Archive for the ‘Healthcare Costs’ Category

Evolution of a Hybrid Embedded Case Management Program

August 8th, 2014 by Cheryl Miller

When a typical embedded and telephonic case management program didn’t yield desired results, namely, coordination of quality care for their high-cost, high utilizers with complex, chronic diseases, Sentara Healthcare System took steps to correct it.

Step one: Reevaluate the current program.

“When we really studied what they (RN Care managers) were doing, only about 25 percent of their time was spent doing care management. What happened was that they wound up becoming basically glorified office nurses. They were working on other projects from either the physicians or the practice manager,” says Mary M. Morin, RN, NEA-BC, RN-BC, nurse executive with Sentara Medical Group (SMG), which is part of Sentara Healthcare System, during A Hybrid Embedded Case Management Model: Sentara Medical Group’s Approach, a recent 45-minute webinar sponsored by the Healthcare Intelligence Network.

Step two: Redefine the RN nurse care coordinators’ job descriptions.

"We were focused on reducing the total cost of care...and improving patient satisfaction. We also measured quality of life. We were looking to see if engagement with an RN care manager improved the patient’s perception of their quality of life," Morin says. To achieve this, SMG looked for RN care coordinators who could "engage patients for the long haul, know how to work with hospital-based caregivers, home health, and life care not just within their own healthcare system."

Core competencies were also established. “RN care managers are different than RNs. We were looking for people that didn’t necessarily have previous care management experience, but who had experience doing patient assessments. They had to have a strong clinical background,” Morin says.

Step three: Rebrand the model as a hybrid program.

The ideal was to establish and maintain patient-centered relationships, Morin continues. The RN care coordinators needed to conduct comprehensive initial assessments with the patient as well as ongoing assessments, so they could identify ongoing needs of the patients and possibly their caregiver, develop care plans and then provide coaching education. They also needed to provide support to both the patient and their caregivers and family members.

Step four: Reap positive rewards.

Through 2013, SMG was able to do the following:

  • Reduce ED visits by 17 percent;
  • Reduce all cause inpatient admissions by 48 percent;
  • Reduce all cause readmissions by 21 percent;
  • Improve seven-day follow-up rates by nearly double. Patients followed by a care manager had a 98 percent seven-day follow-up rate within the medical group; the average rate was 49.5;
  • Reduce total cost of care by 17 percent.

Psychological and functional health of patients was also improved, Morin says. Assessments pre-and post-engagement with care managers showed a 48 percent improvement in the first stages of depression, and a 6 percent improvement of physical health. And patient satisfaction also increased.

It all comes down to increased attention from the care manager, Morin says. One example is intense transition follow-ups, so that within 48 hours of discharge, the patient is seen or called, and given a clinical assessment. And prior to discharge? "We implemented a first call strategy. When the patient thinks of the emergency department (ED), we want them calling their care manager first."

Listen to an interview with Mary Morin here.

5 Market Trends Impacting Value-Based Reimbursement: “It’s Not Just About Volume”

July 31st, 2014 by Cheryl Miller

Accompanying the move to value-based care and reimbursement is the need to align economic and practice incentives to create accountability, says Cynthia Kilroy, senior vice president of provider strategy and business development, Optum. It is not just about volume, but about managing populations, and investing in capabilities and tools to manage populations.

We are seeing five trends in the industry, with implications for each of them.

First, there is a consolidation of the provider community that physicians are organizing, and then hospital systems or large integrated delivery networks (IDNs) are purchasing physicians. We are seeing both an affiliated and an employed model in the market right now.

Another trend is system affordability. Premiums have been increasing significantly — more than 30 percent over the last five years. The challenge that CMS and some payors are focusing on is how to make healthcare more affordable to the community at large.

A third trending area is value-based care, and aligning the economic and the practice incentives to create accountability. It is not just about volume, but about managing populations. This leads into the fourth trend, which is that provider organizations are investing in capabilities and tools to manage populations. Then the incentive models are moving more around that population care, which is more challenging to measure.

Finally, there is a significant amount of interest in finding performance metrics. There is HCAHPS®. Every other payor is asking for different performance metrics from organizations; how do we focus that into the right incentive, especially from an incentive program for physicians? Each organization will be trying to achieve something different; each market is very different. I may see one provider organization focus in particular areas and disease states around quality. In other markets there might be something completely different. It is based on what is going on in that particular market and practice.

Excerpted from 6 Value-Based Physician Reimbursement Models: Action Plans for Alignment, Analytics and Profitability.

2014 Value-Based Priorities: Population Health, Care Coordination, Integrated Care

July 3rd, 2014 by Cheryl Miller

From an early surge in Medicare accountable care collaborations (ACOs) to the problematic rollout of the nation’s historic health insurance exchanges during a 16-day government shutdown, healthcare in 2013 was nothing short of unpredictable. Respondents to HIN’s tenth annual Healthcare Trends and Forecasts survey identified a trifecta of value-based priorities for 2014, deeming population health management (56 percent), care coordination (51 percent) and integrated care delivery (42 percent) initiatives most worthy of their attention in 2014.

In tandem with these Triple Aim priorities, respondents also selected the accountable care organization (ACO) as the care delivery model most likely to transform healthcare, from both cost and care delivery perspectives. The patient-centered medical home has held this distinction for the last two years.

Some key findings from the survey include the following:

  1. The top business areas affected by the 2013 economy were growth (65 percent, still the top area but down from 72 percent in 2012); hiring and recruitment (65 percent); capital improvement (48 percent); and service expansion (43 percent).
  2. The top five factors impacting healthcare business in 2013 were not limited to purely financial issues as they have been in recent years: budget constraints (42 percent), the Affordable Care Act, or ACA (30 percent), reimbursement (28 percent), care transitions (27 percent), and the economy (25 percent).
  3. Beyond the ACO and the patient-centered medical home (PCMH), the care delivery systems with the most transformational potential were comprehensive primary care (19 percent) and bundled payments (11 percent).
  4. Beyond population health management, care coordination and integrated care delivery, the areas of healthcare most ripe for development are e-health and telehealth (39 percent), access to healthcare (33 percent), health and wellness (26 percent) and dual eligibles (25 percent).
  5. Impacts from continued rollout of ACA initiatives in 2014 include (in respondents’ own words): expansion of customer base from implementation of physician ACO and bundled payment programs; reduced reimbursement, requiring more efficiency and cost reductions; the challenge of delivering primary care services with improved outcomes and transparency in reporting; and revenue streams created by exchanges, along with a need to add primary care practitioners.

Excerpted from Healthcare Trends & Forecasts in 2014: Performance Expectations for the Healthcare Industry.

Infographic: The Quest for Value in Healthcare – A Place for Consumers

July 2nd, 2014 by Jackie Lyons

As the American healthcare marketplace evolves, consumers now face an abundance of healthcare options, with greater access to quality ratings and price information. Nearly half of consumers say the healthcare system misses the mark on delivering value, and only one in five consumers feels prepared for future healthcare costs, according to a new infographic from Deloitte.

This infographic identifies three disruptors emerging in healthcare and provides insight to the healthcare system through the eyes of a consumer.

Healthcare Innovation in Action: 19 Transformative Trends, a 40-page exclusive resource, examines a set of pioneering efforts supporting the industry's seismic shift from a volume-based culture to one built around value and patient-centeredness.

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.

Narrow Networks Top Payor Product Innovations List for 2014

June 17th, 2014 by Patricia Donovan

If recent market data is any indication, employers are gravitating toward narrow networks in greater numbers. For instance, a March 2014 Wells Fargo Insurance survey of more than 70 insurance companies placed narrow networks among the top three employer product innovations in 2014, along with are accountable care organizations (ACOs) and increased wellness programs.

In just one example, Harvard Pilgrim HealthCare this week introduced ElevateHealth℠, a partnership with Dartmouth-Hitchcock and Elliot Health System that is a non-profit, high-performance, defined-network product offering access to premier hospitals and providers in New Hampshire.

With its emphasis on care coordination within the network, ElevateHealth insurance premiums on average offer 10 percent savings compared with Harvard Pilgrim’s similar full-network plans, the insurer said.

And last month, UnitedHealthcare announced it would cut 2 to 4 percent of the physicians in its Medicare Advantage network in some Virginia service areas.

In theory, narrow networks—and their close cousins, tiered, tailored and high performance networks—sound like a good thing: health insurance products that group providers into tiers based on their cost or efficiency of care, then steer patients to choose these providers through lower premiums or cost sharing.

In practice, however, some consumers served by narrow networks are balking at the difficulty of obtaining appointments with network providers. Earlier this month, the Wall Street Journal reported that insurers in several states are expanding hospital and physician networks for plans sold through the Affordable Care Act's health insurance exchanges amid gripes from patients and state officials about limited provider choices.

Anthem Blue Cross, Blue Shield of California, Health Net and WellPoint are among insurers that have substantially expanded provider networks in its exchanges, the article stated. And more providers are slated to join Harvard Pilgrim HealthCare's ElevateHealth's network beginning in July.

Earlier this year, industry thought leaders analyzed what the proliferation of narrow networks means for healthcare. Steven Valentine, president of The Camden Group, talked about the impact on both providers and consumers.

"First of all, we anticipate an increase in the number of covered lives," Valentine said during HIN's annual healthcare trends forecast. "Providers are going to see an increase in patient volumes, especially primary care providers. And especially providers in states that have opted to stay in Medicaid."

However," he continued, "Many of the qualified health plans have narrow networks, so patients are probably going to be confused about which doctors are in their networks and probably will shift around until they can find the right place for them."

Providers in networks with bronze plans will probably have much higher increases in patient volumes, he predicted. "And other providers will probably see some shifting until patients can figure out where they need to go."

Regardless of the confusion, Valentine expects the trend of narrow networks to continue. "We clearly see narrow networks operating in conjunction with tiered benefit plans; that is, a lower premium, a more narrow network. We’ve clearly seen that in some of the exchanges as we look at the various medal options that are available. Narrow networks are here to stay; they are not going to go away."

Catherine Sreckovich, managing director in the healthcare practice at Navigant, concurs. "I agree 100 percent. We’re going to see [narrow networks] more and more. And to the extent there continues to be competition in the exchanges and more health plans trying to get involved, this trend will continue."

Excerpted from: Healthcare Trends & Forecasts in 2014: Performance Expectations for the Healthcare Industry

Profiting from Payment Bundles: Post-Acute Care Presents Opportunities

June 2nd, 2014 by Patricia Donovan

On the landscape of opportunity for hospitals to profit from bundled payments, the potential lies in post-acute care, advises Kelsey Mellard, vice president of Partnership Marketing and Policy with naviHealth.

Preoccupied with such urgencies as avoiding CMS readmissions penalties and adhering to meaningful use requirements, most hospitals haven't taken the time to examine potential cost savings from engaging post-acute providers in bundled payment initiatives, Mrs. Mellard explained during a May 2014 webinar on opportunities from bundled payments.

But recruiting high-performing skilled nursing facilities, inpatient rehabilitation facilities and long-term care hospitals into its post-acute care (PAC) network has helped to drive down SNF, IRF and LTAC per member per month (PMPM) costs for naviHealth, which bills itself as a risk partner for health systems and health plans managing PAC utilization and spend.

naviHealth is also an awardee convener for model 2 and model 3 of the CMS Bundled Payments for Care Improvement (BPCI) pilot. Model 2 concerns itself with retrospective acute care hospital coupled with post-acute care episodes, while model 3 is restricted to care episodes involving retrospective post-acute care only.

While there are more than 300 healthcare organizations participating in the BPCI pilot, naviHealth is most engaged in model 2, whose bundled reimbursement rewards efficiency, communication, accountability, Ms. Mellard noted.

The naviHealth model of coordinated, data-driven care has helped to reduce its average post-acute care costs in the Medicare population to $53 per member per month (PMPM)— almost half the national average.

"We impact and work with the discharge planners to identify the most appropriate setting for our beneficiaries and the duration of the setting, and then manage that readmission risk and prevention program that follows."

To identify potential participants for its PAC network, naviHealth has created dashboards that evaluate efficiency, quality and other metrics such as volume obtained from CMS. They also consult with care managers for recommendations, then invite the post-acute care providers to a 'town hall meeting' with our hospital partners to provide an overview of the bundled payment program.

"It's been fun to see the level of excitement of how the business model is fundamentally changing. Everyone wants to be at the table, because they know that we are entering a risk-bearing phase of our business and within healthcare in general."

While CMS has closed the opportunity to sign up for bundled payments for the moment, the time is still ripe to engage with providers already participating, she said.

Overall, given the level of activity, conversation, and pending legislation associated with episodic-based reimbursement, the future for bundled payments looks bright, concluded Ms. Mellard.

Listen to an extended interview with Kelsey Mellard.

Infographic: Accountable Care Organizations – An Overview

May 21st, 2014 by Jackie Lyons

It is projected that Medicare could save as much as $940 million over four years with accountable care organizations (ACOs), according to a new infographic from University of Southern California Keck School of Medicine.

This infographic also presents an overview of ACOs, as well as the goals of coordinated care, ACO structures, types of programs and ways patients can benefit from ACOs.

You may also be interested in 2013 Healthcare Benchmarks: Accountable Care Organizations, HIN's third annual compendium of metrics and benchmarks on ACOs. This 65-page report documents the numerous ways in which accountable care is transforming healthcare delivery, particularly in the area of care coordination, where the ACO model has had the greatest impact for this year's respondents.

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.

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Infographic: Medicated to Death

May 16th, 2014 by Jackie Lyons

Approximately one in five Americans take five or more prescriptions, which can lead to risks such as addiction or drug-resistant infections, according to a new infographic from Top RN to BSN.

This infographic details the statistics behind the use of medication in the United States, as well as the causes and risks of overmedication.

Want to know more about medication and prescription drugs trends? 2013 Healthcare Benchmarks: Improving Medication Adherence provides actionable information from more than 100 healthcare organizations on efforts to improve medication adherence and compliance in their populations.

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Infographic: What Healthcare Has Lost and Gained Since the 1960s

April 30th, 2014 by Jackie Lyons

Total U.S. healthcare spending increased from $27B in 1960 to $2,593B in 2010, according to a new infographic from The Advisory Board Company.

This infographic also outlines other healthcare costs, provider profits, Medicare enrollment, the rise of healthcare issues in America and much more.

Want to know how else has healthcare changed? Healthcare Innovation in Action: 19 Transformative Trends examines a set of pioneering efforts supporting the industry's seismic shift from a volume-based culture to one rewarding value and patient-centeredness. Dozens of adaptations are explored in the 40-page resource, which delivers succinct descriptions of programs that are transforming healthcare delivery.

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Infographic: Healthcare Costs in Retirement

April 25th, 2014 by Jackie Lyons

An average 65-year-old couple will spend $220,000 on healthcare costs over the course of 20 years of retirement according to a new infographic from AARP.

This infographic shows how much of the costs are covered by Medicare, how confident adults are with their savings, how being healthy now can affect those future costs and more.

Medicare Star Ratings: Key Steps to Prepare for Changes in 2014 and 2015, a 222-page report, examines upcoming changes to the stars rating program as detailed in CMS's 2014 Star Rating Final Call Letter. It includes tools and insights needed to achieve the highest level star ratings possible on all of CMS's quality measures.

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.

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