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From the Consultant’s Corner 2/7/16

February 7, 2017 Guest articles No Comments

Healthcare Reform’s Impact on Revenue Cycle Integration

The Affordable Care Act has expanded access to more than 20 million Americans who were uninsured. MIPS will accelerate the shift from fee-for-service to value-based reimbursement. While only 30 percent of healthcare payments were value-based in 2015, that is expected to rise to 50 percent by 2018. This shift demands closer integration between clinical and financial operations. After years of working to qualify for Meaningful Use, PQRS and other reimbursement incentives, value-based programs including MACRA now require organizations to tackle even tougher clinical/financial integration issues, such as how to improve patient access and better manage care quality. Managing patient care, in terms of access, services, and costs, however, requires clinical and financial operations to coordinate their efforts and align their priorities. The integration of EHRs, clinical workflows, and care coordination are vital to the revenue cycle. A clinically-driven revenue cycle has created a paradigm shift in the traditional revenue cycle mindset.

Healthcare reform and the shift to value-based care has placed a greater emphasis on improving patient access. This includes access to the appropriate medical services in a timely fashion (patient satisfaction, patient “keepage,” and care management), patient-centric financial counseling and proactive self-pay strategies. A more defined focus on patient access in the front-end sets the foundation for a clinically-driven revenue cycle. With these thoughts in mind, there are three key areas of the revenue cycle where healthcare organizations must focus integration efforts:

1. Patient Access

A clinically-driven revenue cycle starts from the time a patient calls to schedule an appointment. The increase in patient payment responsibility places critical emphasis on front-end functions including eligibility verification, prior authorization, and financial counseling. These activities, as well as patient check-in, also represent an ideal opportunity to address outstanding patient responsibilities.

Financial transparency can also increase patient satisfaction and help reduce the current bad debt average of 25-30 percent, but this requires an adjustment of focus and resources to the front-end of the revenue cycle to improve overall performance measures. An increasingly common approach adopted by many organizations is to centralize patient access operations, standardize policies and procedures, and leverage PM technology in order to:

  • Ensure the capture of clean demographic and insurance data.
  • Validate insurance coverage.
  • Educate patients on their estimated responsibility.
  • Assess patient propensity to pay and offer financial counseling.
  • Collect patient payments like co-pays when registering or at time of
    check-in.

A centralized access center provides the patient with a single point of contact to address all front-end related questions and allows staff to be proactive rather than reactive. These preemptive measures will enhance patient satisfaction, which greatly influences reimbursement. A satisfied patient is less likely to seek services outside of their system. From a reimbursement perspective, this enables more effective care management in a value-based environment.

2. Integration of Clinical and Financial Workflows

With patient access and front-end operations being a large influencer of reimbursement, another factor that affects the revenue cycle is how clinical documentation and coding workflows are implemented and executed. Clinical workflows and EHR design must support, not hinder, a clinician’s ability to document patient care. It is also essential for physicians and staff to be properly trained on those systems. If diagnoses, orders, procedures, etc., are not properly documented/coded, it will ultimately result in billing delays or potentially lost revenues. If something is not captured, it will not be billed for on the back-end, which results in a loss of revenue. Long-term, this also impacts the ability to effectively manage population health programs.

The various technologies available to healthcare organizations contributes to revenue cycle workflows. Workflows and processes must parallel the technology being utilized. Fully integrated clinical and financial systems do provide several benefits. Organizations should adapt IT systems to support the clinical workflow and resist the urge to alter their workflow to accommodate IT platforms.

3. Reimbursement Analysis

Value-based contracts require more complex reimbursement analysis than periodic, retrospective reviews to see whether insurance claims were paid according to contract terms. Going forward, both financial and clinical teams will need to work together to assess reimbursement. The quality department will need to continually monitor clinical metrics for accuracy, for example, while the financial department will need to ensure accurate payment based on those metrics. Tight clinical/financial system integration — or clinical and financial reporting from one system — can help practices better manage cost and quality data together.

New Opportunity

Consolidating patient access, developing collections efficiencies, and bringing clinical and financial viewpoints to the reimbursement process can help practices thrive under value-based care. Keep in mind that these strategies all require integrated technologies, not technology-dictated workflows. With emerging value-based models, tremendous opportunity exists for organizations to create a clinically-driven revenue cycle that reduces costs and improves the patient experience — all the while achieving key tenets of healthcare reform.

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Brad Boyd is president of Culbert Healthcare Solutions.


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Readers Write: MIPS is Here – Don’t Be Afraid

January 19, 2017 Guest articles No Comments

MIPS is Here – Don’t Be Afraid
By Mandy Long

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Some feel that the Merit-Based Incentive Payment System, part of the Quality Payment Program intended to improve the healthcare continuum by advancing quality-based care, has created new risk and uncertainty for a main industry pillar – providers. On the one hand, physicians who have been participating for years in the Physician Quality Reporting System and Meaningful Use state they feel ready for MIPS reporting. On the other hand, some have voiced concerns over needing more time to understand the program and prepare their practices due to a lack of resources, including staff and funding.

MIPS presents opportunities and challenges, and practices should stay educated regarding value-based reimbursement. As the chair of the Electronic Health Record Association’s Clinician Experience Workgroup, I’ve spoken with numerous clinicians, stakeholders, and industry experts about the concerns physicians have over the new reporting requirements and potential pitfalls.

While another mandate may seem daunting, many of today’s modern technologies can help address these changes and aid in the clinical, financial, and operational success of physicians. Here are four common MIPS-related concerns I’ve heard and accompanying reasons why the right technology and EHR vendor can help alleviate those stressors:

1) Concern: Practices are concerned about the lack of resources and time needed to help staff understand the new requirements.

Why? Understanding the complex requirements of MIPS can be difficult and overwhelming, especially for practices that feel they have less time and inadequate resources to develop the necessary knowledge.

Resolution: Work with a vendor that doubles as a responsive training and support team. Not only should they supply a modern solution that is intuitive and easy to use, but they should also offer services such as concierge coaching, education, and advisory services for practices that may not have the necessary in-house talent (or time). With limited resources, it is important to have an expert available to keep your staff well-informed as legislation evolves in our industry.

2) Concern: Practices are concerned that their staff doesn’t have the right experience with EHR systems and skills to leverage data needed for participation.

Why? Most physician practices have limited time to devote to additional administrative duties, including collecting and reporting data on quality measures and completing required documentation needed for participation in the new payment models.

Resolution: Select a vendor that has a proven track record in MU attestations and PQRS reporting, and offers an EHR system with structured data that automates the process. The right system should not increase overhead, but rather make your current team more efficient by streamlining data entry and reporting for each patient visit.

3) Concern: Practices that fight joining larger organizations are concerned that they lack the data needed to compare their performance to that of other practices or benchmarks.

Why? Some industry thought leaders have said that MIPS was a Congressional effort to push doctors to join larger organizations, which many consider better equipped to manage and coordinate care across the continuum. It is believed that practices that do so are more likely to participate in quality monitoring or clinical benchmarking than practices that do not share resources.

Resolution: Implement a solution with native analytical capabilities that documents near real-time comparative benchmarking of quality and cost. Your system should not only track individual physician performance and practice performance, but should also show you where you stand when compared to other physicians in your specialty.

4) Concern: Practices are concerned that they lack financial resources needed to make initial investments.

Why? Practices may not have a budget that can absorb the investments and resources necessary to keep up-to-date on and purchase solutions that meet regulatory requirements, especially when it comes to dedicated headcount to focus on quality programs.

Resolution: Avoid headaches by investing intelligently now with a partner offering services and solutions to help you avoid the end-to-end burden yourself. Your vendor should offer a specialty-specific, all-in-one suite of solutions and help develop a roadmap supporting your practice’s evolving needs. Your system should have MIPS success embedded in its technology, and shouldn’t require you to re-enter data already being collected during the clinical visit. It should offer services to educate and train your staff on how to appropriately document to succeed in the new MIPS landscape, and keep you knowledgeable as requirements evolve.

While CMS recognizes some difficulties that practices will face with new legislation, successfully navigating MIPS ultimately falls to the provider in selecting a partner who will best support their long-term goals. If you’re experiencing concerns similar to those listed above, don’t wait and see how these measures will impact your operations and finances. Find a great partner and adopt the right solution to prepare for the volume to value transition.

Mandy Long is VP of product management at Modernizing Medicine in Boca Raton, FL. 


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Readers Write: Inspiring IT Action to Improve Flu Season Outcomes

January 17, 2017 Guest articles No Comments

Inspiring IT Action to Improve Flu-Season Outcomes
By Sara Johnston

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The busy cold and flu season can be a challenging time for physicians inundated by patients with coughs, colds, and fevers – not to mention the calls, questions, and scheduling demands associated with them. The added interactions can cause delays to the appointment schedule and result in unhappy patients left waiting for appointments longer than necessary all the while increasing the chances of potential exposure to  viruses lurking in the waiting room. To help alleviate this burden, physician practices should consider using a point-of-care education strategy to deliver flu vaccine information. In so doing, they can reduce the headaches and burdens associated with flu season and inspire healthy actions to improve outcomes, while at the same time improving the patient experience, enhancing patient loyalty, and increasing practice profitability.

Point-of-Care Education

POC education leverages the moment that healthcare is top-of-mind with patients – as they are waiting to see their provider – to deliver health-related messaging. Messaging can be delivered via print or digital channels; in the waiting room or exam room; and typically takes the form of video loops on a television monitor, tablet-based interactive modules, print brochures, or wall panels. Individual practices typically tailor the offering with messages specific to their practice.

For physicians, there are many benefits to educating their patients on the flu vaccine. Having higher rates of vaccination among their patient base means that patients are less likely to get sick with the flu. The vaccine also can be an important preventive tool for patients with other chronic health conditions, and can help reduce hospitalizations. At the same time, by increasing the number of vaccinated patients, physicians are less likely to experience interrupted workflows and additional winter scheduling pressures, since fewer patients will require emergency sick appointments for unexpected flu visits. Practice productivity can increase, as the burden of remembering to remind patients about flu vaccines and other practice announcements can be incorporated into the POC offering.

Action Leads to Positive Outcomes

When patients are engaged at the point of care, they are more likely to be inquisitive about their health and to discuss treatments with their physicians. In partnership with 15 practices running flu education campaigns, AccentHealth recently conducted interviews with a research firm to assess patient behavior in response to POC messaging. The study showed that patients who were exposed to flu-specific POC messaging were 68 percent more likely to discuss the vaccine with their doctor that day, and patients who typically do not vaccinate were 8.6 times more likely, compared to those who were not exposed to the messaging.

What’s more, recall rates were quite high and patients appreciated receiving the information while in the waiting room. A large majority of patients found the flu information helpful, relevant and effective. Not only did the POC messaging lead to more interest and discussion with their healthcare providers, patients exposed to messaging were ready to take action. The discussions that day led to significantly more doctor recommendations for the vaccine compared to patients not exposed to the flu-specific POC messaging; a number of patients received the vaccine that day or planned to shortly thereafter.

Satisfied Patients

When patients recalled the flu messaging at the point of care, they were more likely to feel cared for by their physician, with 80 percent noting that the messaging reflected positively on the doctor’s office. The degree to which patients valued the information is reflected in the fact that not only did they initiate conversations with doctors, but they were also 87 percent more likely to recommend the flu vaccine to their friends compared to those who did not see the messaging.

The survey confirmed that patients view the physician’s office as their top source of information for flu and flu vaccines – more so than Internet-based information, print media, advertising, family, and friends. This includes not only conversations with their healthcare provider but also the information available in the doctor’s waiting room.

Increasing Practice Profitability

Providing flu education at the point of care can add to a practice’s profitability. Research shows that patients influenced to take action typically do not plan to receive the flu vaccine at another location. Flu vaccines administered at the practice can augment practice income, sometimes providing a significant portion of the overall revenue.

In short, POC flu education can be an effective tool for physicians looking to improve patient outcomes, create office efficiencies, and generate additional revenue for the practice. By educating on flu vaccines, physician practices can improve the patient experience, create greater loyalties, and help patients feel greater care.

Sara Johnston is senior manager, Insights and Analytics, at AccentHealth in New York City.


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Readers Write: Maximizing Patient Engagement Amid Resource Limitations

January 10, 2017 Guest articles No Comments

Maximizing Patient Engagement Amid Resource Limitations
By Devin Gross

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In today’s rapidly evolving healthcare environment, new reform measures and emerging payment models have put a focus on delivering positive health outcomes and high-quality healthcare, while containing costs. These new demands can only be fully achieved when healthcare organizations and physicians actively – and successfully – engage patients in their care. This requires organizations to extend the reach of their clinicians beyond the clinical setting to drive enhanced relationships with patients that generate stronger engagement.

This poses a significant challenge for independent practices as, historically, reimbursement models have not been optimized for them, nor are these groups fully equipped to engage patients beyond episodic visits. Traditionally, reimbursement for physician practices has been tied to episodic care, with little incentive to collaborate or activate patients in care decisions. These newly introduced value-based payment programs are requiring a change in care delivery for maximum reimbursement and encouraging a more coordinated care effort across patient populations. This additional step serves as an added hurdle for physician practices, which are navigating these complex requirements while facing significant bandwidth issues generated by consolidation pressures and resource constraints.

While physician practices are facing numerous challenges, they must consider new approaches to drive quality outcomes, and effectively treat and engage patients. These methods go beyond employing a larger staff to reach populations, which can be a significant undertaking. Technology can serve as a powerful tool to help extend the reach of physician practices in an effective engagement strategy. Developing and implementing an engagement strategy requires a thoughtful methodology. Before deploying a new strategy, there are three things every practice should consider:

  1. An engagement strategy must fit within the current workflow and culture, and align with the organization’s business priorities. If a strategy does not seamlessly fit into the organization, it will not be supported by the stakeholders expected to adopt it. Thoughtful planning and deployment is required for success.
  2. An engagement strategy must address patient needs. Patient engagement initiatives must be delivered to patients at the right place and right time, but also be designed to create an emotional connection that cultivates and extends the patient-provider conversation. Technology can support this. But, technology that fails to mimic human interaction and is designed without an empathetic approach to communication and content will not be successful in strengthening the physician’s relationship with the patient.
  3. Measurement is key. It is important to establish goals and regularly measure progress. Understanding what is not working is as critical as understanding what is, so necessary refinements can be made. This intel can only be gained by consistently evaluating the efficacy of an engagement strategy.

While the race to implement a patient engagement strategy can be seen as an uphill battle, technology can play a significant role in overcoming barriers. Practices are typically built to support episodic patient visits. But the transition to value-based care requires maintaining relationships beyond the clinical setting – an expensive task if poorly executed. This, coupled with limitations created by inadequate resources, increases the strain on physicians to manage these patient populations, making way for technology to deliver on its promise.

Patient engagement isn’t easy, and pressure will continue to mount for practices to engage patients in the management of their own care. Extending the clinician’s reach and, ultimately, the relationship with the patient beyond the four walls of the clinical setting, is necessary to successfully engage patients that generate optimal reimbursement as financial models continue to emerge and evolve. The need for technology will be driven by resource constraints on independent practices hoping to survive amidst the changes. The potential value of technology is great – and practices able to recognize that value and implement in a meaningful way will not only be able to drive improved clinical outcomes, but also address key business problems impacting reimbursement.

Devin Gross is CEO of Emmi Solutions in Chicago.


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Readers Write: Steady Sailing for the Future of Value-based Care

January 5, 2017 Guest articles No Comments

Steady Sailing for the Future of Value-based Care
By Joe Guerriero

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Changes are coming for healthcare reform—that is a certainty under President-elect Trump’s incoming administration. However, while some aspects of current legislation may be in question, the future of value-based care remains secure.

The reality is that the accountable care movement has experienced notable growth, and demand for value-based care is not going away. Consider recent statistics published by CMS. The number of ACOs participating in the Medicare Shared Savings Program (MSSP) grew from 200 in 2013 to 432 in 2016, now representing nearly 7.8 million beneficiaries. More importantly, early indicators reveal that value-based models work. Average quality measures by MSSP program participants improved by more than 15 percent between 2014 and 2015, and 31 percent generated savings above their minimum rate in 2015.

For many industry stakeholders, the big questions are: “Will the ACA be repealed?” and “How will changes impact current value-based care models?” By all accounts, eliminating every piece of the legislation is unlikely, and the more probable scenario involves keeping what is popular with voters as well as the most effective measures, and tossing the rest.

To date, President-elect Trump has consistently advocated price transparency and greater consumer empowerment in healthcare. As such, cost management and clinical outcomes are expected to remain a focal point of his administration. That means providers must continue preparing for the future of value-based care by leveraging evidence-based tools that deliver the most effective, cost-efficient clinical guidance.

What to Expect Going Forward

While no crystal ball exists that will foretell the future of value-based care, the Trump administration’s agenda will likely pursue a less-regulated approach to alternative payment models. In addition, Trump’s previous policy statements and the cabinet he is assembling suggest that bundled payment expansion and Medicaid reform may take precedence over MSSPs and ACOs. Meanwhile, providers can expect increased scrutiny of the Center for Medicare and Medicaid Innovation, the arm of CMS that is responsible for assessing the viability of innovative payment and care delivery models. Current political and industry criticism of the program could lead to congressional pursuit of more control, and many insiders expect at least some changes that increase oversight of payment reform decisions.

While the face of value-based care models may change, industry stakeholders — including the American Academy of Family Physicians — consistently assert that implementation of MACRA will continue. Now in effect, MACRA was not only overwhelmingly supported by Congress to address needed payment reform, but also ups the ante on participation in risk-bearing arrangements.

In truth, questions regarding how the new administration will view penalties versus incentives for quality performance are important to consider. While previous programs financially incentivized participation in quality reporting, MACRA is designed to penalize those slow to join the value-based movement. If this trend continues, the stakes for performance improvement will become increasingly heightened. To prepare, providers need to equip themselves with tools to support the efficient delivery of high-quality care. Evidence-based decision support platforms, for example, can help them design the most effective treatment plans in less time. In turn, they can avoid unnecessary care and hospitalizations that increase costs and reduce payment under MACRA and other value-based reimbursement models.

Advancing Evidence-Based Practice

The costly impact of unnecessary care and care variations is well documented, with some estimates pointing to between $158 billion and $226 billion in overtreatment alone, according to a Health Affairs 2012 Health Policy Brief. Recognizing this variation is critical. Providers are increasingly acknowledging the importance of reliable, evidence-based clinical decision support tools in reducing needless variation and increasing care standardization. These tools exist to help physicians and multi-disciplinary clinical teams more accurately and efficiently assess patients and target the most appropriate and effective interventions. Furthermore, clinically validated guidelines help physicians and patients set realistic recovery expectations, building stronger provider-patient partnerships and better overall patient engagement. The result is a faster and more cost-effective return to health.

When shared across the care continuum, point-of-care, evidence-based guidelines empower better care coordination by keeping clinical teams on the same page. Physicians have access to the same clinically validated treatment plans and can review recovery expectations, benchmark progress, and make needed adjustments. Ultimately, care delivery becomes more effective and efficient— the overriding goal of value-based care.

Value-based Care is Here to Stay

There is much hanging in the balance for the healthcare industry as 2017 ushers in a new president, administration, and Congress. In the face of uncertainty, providers can bank on two projections – changes are coming to the ACA and value-based care is here to stay. Thus, the logical response is to stay aware of evolving policy changes and continue preparations for value-based care — especially MACRA. Forward-looking providers are already on this path, recognizing the importance of standardized care and implementing the best evidence-based decision support tools at the point-of-care to guide providers toward higher-quality, cost-effective clinical decisions.

Joe Guerriero is senior vice president of Reed Group’s MDGuidelines in Westminster, CO.


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