Posts Tagged ‘pay for performance’

Guest Post: 6 Ways Predictive Analytics Will Move Healthcare Forward in 2016

June 28th, 2016 by Anand Shroff, co-founder and chief technology and product officer, Health Fidelity

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Identifying at-risk patient populations is one way to use predictive analytics to generate rapid returns.

In non-healthcare sectors like retail and manufacturing, ‘predictive analytics’ was arguably the top buzz phrase of 2015. Respected industry analyst Gartner even included predictive analytics in its ‘Top 10 Strategic Technology Trends’ roundup. Predictive analytics have become increasingly important in the healthcare industry, too, as the volume of electronic data grows.

But healthcare organizations have grappled with how to access, analyze and apply their data. Many lack the advanced automated capabilities needed to extract meaning from complex, unstructured data sets from multiple sources. However, it’s crucial to find a way, since the stakes are incredibly high: A McKinsey & Company study estimated that the industry could extract $300 billion in value annually from big data and drive overall healthcare expenditures down by 8 percent.

The key to extracting maximum value from healthcare data sets is to use predictive analytics and cloud-based technologies. By analyzing current and historical data and using the findings to predict future events and trends, healthcare enterprises such as accountable care organizations (ACOs) and others can address the cost-quality equation that is so essential to successful operations in an outcomes-based environment.

The pay-for-performance ecosystem ACOs and other healthcare organizations operate in today demands new strategies to handle bundled payments and population health management challenges, and predictive analytics are tailor-made to produce the insights they need. Using predictive analytics to assess current data sheds new light on the following key metrics:

  • The relationships between cost, quality and patient outcomes;
  • Clinical best practices that drive optimal patient outcomes; and
  • Individual and population-level health risks.
  • By submitting current metrics to predictive analytics, healthcare organizations will gain incredibly valuable insights into how various factors intersect to affect outcomes and which issues they need to address first to drive improvements and value. As they respond to changes in payment models in 2016 and beyond, healthcare organizations will also use predictive analytics to refine their strategies by:

    • Gaining insights into risk factors and how to optimize risk management;
    • Identifying the practices, performers and results that affect organizational performance; and
    • Assessing the impact of ACO reimbursement and bundled payment strategies.
    • Taken together, these are the six ways predictive analytics will move healthcare forward in 2016. By leveraging the power of predictive analytics, healthcare organizations will be able to clearly identify the factors that drive clinical quality and operational expenses. And by applying this information, they can predict and manage clinical and financial performance with greater accuracy. Moreover, they’ll have the opportunity to drive continuous improvement in practices and processes, which will minimize costs while maximizing care quality going forward.

      Healthcare organizations that want to put predictive analytics to work for their operations should consider a two-part strategy that focuses on simple, high-value initiatives first. They’ll need to create an infrastructure that allows them to secure quick wins and then address more complex projects—for example, focusing on revenue improvement by using predictive analytics to proactively manage risk can pay tangible, substantial dividends in the short term.

      Identifying at-risk patient populations in terms of the 30-day readmission window is another way to use predictive analytics to generate rapid returns. Once healthcare organizations have the right processes and practices in place, they can branch out into more complex initiatives like analyzing value-based payment models such as the ACO, episode-based care and patient-centered medical homes. The ability to use discrete and unstructured clinical, financial and operational data to improve performance is the key to success.

      Organizations that embrace predictive analytics in 2016 and beyond will have a key competitive advantage: They will have finally unlocked the value of their data. Predictive analytics have transformed many business sectors in 2015, and 2016 is shaping up to be the breakthrough year for predictive analytics in healthcare, driving better value and outcomes. That’s good news for healthcare organizations and patients alike.

      Anand Shroff

      Anand Shroff, co-founder and chief technology and product officer of Health Fidelity.

      About the Author: Anand Shroff is a co-founder and chief technology and product officer of Health Fidelity. He is responsible for the company’s product strategy and execution and marketing initiatives. He has championed the cause of enterprise performance improvement by promoting electronic capture, exchange and analysis of healthcare data. Prior to founding Health Fidelity, Anand was vice president of EHR and HIE products at Optum. Anand has an MBA from the Haas School of Business at the University of California, Berkeley and an MS in Computer Science from the University of California, Santa Barbara. Anand has an undergraduate degree in Computer Engineering from the University of Mumbai. Connect with Anand on LinkedIn and on Twitter.

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

5 Requirements for Highmark Pay-for-Performance Participation

October 28th, 2014 by Patricia Donovan

Highmark Inc.’s well-established physician pay for performance program, Quality Blue, continues to evolve, providing its 6,300 enrolled primary care physicians the opportunity to earn bonus payments across a variety of measure sets. Here, Julie Hobson, RN, BSN, manager of provider engagement, performance and partnership at Highmark Inc., describes minimum requirements for physician participation in the program.

Our program is open to all the primary care providers (PCPs) in our network. However, there are some participation requirements. The incentive payment is rewarded to the practices based on their total score and is in addition to their fee-for-service (FFS) schedule.

There are over 113 evaluation and management (E&M) claims, both outpatient/inpatient, that we provide the incentive monies to. The quality scores are calculated on a quarterly basis and the incentive payment that the practice receives is paid for on that particular quarter.

There are five requirements that must be in place to be able to participate in our program. First, there has to be a participating provider agreement signed and in Highmark’s hands; second, an incentive participation agreement must be completed as well.

The third requirement is IT capabilities: the practice must have a Web-based provider application in their office. This is the Web-based application that we choose and it allows for real-time transactions. It is HIPAA-compliant and allows for sending and receiving of information to us and from us, as well as to them and from them.

Fourth, the practice must meet certain thresholds of E&M claims and electronic claims submission in a 12-month period.

And finally, they must achieve a minimum total score within the program.

Source: Guide to Value-Based Reimbursement: Profiting from Payment Bundling, PHO Shared Savings, and Pay for Performance

Julie Hobson, RN, BSN, is a manager in Highmark Inc.’s provider engagement, performance, and partnership department, which is accountable for advancement and deployment of strategic design and development of provider driven health management transformation.

Payment Bundling Requires Suspension of FFS State of Mind

March 25th, 2013 by Patricia Donovan
payment bundling shared savings

Webinar Replay: Moving Forward with Payment Bundling

Four hundred healthcare providers — about a tenth of all hospitals in the United States — can’t be wrong, can they?

That’s the number signed on to participate in a Medicare payment bundling pilot run by CMS, their biggest payor. And while it’s too early to know if the reimbursement concept will stick, one thing’s for certain, noted Jay Sultan during a recent webinar on Moving Forward with Payment Bundling: there’s a growing body of proof that the payment model works.

As an example, Sultan, associate vice president and chief product portfolio architect for TriZetto® shared some data from California’s Hoag Orthopedic Institute, formerly two surgical groups who have collaborated in a bundled payment model and “reengineered every aspect of care, from beginning to end, significantly lowering its common cost structure.” In one proof point shared by Sultan, Hoag reduced infection rates for knee replacements to 0.1 percent, significantly below the national 2 percent average, Sultan explained during the advice-filled session. The savings per avoided infection is about $60,000, he said.

While the federal payor has yet to report, early feedback from CMS’s recently concluded ACE bundled payment demo is largely positive in terms of revenue for participating payors, hospitals, physicians — even the patients in the pilot received a rebate from CMS, he added.

Based on Sultan’s own research, he is “not aware of any prospective payment, bundled payment program that was not beneficial for the providers, the payor and the members.” He contrasted prospective payments with retrospective payments, which he characterized as similar to fee-for-service (FFS) but with the possibility of receiving a bonus afterward.

There is a place for both payment types, but prospective does a better job of transforming care, Sultan noted.

Sultan went on to outline the general challenges for both payors and providers of crafting an episodic payment program, which could take up to 12 months. A strong analytics framework for both health plan and provider use is essential. What is also required is a mind shift on the part of entities unused to working together and sharing data, who need to realize that “under payment bundles, the provider and the payor have an opportunity to collaborate, instead of competing against each other in a zero sum way.”

For payors, some prickly areas early on might include provider contracting, claims administration, and impact on member responsibility.

Providers, for their part, must become adept at managing risk. Providers “need to be able to get the data, to develop analytics, and to develop methods for collaborating with each other — including the fact that some providers are going to lose,” he emphasized.

Sultan offered a wealth of advice for each entity contemplating a shift to bundled payments. For all stakeholders, what will be required is a paradigm shift away from FFS, the foundation for much of the industry’s day in, day out day out operations. “We measure our utilization by it, we evaluate our quality by it, we do all these things based on fee-for-service.

“When you change that, whether you’re changing it for shared savings ACOs, moving from FFS to capitation, or going from FFS to payment bundling, it has profound impacts throughout the entire organization.”

Sultan provides more advice on bundled payments, from two key factors to keep in mind when trying to engage physicians in the model to the major decision facing primary care now that CMS has introduced bundled payments for care coordination tasks, in this expanded interview.

Rollout of Florida Blue Medical Home Exercise in Quality, Innovation

May 30th, 2012 by Patricia Donovan

Don’t rely on technology, and don’t expect busy doctors to take on added administrative tasks. Those are just two lessons that have shaped Florida Blue’s programs to improve the quality of primary care over the last eight years.

And while Florida Blue’s name may be new, its mandate to identify and close critical gaps in patient care is longstanding.

The organization formerly known as Blue Cross Blue Shield of Florida (Florida BCBS) has had a quality-focused program to recognize excellence in primary care since 2004, explained Barbara Haasis, RN, CCRN, Florida Blue’s senior clinical lead, quality reward and recognition programs in a recent webinar on The Patient-Centered Medical Home: Lessons from a Statewide Rollout.

In 2004, Florida BCBS rolled out Recognizing Physician Excellence (RPE), its first statewide pay-for-performance (PFP) quality program for more 4,000 primary care physicians.

Seven years later, when the Florida payor decided results from the RPE program had topped out, it shifted direction to a patient-centered medical home (PCMH) approach, which reflected both industry trends and requests from employer groups.

In parallel with RPE, it piloted its PCMH program with a small number of practices in 2010, focusing on patients with diabetes and hypertension. The practices in the pilot were offered a registry to record patient data, but the expectation that electronic health record (EHR) data could be dropped into the registry was not met. Neither were busy physicians willing to complete the patient information forms themselves.

Based on lessons learned in the pilot, Florida Blue opted not to require any type of e-connectivity or EHR when it rolled out the program statewide in 2011, aligning instead with the e-connectivity standards of national programs such as the NCQA medical home recognition program.

However, mandates to utilize e-prescribing and to provide at least six hours of after-hours coverage are included in the program’s eligibility requirements.

Today there are more than 1,800 physicians in the program covering 25 counties; well over half a million Florida Blue members see a physician participating in the PCMH.

Florida Blue issues quarterly scorecards to its PCMH physicians that contain the results of their quality metrics in six key ares as well as feedback on their total cost of care. Overall, Florida Blue finds that physicians participating in the medical home program are more efficient in their total cost of care and have better quality outcomes than those who have never participated in a quality program before.

Nurse educators and medical field directors from Florida Blue support the physicians in the delivery of patient-centered care. Ms. Haasis said Florida Blue will also add four practice transformation coordinators to assist practices in the transition to the medical home model of care.