Archive for the ‘Healthcare Costs’ Category

Infographic: Six Health Plan Design Changes To Maximize ROI

January 2nd, 2015 by Melanie Matthews

Employers are using a number of strategies to maximize health plan return on investment in light of increasing healthcare costs.

A new infographic by Towers Watson explores the strategies and approaches companies are adopting, such as new coverage or utilization restrictions on specialty pharmacy, employee accountability, technology and more.

Narrow Network Strategies and Trends for Health Plans and PBMsNarrow networks — for both medical and pharmacy providers — are gradually becoming more accepted by carriers, plan sponsors and patients. Smaller provider networks allow payers to manage overall healthcare costs while still maintaining access to benefits — an important consideration as plan designs become more commoditized in the age of public and private health insurance exchanges.

Narrow Network Strategies and Trends for Health Plans and PBMs outlines the tactics health plans are using to restrict medical and pharmacy networks while still maintaining adequate access to care and positive relationships with providers. It also summarizes case studies of health plans and PBMs that have formed narrow networks and the results they've seen.

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The Year in Healthcare Intelligence: Reimbursement, Value-Based Results Resonate with Readers

December 29th, 2014 by Patricia Donovan

Newswise, fee-for-value healthcare initiatives eclipsed fee-for-service models.

When survival of healthcare providers hinges on payment for services rendered, it's not surprising our 2014 readers closely tracked news of emerging payment models and results from patient-centered, quality-based initiatives.

Here is a retrospective of stories that dominated our readers' news feeds over the last 12 months:

  • We reported on results from many accountable care organizations (ACO) over the last year, but few generated interest like the Anthem Blue Cross-Healthcare Partners accountable care collaboration that saved more than $4 million. The program succeeded by sharpening its focus to those with two or more chronic diseases—the population that research shows can most effectively be helped by coordinated care, officials state. A dedicated staff of care managers and care coordinators identify hospitalized ACO patients, coordinate transitions of care, and ensure patient care and healthcare resources are accessible.

  • Heads also turned when the Centers for Medicare and Medicaid Services (CMS) proposed updated penalties and incentives for its Medicare Shared Savings Program (MSSP), an accountable care initiative for Medicare beneficiaries. The proposed rules are designed to strengthen MSSP by placing greater emphasis on primary care services and promoting transitions to performance-based risk arrangements. CMS is also suggesting a third ACO model," track 3," which integrates some elements from the Pioneer ACO model.

  • The patient-centered medical home (PCMH) model, a stepping stone to an ACO, garnered its share of readership, especially when the National Committee for Quality Assurance (NCQA) added five measures to its medical home criteria, the gold standard for patient-centered measurement.

    In its third iteration of PCMH standards since 2008, the NCQA added behavioral health integration and care management for high-need populations, among other new criteria.

  • The patient-centered model suffered a setback, however, when one of the first, largest, and longest-running multipayor trials of PCMHs in the United States was associated with limited improvements in quality and was not associated with reductions in use of hospital, emergency department (ED), or ambulatory care services or total costs of care over three years. Research by Rand Corporation and colleagues centered on patient-centered activities in the Southeastern Pennsylvania Chronic Care Initiative.

  • There was good news on the medical home front, however: A study published in September, 2014 attributed reductions in emergency room visits, principally by patients with chronic illness, to the PCMH approach. Research by Independence Blue Cross (Independence) and CTI Clinical Trial and Consulting Services (CTI), and published by Health Services Research, found that transitions to a medical home were associated with a 5 to 8 percent reduction in ED utilization. This finding is specific to patients with chronic illness(es) having one or more ED visits in any given year. These reductions were most evident among patients with diabetes.

  • Readers also paid attention when Geisinger Health System, an early adoptor of care coordination for chronic illness, announced that its all-or-none or “bundled” approach to primary care for patients with diabetes produced better health outcomes, and the benefits happened quickly for the more than 4,000 patients in the study. The system-wide approach was not easy, warned Geisinger: the model requires constant evaluation, and must be scalable across a variety of practice settings.

  • Also raising the bar for physician practices was Highmark, which shared six requirements for the "best practices" element of its successful pay-for-performance initiative. Physician practices can earn additional rewards for completion of an office-based best practice project, essentially a small pilot, that involves measurement and reporting.

  • On the flip side, reporting of some questionable hospital pricing strategies rated some page views as well. Data released early in 2014 by National Nurses United (NNU) and the Institute for Health and Socio-Economic Policy (IHSP) found that some U.S. hospitals charge more than 10 times their cost, or nearly $1200 for every $100 of their total costs. Public oversight or regulation seems to help constrain excessive pricing, researchers found; Maryland, probably the most regulated state in the United States, has the lowest average charges of all the states among its 10 most expensive hospitals.

  • Cost savings aside, readers seemed especially attuned to new approaches or technologies designed to streamline healthcare delivery and enhance the patient experience, such as an uptick in remote monitoring.

    One hundred percent of respondents to the Telehealth in 2013 Survey by the Healthcare Intelligence Network monitor weight and vital signs, up from a respective 79 and 77 percent in 2010. The health conditions monitored remotely remain the same from 2010, the top three being heart failure, COPD and diabetes.

  • And finally, as all eyes focus on care management interventions that span the healthcare continuum, many readers responded to a story on a CMS pilot that would give hospice patients more options in the type of care they wish to receive at the end of life. Under the Medicare Care Choices Model, individuals who meet Medicare hospice eligibility requirements could receive palliative care services from certain hospice providers while concurrently receiving services provided by their curative care providers.

Were these stories on your news radar in 2014? Stay up-to-date in 2015 with the latest healthcare news, trends and benchmarks with a free subscription to the Healthcare Business Weekly Update.

11 Statistics About Remote Patient Monitoring

December 23rd, 2014 by Cheryl Miller

Remote monitoring of individuals with multiple chronic conditions reduced hospitalizations, hospital readmissions and ER visits for more than 80 percent of respondents and boosted disease self-management for nearly all of these monitored patients, according to the 119 respondents who participated in the Healthcare Intelligence Network's inaugural survey on Remote Patient Monitoring in March 2014. Other targets of a remote monitoring strategy included frequent utilizers of hospitals and emergency rooms (ERs) (62 percent) and the recently discharged (52 percent).

Following are seven more statistics from the Remote Patient Monitoring survey:

  • Fifty percent of respondents rely on specific diagnoses sets to identify candidates for remote monitoring.
  • More than a quarter of respondents (27 percent) target the frail and/or home-bound with remote monitoring programs.
  • Reimbursement for remote monitoring, followed by the education of patients in this technology, were identified by respondents as the chief challenges of these remote care management efforts.
  • Two-thirds of respondents said remote monitoring reduced bed days.
  • Telephonic case management is a component of remote monitoring efforts for 71 percent of 2014 respondents.
  • About a third of respondents report the use of either a Web interface or a dedicated mHealth app to supplement remote monitoring.
  • A patient-centered touch, such as a follow-up phone reminder to use a monitoring device or a personal coaching session, was frequently cited as a noteworthy supplement to remote monitoring technology.

Source: 2014 Healthcare Benchmarks: Remote Patient Monitoring

http://hin.3dcartstores.com/2014-Healthcare-Benchmarks-Remote-Patient-Monitoring_p_4868.html

2014 Healthcare Benchmarks: Remote Patient Monitoring delivers a comprehensive set of metrics from more than 100 healthcare organizations on current practices in and ramifications of remote monitoring for care management of chronic illness, the frail elderly and remote populations.

Infographic: Out-of-Pocket Costs and the Elderly

December 1st, 2014 by Melanie Matthews

Nineteen percent of Americans over age 65 skip needed healthcare because of high out-of-pocket costs, according to a new infographic by the Commonwealth Fund.

The infographic also looks at how this compares to the elderly in France and Sweden.

Remote Patient Monitoring for Enhanced Care Coordination: Technology to Manage an Aging PopulationFrom home sensors that track daily motion and sleep abnormalities to video visits via teleconferencing, Humana's nine pilots of remote patient monitoring test technologies to keep the frail elderly at home as long as possible. When integrated with telephonic care management, remote monitoring has helped to avert medical emergencies and preventable hospitalizations among individuals with serious medical and functional challenges.

In Remote Patient Monitoring for Enhanced Care Coordination: Technology to Manage an Aging Population Gail Miller, vice president of telephonic clinical operations in Humana's care management organization, Humana Cares/SeniorBridge, reviews Humana's expanded continuum of care aimed at improving health outcomes, increasing satisfaction and reducing overall healthcare costs with a more holistic approach.

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Infographic: Hidden Costs of Healthcare

November 28th, 2014 by Melanie Matthews

Rising consumer out-of-pocket (OOP) healthcare spending also impacts hospitals, life sciences companies and health plans, according to Deloitte's Center for Health Solutions.

Government data shows rising OOP spending for consumers, but excludes some types of health-related items and services that can add significantly to the total amount and consumer share of spending. This infographic exposes these "hidden costs" that account for almost one-fifth of total health care spending.

Bundled Payment Models: Bottom-Line Strategies for InsurersCase studies of two insurers that have developed bundled payment systems to reimburse providers for several episodes, including total joint replacements, congestive heart failure and colonoscopy. From how the payers got started to the pitfalls they encountered and the latest financial and quality outcomes seen, this report walks through the entire process of building a bundled payment system.

Bundled Payment Models: Bottom-Line Strategies for Insurers provides the details of how two insurers — Horizon Healthcare Services, Inc. and Arkansas Blue Cross and Blue Shield — developed successful programs to reimburse providers for episodes of care, combining payments for all aspects of treatment rather than paying providers individually for tests, office visits and procedures.

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CMS Chronic Care Management Medicare Reimbursement: Sizeable Revenue, Health Outcome Opportunities

November 21st, 2014 by Cheryl Miller

Beginning January 2015, Medicare will pay a flat, monthly chronic care management (CCM) fee to providers coordinating care for beneficiaries with more than one chronic condition. This change will expand the current Medicare payment policy to include non face-to-face management services previously included within payments for evaluation and management (EM) services, amount to about $40 a beneficiary, a sizeable new source of revenue for eligible providers.

The targeted population is also substantial; as recent news story reported by the Healthcare Intelligence Network (HIN), 87 percent of U.S. adults ages 65 and older have at least one chronic illness, and 68 percent have two or more, the highest rates in a new 11-country Commonwealth Fund survey.

But healthcare organizations do not have that much time to prepare for the newly released 2015 Medicare Physician Fee schedule, which finalized the CCM reimbursement. Who can bill for CCM, what constitutes a chronic condition, which patients are eligible to receive CCM services, and the scope of services required were among the issues discussed during Chronic Care Management Medicare Reimbursement: New Revenue Opportunities for Care Coordination, a November 19th webinar, now available for replay. Rick Hindmand, an attorney with McDonald Hopkins, a law firm that advises a nationwide client base extensively on healthcare reimbursement, shared insight on these issues and how to best prepare for this reimbursement opportunity.

Those allowed to bill for CCM reimbursement fall into one of five categories: physicians, advanced practice registered nurses (APRNs), physician assistants (PAs), clinical nurse specialists and certified nurse midwives. If these practitioners are part of a practice entity, that entity can bill for it as well.

Beneficiary requirements are not as clear cut, Mr. Hindman continued. Eligible patients must have at least two chronic conditions that are expected to last at least 12 months or until death, and those conditions need to create a significant risk of death, acute exacerbation/decomposition or functional decline. Specific definitions of conditions can be found at CMS’s Web site.

And because CMS does not want to pay for duplicative services, CCM is not allowed for beneficiaries who receive services for transitional care management, home healthcare supervision, hospice supervision, and various end stage renal disease (ESRD) conditions. Patients attributed under the Multi-payer Advanced Primary Care Practice Demonstration (MAPCP) and the Comprehensive Primary Care (CPC) Initiative are also excluded.

Once these requirements are satisfied, providers must offer and document 20 minutes of CCM services a month, which enhance access and continuity of care, care management, transition management, and coordination, Mr. Hindman continues.

The CCM fee comes to about $40 a beneficiary, a significant revenue source once applied to all patients within a practice. Why the change now? Mr. Hindman speculates that CMS is finally realizing that care management is a crucial component of primary care. But questions and details await future guidance from CMS, and satisfying and documenting compliance with the CCM reimbursement requirements is going to present a challenge for many practices.

But the time and effort is worth it, he says. "With careful structuring, chronic care management can provide the potential to improve the health of their patients, while also providing some significant financial benefits for the practice."

To listen to an interview with Mr. Hindman, click here.

Strong Signals Favor Bundled Payments to Reduce Cost of Care

October 21st, 2014 by Patricia Donovan

Besides piloting the use of bundled payments to enhance healthcare quality and efficiency, CMS's 2013 introduction of CPT codes for physician management of care transitions after discharge signals the federal payor's increased comfort with episodic-based reimbursement. Jay Sultan, associate vice president and chief product portfolio architect for TriZetto® offers his perspective on the future of bundled payments in healthcare.

Healthcare is such a cyclical industry. Anybody who says this is the new movement and it’s here to stay has a better ability to read the future than I do.

I believe that bundled payment is going to continue to increase adoption. And then I think we’ll see a pullback in rate of adoption that will be caused by two things: one will be just the fact that we’ll have picked off all the low fruit, and what’s left is harder. I’m sure there’s somebody out there who wants to do a bundle of fibromyalgia, but I don’t want any part of that. The second reason they’ll pull back is because they’ll learn some negative lessons.

One of the things about payment bundling to date, at least in the prospective payment bundling (think model four of the CMS program), is that many commercial programs are just getting started right now. One lesson to date is there just are no negative examples. There’s negative examples in retrospective payment bundling. For prospective payment bundling, we haven’t had failures yet. Those are inevitable and they’re going to come. And as they come, I think that will create a somewhat inhibiting effect.

But overall, it’s hard to imagine. What payment bundling does is change the inner purchase. We’re saying, we’re tired of buying CPT codes of services. Instead, we want to start buying longitudinal care as an episode, as a bundle. And that trend is exactly where capitation takes them, exactly where partial capitation takes us. It’s where our provider-run health plans take us. It’s just another point along the continuum of how much risk providers are taking.

I don’t think bundled payments are going to go away. CMS is signaling very, very strongly that this is part of its future, for a basic reason. It’s one of the few tools it has that can actually reduce the cost of care. For those who think that this is going to go away, I’d harken you back to the onset of DRGs. Today, DRG-based care is pretty pervasive. But it certainly doesn’t cover all of care. It doesn’t even cover all of hospital care. It doesn’t cover all of CMS hospital care.

value-based reimbursement
Jay Sultan is the associate vice president and product manager for value-based reimbursement at TriZetto®. With more than 12 years of consulting and development experience in the payer and hospital settings, Sultan is responsible for developing innovative solutions such as payment bundling and other forms of value-based reimbursement. He is also providing leadership on the adoption of clinical analytics into TriZetto solutions.

Source: Value-Based Reimbursement Answer Book: 97 FAQs on Healthcare Models, Measures and Methodology

Adventist Population Health Management Incentives Engage Employees, Curb Costs

October 16th, 2014 by Cheryl Miller

If employees are healthier, they're more effective, engaged in their work, and more present, says Elizabeth Miller, vice president of care management at White Memorial Medical Center (part of Adventist Health). Presenteeism is part of the company's "Engaged Health Plan," a patient engagement strategy that is targeted to save as much as $49 million overall.

To engage patients, you can offer incentives. For example, at Adventist Health we outreach to our entire organization, our own employees, and we are on track to save millions of dollars with that. We call it ‘The Engaged Health Plan’ and it’s a reduced monthly cost on their health insurance. It is a bi-weekly reduction of $50, which is significant. They’re saving $100 a month. We engaged by taking their blood pressure, their weight and their blood glucose. We created an exercise plan for them with their consent, talked to them about their physical conditioning and what they wanted to see in their physical. We also talked about the ideal health population, and how we consider a healthy employee a more effective employee.

It’s costing our organization money to put this on; even though it’s our own health plan, it does cost. Why did Adventist Health go in this direction? You can see with the cost and the savings that it will save us $49 million. It is a mission. We are a faith-based organization, but it is a mission of ours to improve the health status. And it is also going to improve us financially. If our employees are healthier, they’re more effective, more engaged in their work, more present. You’ve heard of presenteeism. These are things that we’ve looked at.

dual eligibles care
Elizabeth Miller, RN, MSN, is the vice president of care management, diabetes program at White Memorial Medical Center, Adventist Health. Ms. Miller is accountable for the daily operations of the care management team, nurse care managers, social workers and the diabetes program, ensuring optimal patient flow through the healthcare continuum of care.

Source: Population Health Framework: 27 Strategies to Drive Engagement, Access & Risk Stratification

4 Factors Driving Resurgence in the Physician-Hospital Organization Model Today

October 10th, 2014 by Cheryl Miller

As healthcare organizations seek the infrastructure to respond to emerging payment models like accountable care organizations (ACOs), bundled payments, narrow networks and direct contracts, the physician-hospital organization (PHO) model is experiencing a resurgence nationwide.

But will it work this time? Four factors make the PHO attractive, says Travis Ansel, senior manager with the Healthcare Strategy Group, during Preparing for Value-Based Reimbursement Models: PHO Development for ACOs, Bundled Payments and Direct Contracting, a 45-minute webinar from the Healthcare Intelligence Network (HIN) now available for replay.

The first most immediate driver is independent physician alignment, says Mr. Ansel. While most markets are mature in terms of employment, there are still a number of markets where there are a significant number of independent physicians in key specialties. In these areas, the PHO model is more of an initial catchall type of alignment model, one that creates a loose tie between the hospital and the physicians in the market, and provides value to the physicians in terms of being protected as part of a larger group without having to become employed. One benefit for the hospitals is that they can align independent physicians en masse and create common incentives, instead of having to negotiate alignment models or arrangements with all independent physicians in their market.

The second driver is the increasing mutual accountability for quality and cost across providers. In the wake of transitioning payment models under payment and insurance reform, insurers and payors are trying to drive mutual accountability for patient costs to physicians and hospitals. The PHO is an appropriate response for those providers to work together to manage the cost of a population and of an episode of care in order to make sure everybody’s successful.

The third factor driving resurgence in PHO activity is the consolidation and distribution of resources that will allow providers to be successful in managing quality and cost. As healthcare reform and payment reform mature, information technology (IT) competencies, clinical competencies, care coordination practices, and exploring the patient-centered medical home (PCMH) concept are often unrealistic at the individual practice level. The PHO gives physicians and hospitals the platform to work on those care competencies together, build them in one place and then distribute them to PHO members — a “win-win for everybody,” Mr. Ansel says.

The final driver is the need for an effective framework for clinical integration. While there are already a number of clinically integrated organizations around the country, “For the bottom 90 percent of healthcare organizations in the country, clinical integration is still that thing that’s on our to-do list, but it always gets bumped to the back of the to-do list; because, we have more immediate needs, or more immediate strategic priorities,” Mr. Ansel says. Clinically integrated models are needed as a strategy to respond to payment reform, to allow joint contracts between physicians and hospitals, and to enable sharing of payments effectively, whether those are shared savings payments, bundled payments, etc. Adds Mr. Ansel:

"The PHO model provides a great initial step to building that clinically integrated network platform, and gives providers and the hospital a great model for working together to start building the competencies towards a clinically integrated network."

Click here for an interview with Mr. Ansel.

Infographic: Provider Payments Trends

October 6th, 2014 by Melanie Matthews

The healthcare payments industry is changing rapidly due to consumerism and regulatory mandates, according to the fourth annual Trends in Healthcare Payments Report by InstaMed. Patient payments to providers have increased 72 percent since 2011 due to these market forces.

InstaMed's new infographic based on the report looks at how patient provider payments are changing administrative requirements by providers, the need for payment plans and how credit card and mobile will impact provider payments in the future.

Provider Payment Trends

The New Hospital-Physician Enterprise: Meeting the Challenges of Value-Based Care Shifting reimbursement models are forcing hospital executives to rethink their approach to physician relationships. New cost and quality demands require hospitals to explore all alternatives—including tighter alignment with physicians. The New Hospital-Physician Enterprise: Meeting the Challenges of Value-Based Care provides expert advice on structuring and sustaining hospital-physician relationships in the post-reform environment.

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