Archive for the ‘Value-Based Reimbursement’ Category

Infographic: Current State of Healthcare Analytics and Artificial Intelligence

September 12th, 2018 by Melanie Matthews

Some 58 percent of healthcare executives say analytics are an important part of value-based healthcare strategy, according to a new infographic by GE Healthcare and Intel.

The infographic examines where analytics will help, the biggest analytics opportunities and the biggest analytics wins so far.

Health Analytics in Accountable Care: Leveraging Data to Transform ACO Performance and Results Between Medicare’s aggressive migration to value-based payment models and MACRA’s 2017 Quality Payment Program rollout, healthcare providers must accept the inevitability of participation in fee-for-quality reimbursement design—as well as cultivating a grounding in health data analytics to enhance success.

As an early adopter of the Medicare Shared Savings Program (MSSP) and the largest sponsor of MSSP accountable care organizations (ACOs), Collaborative Health Systems (CHS) is uniquely positioned to advise providers on the benefits of data analytics and technology, which CHS views as a major driver in its achievements in the MSSP arena. In performance year 2014, nine of CHS’s 24 MSSP ACOs generated savings and received payments of almost $27 million.

Health Analytics in Accountable Care: Leveraging Data to Transform ACO Performance and Results documents the accomplishments of CHS’s 24 ACOs under the MSSP program, the crucial role of data analytics in CHS operations, and the many lessons learned as an early trailblazer in value-based care delivery.

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Infographic: Proposed Changes to ACO Involvement in the Medicare Shared Savings Program

August 29th, 2018 by Melanie Matthews

The Centers for Medicare and Medicaid Services has proposed a new “Pathways to Success” rule to increase the financial risk doctors and hospitals participating in the Medicare Shared
Savings Program take on to increase accountability of healthcare quality and spending for patients, according to a new infographic by the South Dakota Association of Healthcare Organizations.

The infographic examines the key changes proposed in the “Pathways to Success” rule.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

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Infographic: Are EHRs Delivering Value-Based Care?

August 15th, 2018 by Melanie Matthews

The majority of health system executives surveyed report that electronic health records (EHRs) alone are not delivering the data solutions needed to succeed with value-based care contracts, according to a new infographic by Philips Wellcentive.

The infographic examines the top-rated technology challenges EHRs lack; where executives are going for needed solutions; and how rip and replace scenarios are not being pursued.

A New Vision for Remote Patient Monitoring: Creating Sustainable Financial, Operational and Clinical OutcomesAs healthcare moves out of the brick-and-mortar traditional setting into patients’ homes and their workplaces, and becomes much more proactive, the University of Pittsburgh Medical Center (UPMC) has been expanding its remote patient monitoring program. The remote patient monitoring program at UPMC has its roots in the heart failure program but has since expanded to additional disease states across the integrated delivery system’s continuum of care.

A New Vision for Remote Patient Monitoring: Creating Sustainable Financial, Operational and Clinical Outcomes delves into the evolution of UPMC’s remote patient monitoring program from its initial focus on heart failure to how the program was scaled vertically and horizontally. Click here for more information.

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Infographic: Reducing the Use of Low-Value Healthcare Services

July 16th, 2018 by Melanie Matthews

The United States spends more, both per capita and as a percent of GDP, on healthcare than any other country, yet fails to achieve commensurate health outcomes. One reason for this discrepancy between health spending and outcomes is the significant amount—upwards of $200 billion per year—that the United States spends on low-value care, according to the University of Michigan Value-Based Insurance Design (V-BID) Center.

A new infographic by the V-BID Center provides a list of the top five low-value clinical services for purchasers to target for reduction. The selected services were chosen based on their association with harm, their cost, their prevalence, and the availability of concrete methods to reduce their use.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

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Infographic: Succeeding in the New World of Healthcare

July 9th, 2018 by Melanie Matthews

From big data disruption to the rise of consumerism and the shift to value-based care, there are powerful shifts reshaping the healthcare industry—and only healthcare executives who capitalize on them will thrive in the midst of an ever-changing marketplace, according to a new infographic by NovuHealth.

The infographic examines five trends that are having a significant impact on the industry.

Healthcare Trends & Forecasts in 2018: Performance Expectations for the Healthcare IndustryHealthcare Trends & Forecasts in 2018: Performance Expectations for the Healthcare Industry, HIN’s 14th annual business forecast, is designed to support healthcare C-suite planning as leaders react to presidential priorities and seek new strategies for engaging providers, patients and health plan members in value-based care.

HIN’s highly anticipated annual strategic playbook opens with perspectives from industry thought leader Brian Sanderson, managing principal, healthcare services, Crowe Horwath, who outlines a roadmap to healthcare provider success by examining the key issues, challenges and opportunities facing providers in the year to come. Following Sanderson’s outlook is guidance for healthcare payors from David Buchanan, president, Buchanan Strategies, on navigating seven hot button areas for insurers, from the future of Obamacare to the changing face of telehealth to the surprising role grocery stores might one day play in healthcare delivery. Click here for more information.

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Infographic: Clinical Documentation to Optimize Value-Based Care in the Outpatient Setting

June 22nd, 2018 by Melanie Matthews

A strong commitment to clinical documentation improvement (CDI) can help healthcare organizations maximize claims reimbursement while improving quality of care, according to a new infographic by Galen Healthcare Solutions.

The infographic examines CDI goals and the impact of improved CDI on the healthcare bottom line.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

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.

Guest Post: Lab Data is the Missing Link in Healthcare Risk Adjustment

June 19th, 2018 by Jason Bhan, MD

Data informing risk adjustment programs is critical under value-based healthcare reimbursement models.

For health plans, value-based care means a continuous need to innovate and improve their risk adjustment, clinical quality, and care management programs. Unless payers identify and receive the correct amount of reimbursement, it is difficult for them to invest appropriately into member care programs for better outcomes while remaining financially successful.

The data informing risk adjustment programs are critical, as they build the foundation for accurate member risk stratification. In that respect, those data sources are directly related to the correct amount of reimbursement payers receive and can invest in proactive care management. In other words, high-quality clinical data delivered quickly enough for a plan to get a member into a care management program early enough is important to the health of the member and the business. The approach leads to improved clinical outcomes and reduced costs in emergency room visits, hospitalizations and chronic condition management.

Lab Data: An Untapped Resource

To achieve such clinical granularity, at scale, plans can turn to diagnostics—or lab—data. Lab data drives approximately 70 percent of medical decisions and, unlike claims data, is available in near real-time. It also provides an unrivaled level of specificity for clinical conditions. When lab data is integrated into plans’ claims- and chart-based programs, it enables earlier, more comprehensive and accurate clinical insights to benefit care management of both existing and new members. Utilizing the same information that clinicians use to make decisions, within the same timeframe, provides a powerful and unique opportunity to intervene and impact a patient’s health.

What Can Lab Data Do for You?

Expanding and improving their clinical data supply with diagnostics data can help health plans to:

  • Provide historical insights on members where claims are unavailable to improve risk adjustment. For new enrollees, this enables the health plan to get new members into the appropriate care/disease management programs from day one.
  • Serve as an early detection system for care management of all enrollees. Plans can identify patients in need of additional or alternative therapy from lab data earlier than from any other data source. For existing members, the detailed results uncover needs that may have been overlooked based on a claims analysis alone.
  • Identify high-risk members for case management and provider interventions from lab data. Optimized risk adjustment aligns reimbursements to health status, enabling the plan to more heavily invest in member care programs.

Applying AI Solutions

When it comes to gaining actionable insights from diagnostics data, plans can benefit from partnering with healthcare artificial intelligence (AI) specialists in the field. Healthcare AI organizations use techniques such as machine learning and natural language processing—coupled with massive computational power—on big data sets, to make sense out of non-standard, complex, and heterogeneous data.

Healthcare AI, when applied to diagnostics clinical lab data, improves risk stratification by identifying diagnoses earlier in the year versus waiting for the claim or searching charts. Rich in clinical details, it presents a more complete picture of the member’s health. Better risk stratification leads to better care management programs; and successful programs have been shown to reduce costs by targeting those most likely to benefit and keeping intervention costs low.

Dr. Jason Bhan

About the Author: Jason Bhan, MD, is co-founder and Chief Medical Officer at Prognos, an innovator in applying AI to clinical lab diagnostics. More than half of the Prognos team is made of engineers, data scientists, and clinicians. Prognos aims to increase the usefulness of disparate healthcare data to better inform clinical decisions and ultimately improve patient outcomes.

Infographic: The Impact of a Changing Reimbursement Landscape

June 18th, 2018 by Melanie Matthews

Most healthcare providers revealed that they wouldn’t drop a contract with a payer even if they knew they were underpaid, according to a new infographic by BillingParadise.

The infographic details recent trends in the reimbursement climate and industry changes that are having an impact on how providers are reimbursed.

Medicare Chronic Care Management Billing: Evidence-Based Workflows to Maximize CCM RevenueSince the January 2015 rollout by CMS of new chronic care management (CCM) codes, many physician practices have been slow to engage in CCM.

Arcturus Healthcare, however, rapidly grasped the potential of CCM to improve patient outcomes while generating care coordination revenue, estimating it could earn up to $100,000 monthly for qualified patients treated in its four physician practices—or $1 million a year.

Medicare Chronic Care Management Billing: Evidence-Based Workflows to Maximize CCM Revenue traces the incorporation of CCM into Arcturus Healthcare’s existing care management efforts for high-risk patients, as well as the bonus that resulted from CCM code adoption: increased engagement and improved relationships with CCM patients.

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Infographic: The Healthcare Value Initiative

June 11th, 2018 by Melanie Matthews

Hospitals are taking the lead in addressing healthcare affordability, according to a new infographic by the American Hospital Association.

The infographic examines how hospitals and health systems have been able to hold price increases to under 2 percent in each of the last four years.

Predictive Healthcare Analytics: Four Pillars for SuccessWith an increasing percentage of at-risk healthcare payments, the Allina Health System’s Minneapolis Heart Institute began to drill down on the reasons for clinical variations among its cardiovascular patients. The Heart Institute’s Center for Healthcare Delivery Innovation, charged with analyzing and reducing unnecessary clinical variation, has saved over $155 million by reducing this unnecessary clinical variation through its predictive analytics programs.

During Predictive Healthcare Analytics: Four Pillars for Success, a 45-minute webinar in March 2018, now available for replay, Pam Rush, cardiovascular clinical service line program director at Allina Health, and Dr. Steven Bradley, cardiologist, Minneapolis Heart Institute (MHI) and associate director, MHI Healthcare Delivery Innovation Center, shared their organization’s four pillars of predictive analytics success…addressing population health issues, reducing clinical variation, testing new processes and leveraging an enterprise data warehouse. Click here for more information.

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Guest Post: Is the Future of Value-based Healthcare Payments at Risk?

May 31st, 2018 by Erin Weber

CAQH CORE report highlights how value-based payment may encounter the challenges fee-for-service faced 20 years ago.

There is an old adage that anyone who doesn’t learn from the past is doomed to repeat it. For those of us in healthcare, it is time to review our history, so we can avoid repeating some of the operational headaches that emerged almost two decades ago.

Beginning in the 1990s, when electronic transactions were first being implemented to administer fee-for-service payment models, organizations began using many different, often proprietary approaches. Although HIPAA standards were in place, there were no agreed-upon expectations for exchanging data, and the content of transactions varied from one organization to another. This slowed automation and resulted in an inefficient, costly and frustrating experience for all parties.

If wireless companies, for example, did not use common approaches for exchanging data, you would need to carry different phones to call people on other networks. This is what health systems started to face with fee-for-service models. Instead of having to connect with four or five different carriers, however, they had to exchange electronic data with every health plan with which they contracted, often a dozen or more.

To help address this challenge, stakeholders across healthcare came together to form CAQH CORE®, a nonprofit collaboration of health plans, health systems, and vendors. Members worked together to develop common rules, many of which have been codified as part of the Affordable Care Act.

Because of these and other industry efforts, more fee-for-service administrative information flows electronically and securely today. Health plans, providers, and clearinghouses have sharply reduced the use of costlier manual phone, fax, and mail processes.

CAQH CORE is starting to see signs that value-based payment operations are following a similar path. Today, as adoption of value-based payment is growing, health plans and providers are developing new approaches to measure, manage, and pay for care. While innovation is needed, a common foundation for basic administrative operations is lacking. Absent this foundation, value-based payment is being managed, in part, using approaches designed for fee-for-service. This is not likely to yield the fluid, reliable, and trusted exchanges of data needed for long-term value-based payment model success.

Given that experience, CAQH CORE began to study the matter in depth by interviewing stakeholders and reviewing the literature. Last month, CAQH CORE published these findings in a report, All Together Now: Applying the Lessons of Fee-for-Service to Streamline Adoption of Value-Based Payments. In it, they identified five areas where greater uniformity can help the value-based healthcare economy thrive: data quality, interoperability, patient risk stratification, provider attribution, and quality measurement. The report also details specific strategies to address each of these areas.

For example, today there are many issues with data quality, particularly involving provider identification. In the value-based payment world, inaccurate information about the provider can yield a cascading series of problems, such as misplaced accountability, erroneous risk-based payments, inappropriate referrals, and higher patient costs. The report recommends more universal and consistent use of the National Provider Identifier as one way to improve data quality and mitigate many of these problems.

This is just one example, but it highlights how acting now, before operational variances can become entrenched in value-based payment models, will help avoid needless costs, inefficiencies, and frustration. Others in the industry are looking at these challenges as well. By working together to apply the lessons learned during the fee-for-service transition, CAQH CORE hopes to energize an effort to ease the pain points in value-based payment and avoid reliving challenges of the past.

Erin Weber

Erin Weber

About the Author:

Erin Weber is director of CAQH CORE, a nonprofit collaboration of over 130 public and private health plans, hospitals and health systems, vendors and others that helps stakeholders uniformly adopt electronic transactions and exchange data efficiently.

HIN Disclaimer: The opinions, representations and statements made within this guest article are those of the author and not of the Healthcare Intelligence Network as a whole. Any copyright remains with the author and any liability with regard to infringement of intellectual property rights remains with them. The company accepts no liability for any errors, omissions or representations.