this changing world.

So, what can healthcare management do to prepare their organizations to deliver more customer-centric care? Although a recent study found that the vast majority of healthcare CEOs plan to improve their ability to innovate, change technology investments and better manage data, very few have made significant headway in these areas. As with any large-scale change, the move to customer-centric healthcare needs to start at the top. To ensure an effective transition, C-level executives, whether the CEO or chief medical officer (CMO), must take the lead to get their teams on board and ensure they can create a sustainable model for the future.

A New Approach to Patient Care

Today’s patients have greater choice in the care they receive, meaning that organizations that don’t provide a positive experience for their patients will struggle to compete. The onus to improve falls on the CEO and CMO, who must revamp the typical patient experience of waiting a long time, only to spend five to seven minutes with the physician. Healthcare leaders can improve the process by making the operation more like a concierge service—scheduling appointments at literal points in time to minimize waiting, enabling patients to enter their information only once and treating patients as valued customers. They should also strive to offer more flexibility by way of extended hours, home visits and telehealth programs that enable patients to have a remote, video-based conversation with their physician.

In addition to optimizing the patient experience, healthcare leaders must also change their cost structures. Rather than the typical process of determining prices behind closed doors and putting a margin on it, costs need to come down, be determined by performance and quality of service and be delivered with greater transparency. More and more, the industry is shifting to a value-based operating model. One such example is the accountable care organization (ACO) model, whereby healthcare providers join together to deliver a payment and care delivery approach that ties provider reimbursements to quality metrics, while driving down costs for an assigned patient population.

The ACO approach links payment to quality improvements that can reduce costs for patients; data from the U.S. Centers for Medicare & Medicaid Services found that the ACO model has led to savings of $417 million since the program began in 2012. As the model continues to evolve, healthcare organizations will be managing a particular portion of the population whom they see regularly. When patients are part of a healthcare organization and receive frequent care, fewer patients will need emergency room service, resulting in lower costs. The industry is increasingly moving towards value-based operating models, but as with any change, implementing the associated customer-centric practices may be easier said than done.

Best Practices to Deliver Customer-Centric Care

To ensure their organizations remain competitive and sustainable in the face of unprecedented change across the healthcare industry, the CEO and CMO must implement the strategies that can lead to positive transformation. Though large-scale changes don’t happen overnight and inevitably will be met with some resistance, healthcare leaders should consider the following best practices to deliver a customer-centric approach:

  1. Meet patients where they are: Today’s healthcare consumers increasingly expect the same level of service from their healthcare providers that they receive in other areas of life and business. Healthcare leaders must spearhead the process changes that meet this demand, by providing greater flexibility, extended hours, home visits and telehealth.
  2. Set the tone for employees: To implement effective change management and overcome employee resistance, CEOs and CMOs must provide strong guidance throughout. Working with other C-suite executives to identify transformation needs, communicate these changes, introduce tools that can facilitate the transition and explain how each employee can contribute to delivering customer-centric care is essential.
  3. Revamp cost structures: To be successful, CEOs and CMOs must deliver on two key priorities: keeping patients healthy and providing service at reasonable costs. This entails designing a fundamentally different operating model and driving down costs for activities that do not provide value – all while offering higher-quality care to their target population.
  4. Seek outside help when needed: Healthcare leaders might not always have the internal senior-level capacity and capability needed to accelerate change. Leveraging the help of an executive talent provider to ensure the organizations have the support and expertise to deliver a more customer-centric patient experience can make all the difference.

Meeting Demand for a New Level of Care

As the ACA has given more people greater access to healthcare—and more options in how they receive that care—healthcare leaders must rethink their current processes to deliver high quality care. If patients are unhappy, they can always switch to another provider. In this age of empowered patients and increased competition between providers, the CEO and CMO must communicate a transformative vision throughout their organizations. This starts with having qualified leadership at the top to guide these changes, the right technology to facilitate the processes and the best team to deliver on this goal. With these factors in place, healthcare organizations can deliver the customer-centric care necessary for success in today’s healthcare climate.

Nick Christiano

About the Author: Nick Christiano is responsible for the overall execution of the National Healthcare Practice for Tatum, a Randstad company. The Healthcare Practice provides executive leadership solutions to healthcare provider organizations, heath plans, private-equity backed bio-tech firms and affiliated organizations where subject matter expertise is critical to a successful client engagement. Christiano is recognized as a leader in the pursuit of optimum patient care, productivity, efficiencies, cost management and navigating new challenges in the healthcare field. He has an M.B.A. in MIS/Finance from the John Hagan School of Business – Iona College and a B.S. with a dual major in Computer Science/Electrical Engineering from N.Y.I.T.

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 remain with them. The company accepts no liability for any errors, omissions or representations.

Infographic: Systemized Care by Physicians

January 6th, 2016 by Melanie Matthews

As patient care becomes increasingly systemized, more doctors say they feel less engaged and less motivated, according to a recent infographic by Bain & Company.

The infographic looks at the growth in the number of physicians using electronic medical records and treatment protocols, along with the growth in the number of doctors who work in large, management-led organizations.

Healthcare Trends & Forecasts in 2016: Performance Expectations for the Healthcare IndustryFrom cost pressures, consumerism and consolidation to a proliferation of patient-centered, value-based delivery and payment models, the state of healthcare continues to challenge organizations in the industry.

Healthcare Trends & Forecasts in 2016: Performance Expectations for the Healthcare Industry, HIN's 12th annual business forecast, pins down the trends destined to impact the industry in the year to come and proposes tactics C-suite executives can employ to distinguish their operations in a dynamic marketplace.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you'd like featured on our site? Click here for submission guidelines.

2015 Healthcare Headlines: Top Stories Trace Route to Value-Based Reimbursement and Care

December 28th, 2015 by Patricia Donovan

Month by month, the industry's top stories confirmed that value-based innovations and collaborations are here to stay.

A look back at the year's top healthcare stories captures the industry's commitment to enhance the quality and efficiency of care delivered while reining in cost. Nearly all of HIN's most-read stories fell into one of two categories: announcements of new value-based models or pilots, or results from existing quality-focused initiatives.

Here are the stories that captured the attention of healthcare executives in 2015:

HHS Announces Timetable, Goals for Medicare Value-Based Reimbursement
Medicare kicks off 2015 with the rollout of an ambitious multi-year agenda for a shift to value-based reimbursement and alternative payment models.

Cigna Collaborative Care Reduced Avoidable ER Visits by 16 Percent
The February release of Cigna’s second-year results from a collaborative care initiative with Granite Healthcare Network documented significant progress in improved health and affordability.

2015 Hospital Market Will Hasten Transition to Value-Based Payment Business Model
The early 2015 economic outlook for the hospital industry continued to favor the largest, most geographically diverse health systems in the market, according to this January 2015 forecast from BDC Advisors.

Medicare Discharge Planning Proposed Rule: More Focus on Patient Preferences, Follow-Up Care and Communication
CMS proposed in October a revision of discharge planning requirements that hospitals, including long-term care hospitals and inpatient rehabilitation facilities, critical access hospitals, and home health agencies, must meet in order to participate in the Medicare and Medicaid programs.

Senate's Repeal of Medicare Sustainable Growth Rate Strengthens Move Toward Value-Based Physician Reimbursement
April 2015 saw the U.S. Senate's landmark repeal of the Medicare Physician Payment Reform Bill, otherwise known as the Sustainable Growth Rate (SGR), a mechanism used to calculate Medicare payments to physicians.

One-Fifth to Launch 'Next Generation ACO' in 2015
Twenty percent of healthcare organizations plan to participate in CMS’s new ‘Next Generation ACO' model in the coming year, according to 2015 Accountable Care Organization metrics compiled in May.

8 Wellmark Medicare ACOs Saved $17 Million in 2014, Boosted Quality by 8%
September saw the release of Wellmark Blue Cross and Blue Shield’s 2014 Accountable Care Organization (ACO) Shared Savings model data, in which eight participating ACOs improved their overall quality scores by 8 percent and saved more than $17 million during 2014.

CMS Launches New ACO Dialysis Model
CMS announced in October its Comprehensive ESRD Care (CEC) Model, designed specifically for beneficiaries with ESRD and built on lessons learned from other models and programs with ACOs, including the Pioneer ACO Model and the Medicare Shared Savings Program.

Final Rule for Joint Replacement Bundled Payments Favors Composite Quality Score
In November, CMS finalized its Comprehensive Care for Joint Replacement (CJR) model, set to begin on April 1, 2016, which will hold hospitals accountable for the quality of care they deliver to Medicare fee-for-service beneficiaries for hip and knee replacements and/or other major leg procedures from surgery through recovery.

Geisinger Pilots Patient Experience 'Warranty' for Select Surgeries
The Pennsylvania health system generated headlines in November with the launch of its innovative ProvenExperience™ warranty, a program that keeps the patient experience front and center by offering refunds to patients undergoing select surgical procedures whose expectations weren't met based on kindness and compassion.

To stay abreast of the latest healthcare headlines in 2016, subscribe free to HIN's Healthcare Business Weekly Update.

What’s the Future of Accountable Care Organizations?

December 22nd, 2015 by Patricia Donovan

CMS launched its Pioneer ACO program in 2012, designing the initiative for early adopters of coordinated care who tend to be more experienced, have an established care coordination infrastructure, and assume greater performance-based financial risk. Following the departure of several healthcare organizations in 2015 from the Medicare Pioneer ACO program, the Healthcare Intelligence Network asked some industry thought leaders what these actions signal for the remaining Pioneer ACOs, other ACO programs and accountable care organizations in general.

(Laura Jacobs, executive vice president, Healthcare Camden Group) The flaws in the ACO model are becoming apparent as organizations are moving into the second and third years of their profiles, of their contracts. That’s the big challenge for the ACO model in general. The big wins in many cases for the ACOs were in markets where the costs were very high to begin with, and organizations were able to achieve their savings relatively easily. Some organizations weren’t even sure what they did to generate savings. But once you get into the second and third years, it becomes harder and harder to continue to achieve the performance thresholds.

That says that the ACO model in its current form must continue to evolve. We must think about how to get the data, how to deal with patient attribution, and how to manage in an environment where the savings will become increasingly difficult to achieve the further along you get. I see the ACO model as a model that will probably evolve to something else. One of the ideas in the Next Generation ACO is to try and continue to tweak that model. I think we’ll continue to see that on both the Medicare side and the commercial side; to see how this ACO structure continually needs to be modified.

(Paul H. Keckley, Ph.D., managing director, Navigant Center for Healthcare Research and Policy Analysis) CMS is doubling down on ACOs. Look at how CMS has pitted ACOs as part of its future. The ACO has the organizing framework, especially around strong primary care provider organizations. Then, sitting beside it are bundled payments, which become the organizing principle for specialists in hospitals on the inpatient side. It’s a pretty interesting Yin-Yang. All the indications from the hill are that this is the future; this is the track that’s been set for these alternative payments.

I think Laura is right. They’ll keep tweaking the program. They’ve doubled down on it, they’ve added three new programs to the first ones. The ACO is here to stay.

Source: Healthcare Trends & Forecasts in 2016: Performance Expectations for the Healthcare Industry

Healthcare Trends & Forecasts in 2016: Performance Expectations for the Healthcare Industry, HIN's 12th annual business forecast, pins down the trends destined to impact the industry in the year to come and proposes tactics C-suite executives can employ to distinguish their operations in a dynamic marketplace.

Healthcare Drivers for 2016: Cost Management, Consolidation, Consumerism

November 19th, 2015 by Patricia Donovan
Healthcare Trends 2016

Healthcare data, both system-generated and consumer-reported, will continue to transform the industry in the year ahead, according to HIN's twelfth annual strategic planning session.

As healthcare heads into a presidential election year, cost management remains a key focus, with infomediation—the growing practice of mining healthcare data about cost, quality, and services—a major tactic against price pressure.

These were just a few predictions by thought leaders during an annual industry strategic planning session sponsored by the Healthcare Intelligence Network.

"The North Star now for healthcare, for all players in the system, is sustainable cost," said Paul Keckley, managing director of Navigant, during Trends Shaping the Healthcare Industry in 2016: A Strategic Planning Session, now available for replay. Multiple forecasts indicate U.S. health costs will increase between 5.6 and 6 percent a year over the next decade, he noted, with the nation's economy only recovering to about a 3 percent growth rate.

"Not to be missed is the pressure on price and therefore, the pressure on reducing operating costs and reducing the cost per episode of care," agreed Laura Jacobs, executive vice president of GE Healthcare Camden Group. "Where you're going to be in that cost value equation is a key strategic question and should be part of your board discussions about where you want to be on that spectrum."

To become leaner and more efficient, healthcare organizations are closing ranks in increasing numbers. Ms. Jacobs predicted that this "dance of consolidation" would continue among all stakeholders in healthcare, with intense scrutiny by the FTC of those collaborations.

Some payors already are well ahead of hospitals, doctors and service providers in the degree of consolidation, added Mr. Keckley. "These super regional systems of care are evolving as a result of this transition of volume to value."

At the moment, health plans are better positioned to profit from healthcare's pay for value formulas and the proliferation of shared risk arrangements, he continued, largely because of the huge data repositories they have constructed. "A very strong meta-analysis of [health plan] data becomes the anchor for shared risk arrangements," Keckley said, referring to the phenomenon known as infomediation. "The strongest asset health plans have is their data." Manipulation of this data to influence population health trends is fast becoming central to health plan operations, he said.

Another type of data the healthcare industry should be cognizant of is consumer-generated healthcare data, in the form of provider reviews on social media or within apps. "Consumer reporting on their experience with providers is not something that providers love," Ms. Jacobs said. "But just as we've experienced with other parts of consumerism, the impact of these kinds of venues will continue."

The panelists also shared thoughts on opportunities in the Medicare Advantage market, the blurring of lines between payor and provider, early returns from provider-sponsored health plans, and the anticipated evolution of primary care as the "epicenter" of healthcare.

Click here to listen to more predictions from Laura Jacobs.