Archive for the ‘Healthcare Quality Ratings’ Category

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.

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.

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

BCBS Michigan PGIP Value Partnership Translates to Quality Improvement, Cost Savings

May 6th, 2014 by Patricia Donovan

Donna Saxton: BCBSM's PGIP has resulted in primary care-specialist collaborations that improved care coordination and reduced unnecessary utilization and spend.

Blue Cross Blue Shield of Michigan's Physician Group Incentive Program (PGIP) is so studded with acronyms it's almost a separate language, jokes Donna Saxton, BCBSM's field team manager of BCBSM's value partnerships program.

And while not everyone speaks PGIP-tian, it's easy to translate the savings and benefits the medical home reward and incentives program portends for the insurer, its PCMH practices and its health plan members.

Ms. Saxton described PGIP's place in BCBSM's Value Partnerships program during Generating Medical Home Savings and Quality Improvements Through Outcome-Based Measures, including the structure of rewards and incentives that have produced results for the plan, which operates the largest network in Michigan.

"PGIP incentivizes providers to enhance the delivery of care by encouraging them to be responsible and proactive in their behaviors, and ultimately driving better health outcomes and also increasing the fee for value that we also desperately need to get to," said Ms. Saxton.

In return, BCBSM provides financing tools and support for the nearly 18,500 primary care physicians and specialists who participate—more than half of BCBSM's physician population.

Aimed at some root causes of high cost healthcare, including a weak primary care foundation, PGIP, which Ms. Saxton described as the organization's "pinnacle" initiative, expects physician organizations (POs) to take responsibility for developing systems of care, motivating its physicians from within and adopting a culture of process improvement. In return, BCBSM places resources and a PGIP field team representative at the POs' disposal.

Some PGIP activities eligible for incentives range from e-prescribing and patient registries to specialist referrals and medical homes' linkage to community services, Ms. Saxton explained. Further, BCBSM has amped up three key medical home initiatives for its organized systems of care (OSC), "putting them on steroids," as Ms. Saxton said, to raise the performance bar and offer more chances for POs to earn incentives.

BCBSM coined the term OSC, which, while conceptually aligned with the goals of an accountable care organization (ACO) is designed to give providers more latitude in detemining their priorities, she noted. "The OSC is where the neighborhood concept comes into play, where you focus on implementation of PCMH neighborhood capabilities in your specialty offices to further address fragmented care." BCBSM specialists are eligible for one-time incentives plus enhanced fees for collaboration with primary care practices.

A counterpart to PGIP incentives is the PGIP PCMH designation program, an opportunity for practices to earn BCBSM's internally developed medical home designation and the added incentives that go with that distinction, such as increased reimbursement for PCMH office visits. The designation comprises 140 capabiities across a dozen areas.

To date, the biggest challenge of PGIP appears to be its extended access initiative, but practices who adopt more open scheduling often have much lower rates of ED and radiology utilization, noted Ms. Saxton.

Connectivity is also an issue for some, especially practices in rural areas of the state or organizations that have not yet adopted EHRs, which will ultimately be required for participation.

Compared to non-BCBSM-designated PCMHs, the organization's medical homes have produced some significant results, including an 11.2 percent decrease in primary-care related ED visits and a 6.7 percent reduction in low-tech radiology usage.

Ms. Saxton shares more on physician incentives and rewards and some outstanding primary care collaborations that have resulted from the engagement of specialists in BCBSM’s medical home program in this audio interview.

Infographic: The Quality of Nursing, Patient Care

April 16th, 2014 by Jackie Lyons

Seventy-five percent of Americans 30 years and older are more concerned with the quality of nursing staff in hospitals than with the availability or accessibility of electronic medical records (EMRs), according to a new infographic form API Healthcare.

While confident in nursing abilities, a majority of consumers feel nurses are spread too thin, which is impacting the quality of patient care. This infographic also provides data on the quality of nursing care, impacts of the Affordable Care Act (ACA), consumer concerns and quality of patient care.

Looking for other ways to increase patient satisfaction? You may also be interested in The Patient-Centered Payoff: Driving Practice Growth Through Image, Culture, and Patient Experience, which is filled with easy-to-implement ideas. This 260-page resource describes how the patient-centered movement has changed medical practice and offer insights into the opportunities this new environment provides to practices.

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.

5 Market Trends Affecting Value-Based Reimbursement

March 25th, 2014 by Patricia Donovan

physician compensation

A new economy is reshaping healthcare delivery, measurement and funding.

Changes in the way healthcare is delivered, evaluated and funded are having a serious impact as the industry gradually shifts from productivity- to population-focused compensation, according to Cynthia Kilroy, senior vice president of provider strategy and business development at Optum.

We are seeing five trends in the healthcare industry that are affecting value-based reimbursement, with implications for each.

First, there is a consolidation of the provider community: physicians are organizing, and hospital systems or large integrated delivery networks (IDNs) are actually purchasing physicians. We’re seeing both affiliated and employed models going on in the market right now.

Another influential trend is system affordability. We’ve talked about this a lot, but premiums have been increasing significantly— more than 30 percent over the last five years. A lot of the challenges and what CMS and some payors are trying to focus on is, how can we make healthcare more affordable to the community at large?

A third area of trends is the value-based care models, or the alignment of economic and practice incentives to create accountability. This does not just relate to volume, but also to how to manage populations. Which leads into the next trend, which is the investment of provider organizations in capabilities and tools to manage populations. The result is that the incentive models are moving more toward that population-based care, which is much more challenging to measure.

And then finally, we have a lot of interest in performance metrics—HCAHPS,® for example. With just about every other payor asking for different performance metrics from organizations, how do we really focus, especially from an incentive program for physicians, into the right incentive? More than likely, each organization is going to be different about what they’re trying to achieve; each market is very different.

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

Infographic: The Failure of U.S. Healthcare Spending

March 5th, 2014 by Jackie Lyons

The average cost of a hospital stay in the United States is $15,734, according to a new infographic from BestNursingMasters.com. This is just one area of expense that contributes to the United States' healthcare spending in comparison to other countries.

This infographic shows life expectancy versus healthcare spending, spending per capita, cost of developing new drugs, health risks that affect the United States and more.

You may also be interested in this related resource: 57 Population Health Management Metrics: Assessing Risk to Maximize Reimbursement. How can your healthcare organization provide the best care while maximizing reimbursement? This 65-page desktop resource delivers performance benchmarks in six key areas of population health management, based on feedback by hundreds of healthcare organizations.


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.

Infographic: 7 Reasons to Engage With Patients Before Their Appointments

February 26th, 2014 by Jackie Lyons

The need to engage patients by preparing them before their appointments is rapidly growing. Positives include efficiency and increased patient satisfaction due to less manual data entry and shorter patient wait times among other benefits, according to a new infographic from Leading Reach.

This infographic provides the top seven reasons to engage with patients before their appointments and 10 examples of information that can be sent to patients before their appointment to ensure satisfaction.

You may also be interested in this related resource: Healthcare Innovation in Action: 19 Transformative Trends. Need more ways to increase patient satisfaction? This 40-page resource examines a set of pioneering efforts supporting the industry's seismic shift from a volume-based culture to one rewarding 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.

Which Value-Based Reimbursement Model Will Ultimately Align Physicians?

February 24th, 2014 by Patricia Donovan


Move over, ACO: a new payment model in town "has an excellent chance of coalescing value around a single model," according to Greg Mertz, MBA, FACMPE, managing director of Physician Strategies Group, LLC.

It's not yet law, but the federal Better Care, Lower Cost Act introduced last month circumvents the ACO's attribution model, which Mertz describes as "loosey-goosey," and targets the sickest and highest cost patients, who are also eligible for financial incentives if they play by the act's health management rules. In Mertz's eyes, the ACO has a limited life span.

Touching briefly on the proposed legislation, Mertz all but left the accountable care organization off his list of six value-based physician compensation models explored during Physician Alignment: Which Model Is Right for You? workshop sponsored by the Healthcare Intelligence Network — except as a footnote under Population Management, a model Mertz described as still evolving.

And while three-quarters of healthcare leaders agree that quality is driving the need for alignment around a preferred reimbursement model, the simple presence of physicians in a hospital does not translate to alignment.

Instead, the financial catnip of incentives will draw physicians to collaborative efforts, he said. Mertz moved workshop participants along a "collaborative continuum" of alignment from an environment of "mutual toleration"—the state of many two- to four-doctor practices today where planning can be challenging—to Population Management, a model he termed "the least defined, most questionable of the value models right now."

In all, Mertz explored the following six models:

  • Process Improvement
  • Physician-Hospital Organization (PHO)
  • Shared Savings
  • Case Pricing/Bundled Payments
  • Co-Management
  • Population Management

Engaging physicians in process improvement efforts is a first step toward much larger things, Mertz noted. "If you can't get doctors to collaborate over something like standard orders, surgical trays or discharge orders, you're going to be hard-pressed to move up the continuum toward any other kind of value models."

Shared savings, a term nearly synonymous with kickbacks until a few years ago, now aligns with the government's goal of reducing costs, Mertz noted, although it can be complex to implement. High cost service lines like orthopedics are good contenders, he added.

Case pricing and bundled payment models have great potential, while population management requires large numbers of physicians and patients. Many questions still surround population management, including the idea model to employ (Medicare's ACO or a commercial payor's), the best quality metrics to measure, and the likely short- and long-term benefits.

To guide workshop participants, Mertz presented examples of a small rural hospital, a competitive community hospital, and a large health system, outlining the challenges, likely realities and possible reimbursement models for each.

Regardless of an organization's size, to foster alignment, healthcare companies should focus on education, engagement and fostering good citizenship among physicians, Mertz said, defining this last concept as being an active participant in organizational efforts.

"Help [physicians] develop the skills and ability to interact with their peers. Just because they have an MD or a DO after their name, doesn't mean they know how to do that."

Those efforts will pay dividends, he notes—including the kind that could eventually end up in physicians' pockets.

Click here for an extended interview with Greg Mertz on the future of accountable care organizations.

Infographic: The Healthcare Transparency Revolution

December 31st, 2013 by Jackie Lyons

'Healthcare transparency' is defined as an effort to provide consumers with tools and information needed to choose providers and treatment options in an informed, convenient and value-driven way, according to HealthSparq. Seventy percent of executives say healthcare transparency is 'very important,' illustrated in a new HealthSparq infographic.

This infographic captures key findings from HealthSparq and The Cicero Group during a recent survey of more than 100 health plan executives about their healthcare transparency views and plans. The infographic includes benefits, tools and best practices for healthcare transparency.

ACA Mandate Just Around the Corner

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.

You may also be interested in this related resource: The Patient-Centered Payoff: Driving Practice Growth Through Image, Culture, and Patient Experience.

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