The Affordable Care Act (ACA) produced a wealth of data from its first two years in operation. Health actuaries voraciously consumed that data, using predictive modeling techniques to solve healthcare industry problems that have never been seen before. While we don’t yet know how the ACA may change, I know actuaries will find solutions, because we thrive in the realm of the uncertain.
Actuaries have always been in the business of data. Centuries ago the work involved scanning clerical ledgers to create the first mortality tables. Today, human activity, including healthcare, is far more complex. Every two days, we create more data than was created from the dawn of civilization through the year 2000.
A significant portion of my recent work has involved studying ACA data, particularly deconstructing a health plan’s performance using the prism of risk adjustment.
Risk adjustment used to be a niche on the spectrum of a healthcare actuary’s work. However, since the ACA risk adjustment program is now a permanent fixture – for the time being – in commercial individual and small group markets, it is the focus of many actuaries’ every day work. Risk adjustment involves adjusting a health plan’s revenue based on a measure of morbidity of the average member enrolling with the plan. It aims to mitigate incentives to select low-risk populations, and instead re-focus the basis of competition on other factors such as quality, efficiency, and benefits delivered.
The program presents a great opportunity for actuaries to apply predictive modeling concepts on large scale data to deliver actionable insights to clients and employers. From the predictive modeling work, actuaries have learned that risk adjustment renders seemingly intuitive notions of health plan performance and profitability rather meaningless. For example, sicker and costlier individuals may have threatened a health plan’s viability in the past. But that may not necessarily be the case going forward.
Guest post by Andrew M. Webster, MS, ASA, MAAA, Associate of the Society of Actuaries, actuary, Validate Health.
Predictive modelers working in the healthcare industry need to be one-part physician, epidemiologist, economist, and data scientist. Because healthcare is offered in a variety of settings, by a diverse set of highly-trained professionals, it requires health actuaries to model future healthcare cost and utilization with a high degree of precision.
It also requires a hands-on approach to data-mining.
During my decade-long career in healthcare, I’ve had the opportunity to work alongside clinicians while programming at an electronic health records (EHR) company and onsite in a hospital’s skilled nursing facility. Through those experiences, I gained firsthand knowledge of patient care delivery.
Because of that experience, I can recognize a sequence of patient events and care transitions when I see them in patient data. Observing how healthcare is delivered helps non-clinicians recognize which problems are most relevant to physicians.
Most clinicians want to know how data analysis will help improve patient outcomes instead of merely focusing on short-term cost reduction. Communicating the modeling results in a way that is meaningful to physicians and integrating results into their daily workflows is essential. While most physicians are not mathematicians, they are highly trained in the scientific method and ask insightful questions when reviewing modeling results from actuaries and data scientists.
As an example of the benefits of predictive modeling, my team helped a 20-physician independent practice determine which segment of its patient population was the most costly. By mining the practice data, we identified a specific Medicare Advantage Plan for patients with Chronic Obstructive Pulmonary Disorder (COPD). The medical practice then used the data to redesign its discharge protocol and develop a COPD care management program to help keep patients out of the hospital, improve quality care and lower costs. The solution was effective because of the hands on approach from everyone involved.
Guest post by Torben Nielsen, senior vice president of product at HealthSparq.
Significant policy changes are inevitably on the horizon for health care in 2017. Though the question marks about what is next for our industry seem endless, Americans are wondering how health care costs will change, and if their insurance carrier will continue to provide them with the coverage they need. One thing we know for certain is that health care industry disruptors will continue to innovate in a way that we can’t ignore. That’s why it’s important for health plans and hospitals alike to embrace the technology that could simplify the way people interact with the health care industry.
To that, here are my five predictions for the industry in 2017:
Artificial intelligence innovations will help people navigate the healthcare system.
From robots and chat bots, to increasing telehealth options, we’re expecting significant innovations in 2017 for both doctors and patients. On the hospital side, chat bots have the potential to streamline the processes that people often get caught up in when visiting their practitioner, or when dealing with insurance protocol. The chat bots of the future will be able to have meaningful conversation that will help people navigate the system, instead of confusing them. A member could say to their health plan, “I’m looking for a cheaper MRI,” and artificial intelligence can help with a more guided search.
Virtual reality will continue moving into the hospital side of healthcare.
With technology like Oculus Rift and HTC Vibe on the market, people around the world are getting used to the idea of virtual reality in health care, too, and we don’t expect that interest to die down anytime soon. Surgeons are already utilizing virtual reality to practice upcoming surgeries, and patients are beginning to see the benefits of this technology, too. For example, at the University of Southern California combat veterans experiencing PTSD are being treated using virtual reality gaming as a healing mechanism to help process trauma. As these tools continue to get smarter, both hospitals and patients will continue to see virtual reality extend into their care practices more regularly in the coming year.
Personalization of healthcare technology will help data transfers happen easier.
Block chain technology has potential to help secure EHR data and health plan member information in a way that streamlines the health care journey for both the patient and the provider. Healthcare processes and experiences can feel very stifled and complicated to all parties in the system (that’s why HealthSparq created #WhatTheHealthCare!) because hospitals and health systems are sitting on so much data that is not connected or easily shared. Data fluidity is a goal for the industry, and with new applications of block chain technology, the health care ecosystem may now see data transfers and fluidity happen much more simply, giving everyone a more holistic view of health care status, options and improvement opportunities.
Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
The story of Geraldine Alshamy explains how a minor complication in healthcare network can be catastrophic! The patient started experiencing severe headaches, and she was rushed to an emergency room. Since she didn’t have a primary care physician, she had a previous condition of hypothyroidism. But because of a lack of proper communication channel, her care process wasn’t the best that she could have gotten and, unfortunately, she had a heart attack!
This story might seem unusual but enough to understand that the consequences of uncoordinated health care could be grave. Health care is too critical and margin of error doesn’t exist here, it is imperative that we realize the importance of coordinating the healthcare sector and bridge the gaps in care.
Why Coordinated Healthcare?
When patients are brought in to be treated, the thing that physicians, nurses, assistants and other professionals require are the relevant medical information about them. For such a scenario, healthcare providers need to be well connected to provide coordinated care through smooth information flow.
According to a survey, some 40 percent of physicians believe that their patients undergo problems because of lack of coordination and information exchange between providers. The possibility of repetitive tests, unnecessary visits to the emergency rooms and preventable readmissions increases, giving way to poor health outcomes. Inadequate care coordination is estimated to cost as much as $45 billion to the healthcare industry, tagged as wasteful spending — $8.3 billion are lost every year because of inefficient technology.
What is the aim?
With everything around us changing and healthcare picking up pace, it’s high time we start thinking accordingly. The future of healthcare is smart teams aiding the one-on-one patient-physician interaction for better outcomes. These teams have physicians, nurses, financial advisors, health coaches and even family members and watch over patient’s health, follow-ups, and the insurance matters as well.
We have to move beyond the paradigm of isolated partial care towards integrated teams performing comprehensive patient care by encouraging the development of technology and providing care at hand with the center of our focus being:
1.) Accessible Care Anywhere
There used to be a time where people were not as well-connected to each other, and the only way of staying informed was telephones, letters, and postcards. With the evolution of information technology, we can safely share every ounce of information.
We need to put the rapid evolution of information technology to use and have patients connected with their physicians. Real-time alerts, genome sequencing, and data analytics will help us establish a world where patients won’t necessarily have to travel to a particular building and wait for hours to get treated.
2.) Connected Care Networks
Coordinated healthcare will hardly be possible without interoperable technology: teams connecting providers and specialists everywhere with the aim to deliver quality care. And the primary requirement for creating this team would be health information exchange, followed by notifying the PCPs.
Guest post by Richard Loomis, chief medical officer and VP of informatics, Practice Fusion.
In 2016 the healthcare industry made a number of meaningful strides on the move to value-based care, culminating in October with CMS issuing the final rule for the Quality Payment Program (QPP). As the largest program of its kind, the QPP will replace existing programs such as meaningful use and PQRS and fundamentally change the way providers receive payment for patients with Medicare Part B coverage.
In 2017, this focus on value will begin to shift to the vast value found in restoring the provider-patient relationship that drives individualized care and best outcomes. Healthcare isn’t ultimately about quality programs, big data or population health management — it’s about improving our shared human experience and to live happier, longer, more fulfilling lives. The healthcare industry will start restoring this humanity by unwinding the complexity of care delivery and supporting individualized care through a number of new and exciting ways in the new year. Below are five themes we’re predicting to see in 2017:
The year of EHR usability: EHR usability will become a critical success factor for providers as the burden of quality reporting continues to grow in an increasingly fee-for-value world. Practices already spend $40,000 per doctor per year — $15.4 billion nationwide — on collecting and reporting information about their care to Medicare, payers and others. These costs will increase in 2017 and disproportionately affect small practices. It will be financially impossible to practice medicine without a user-friendly EHR. Given this emphasis in usability, more EHRs will turn to offering cloud-based solutions to stay relevant and cost-effective.
Real world evidence comes of age: Real world evidence (RWE) will increasingly be used to support FDA approval for marketing new drugs, leading to further investigation through one or more RWE studies. Although randomized clinical trials continue to be the gold standard for establishing efficacy and safety, they may not reflect typical patient care or day-to-day experiences. RWE studies can include larger sample sizes and a greater breadth of patient demographics and clinical circumstances, which can help supplement the data derived from clinical trials. The FDA has already signaled their interest in RWE, and in 2017 we will begin to see it come to fruition.
Small practices recognized for their oversized role: Small independent practices are a cornerstone of the healthcare ecosystem: Independent solo and small practices are shown to have a lower average cost per patient, with fewer preventable hospital admissions, and a lower readmission rate among their patient populations. For CMS to drive additional value through the QPP, they will start to recognize and support small practices in 2017.
As developers of electronic health record (EHR) software, my company gets into a lot of conversations with providers about their expectations for the future. This information helps us make decisions about what to build next. Here are three trends we’re hearing from our customers right now:
Low-tech beats high-tech in telemedicine
Unlike the way it was imagined decades ago by science fiction writers, telemedicine does not necessarily mean holographic images or live video conferencing with a physician half a continent away. Patients would rather receive “low tech” remote care from their primary care physician who has a full picture of their health status.
This form of telemedicine happens whenever an EHR system adds to a patient’s clinical chart the messages, pictures, or videos sent securely via smartphone. It happens whenever a smartphone connects to a remote health monitoring device for collection of real-time data such as blood pressure, oxygen levels, and heart rate.
The new rules allowing reimbursement of telemedicine and other non-face-to-face services will encourage physicians to bill for these remote care activities. Medicare’s recently expanded set of billing codes for Chronic Care Management (CCM) is a good example of how the future of value-based care goes beyond the office visit to keep patients out of hospitals and emergency rooms. The ability to securely and rapidly receive and answer a patient’s questions via text, and then capture those activities in the patient’s permanent clinical record is a critical step in that direction.
Primary care providers are trying new types of practices
Primary care physicians are frustrated with the hassle and expense of dealing with insurance companies. The new Medicare fee-for-value quality payment program is creating uncertainty about future reimbursement levels and requires additional reporting. Also, there is an acute level of burnout with “corporate medicine,” which has providers booked for dozens of daily appointments, only to spend less than 15 minutes with each patient.
In order to remain independent, a small but growing group of primary care practitioners are becoming more financially creative and experimenting with new models of practice. One example is direct care, in which a financial relationship is established directly between patient and provider, cutting out insurance altogether. This model includes concierge and direct primary care (DPC), where patients become “members” of a practice and pay a fixed monthly fee for unlimited primary care – similar to a gym membership, but for healthcare. Another example of direct care is the cash-only practice that sees walk-in patients for urgent care.
EHR interoperability will catch FHIR
Physicians and their patients are frustrated with the lack of interoperability in health IT. The concept of having a patient’s medical records accessible to any authorized provider at any time is still a rare occurrence. When a patient switches primary care physicians, the first office typically prints out and faxes their medical records to the second office, which introduces the possibility of errors, HIPAA violations, and others.
Guest post Ken Perez, vice president of healthcare policy, Omnicell.
One of the Affordable Care Act’s overarching goals is to lower cost, and one way it intended to accomplish this was by providing Medicaid coverage to more low-income adults, giving them greater access to and ability to pay for sources of care outside the emergency department (ED), resulting, in theory, in reduced ED use.
ED use is a significant driver of cost, accounting for 5 percent to 6 percent of U.S. health expenditures. Medicaid alone spends $23 billion to $47 billion each year on ED care.
There have been a number of different studies on the impact of providing Medicaid coverage to previously uninsured adults.
Some high-level research suggests that Medicaid coverage does not affect ED use. Pines, et al. analyzed ED use in 36 states—some of which were Medicaid expansion states and some were nonexpansion—for 2014, the first year of expanded Medicaid eligibility. The researchers concluded that there were no significant differences in overall ED use between expansion and nonexpansion states, though Medicaid-paid ED visits rose by 27.1 percent in the expansion states, while uninsured visits dropped by 31.4 percent and privately insured visits fell by 6.7 percent.
Most importantly, the researchers admitted, “…we do not know which visits were by patients who obtained new health insurance (Medicaid) in 2014, as opposed to those who were continuously enrolled, were uninsured, or may have switched insurance type” (Pines, et al., “Medicaid Expansion In 2014 Did Not Increase Emergency Department Use Bud Did Change Insurance Payer Mix,” Health Affairs, Aug. 2016).
In contrast, a randomized, controlled study by Finkelstein, et al. in involving 24,646 lottery-selected uninsured individuals in Oregon who were granted Medicaid coverage in 2008 showed that they increased their ED visits by 40 percent in the first 15 months after receiving coverage. Many observers speculated that the rise in ED use was due to pent-up demand and would therefore dissipate over time as the newly insured found and used other sites of care or as their health needs were met and their health improved. However, the researchers were unable to find any evidence that the increase in ED use due to Medicaid coverage is driven by pent-up demand that decreases over time; in fact, they found that the effect on ED use appears to persist over the first two years of coverage.
In addition, the study determined that Medicaid coverage increased the joint probability of a person’s having both an ED visit and an office visit by 13.2 percentage points, indicating that expanded coverage will not necessarily drive material substitution of office visits for ED use (Finkelstein, et al., “Effect of Medicaid Coverage on ED Use—Further Evidence from Oregon’s Experiment,” New England Journal of Medicine, Oct. 20, 2016).
As the randomized, controlled trial is the gold standard of research, Oregon’s study and its conclusions get the nod in the debate about the impact of Medicaid coverage on ED use.
Mobile technology is impacting every element of American healthcare–from insurance and billing to documentation and caregiving, the impacts are being felt. The truly transformative element of the mobile revolution is not the technology itself, or the way it changes the look and feel of the tasks it affects. Despite complaints of the depersonalizing effect of technology, the ultimate value of mobile in the sector will be how it enhances and encourages communication.
Providers are Going Mobile
Already, flexibility and functionality have already drawn providers to mobile devices and solutions. Voice-to-text technology and similar automated solutions are in the offing to relieve the documentation burden that has dampered some amount of enthusiasm toward digitization. Bolstered by these advancements, caregivers will go from subjects of their EHRs to masters of patient encounters.
One of the huge benefits of mobility–as opposed to simply being networked on desktop computers or having a digital health records solution–is the capacity for greater native customization and app development. Native apps are like the currency of the mobile, smart device world providers are entering. Developers can deliver personal, branded interfaces that allow doctors to choose precisely how they want their dashboards to look, giving their EHRs a custom touch that has been sorely lacking throughout their implementation.
App-centric development will further reduce the friction of adoption and utilization, giving doctors a sense of empowerment and investment, rather than the bland inertia that has carried digitization thus far.
The personalization of the technology through app development will help boost adoption, and return the focus to what the technology enables, rather than how it looks or what it has replaced. Mobile technology’s strength will be in reconnecting doctors and patients, and creating bridges of data and communication across the continuum of care.
Guest post by Suzanne Travis, VP, regulatory strategy, McKesson.
Shifting to value-based reimbursement (VBR) is a challenging journey, and trying to proactively manage risk at the same time only makes things more complicated. However, there are simple ways a provider organization can more proactively position their organization for a shift to VBR. While there is no fool-proof method or one-size-fits-all approach, here are four strategies that can help steer providers on the right path, no matter where they are in the VBR transition process.
Start with a program that aligns with organizational goals
Participation in alternative payment and delivery models are on the rise. The American Hospital Association estimates that more than 60,000 providers are participating in a delivery system reform model — and that number is growing. The overarching goal of implementing new health care delivery system models is simple: to provide better, more efficient and coordinated care for patients. However, each model has its own nuances and can sometimes require a different approach. Healthcare organizations should be well-served to take a deliberate path to succeed in their journey to value-based care. First, look at each model to understand how it measures and incentivizes participants and the type of care delivery changes it requires. Select models where you have an alignment on goals, room for improvement, and where you can start with upside-only incentives. It’s better to engage now, when participation can be voluntary and downside risk can be deferred.
Getting started is, of course easier said than done. The American Academy of Family Physicians found that a top barrier to adopting alternative care delivery models is a lack of understanding of the elements and actions for success. There are materials and organizations out there that can help guide the transition. For example, the Global Center for Health Innovation explains the models and provides guidance on questions to ask and tools to consider. The Office of the National Coordinator recently launched the Health IT Playbook that includes a state-by-state listing of federally funded sources of technical assistance to support practice transformation activities. Don’t let a knowledge-gap deter you from achieving your goals.
Be ready to act when new opportunities arise
New payment models continue to be introduced and new cohorts are being added to existing programs. Whether you are impacted by a mandatory model, such as the Episode Payment Model CMS recently proposed, or a new voluntary program is announced, be ready to adapt. Take for example the recently announced Comprehensive Primary Care Plus initiative. Participating practices have a choice of two tracks with the same care delivery requirements, but with different financial risk components. Both tracks aim to provide funding for infrastructure and process transformation. Keeping your finger on the pulse of these opportunities and being prepared to act quickly to engage can help you enter into programs that allow you to learn with less risk. If you know what your goals are, you’ll be able to spot the right opportunity to get started.
Partner with your vendors
As providers adopt new care delivery models and take on more risk, contracted vendors should be expected to engage as partners who can work collaboratively to solve new problems.
Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
P.J. Carter in a blog explained how the lack of interoperability resulted in extreme physical pain to his father who had to go into an eye surgery for the repair of a detached retina. His father was told by his eye specialist that and an urgent operation had to carried out. The operation began, but doctors could not access the past medical record of his father. Since doctors were unaware of the medical history, they had to carry out a painful operation of the eye without anesthesia! His father was awake the whole time and had to endure the pain.
Healthcare industry is lagging the most when it comes to advancements. There have been innovations, but equal implementation has been lacking. The cost of care has risen to over $10,000 per person in the US because there is huge expenditure on various digital infrastructures, but not for the meaningful use of them.
Interoperability and Its Types
Interoperability is a term that has no single definition. In broad terms, interoperability is the ability of systems and devices to exchange vital information and interpret it. For healthcare, interoperability is the ability of computer systems in hospitals to communicate, share critical information and put it to use to achieve quality health services delivery.
There are three levels of health information technology interoperability:
1) Foundational: This is the most basic level of interoperability. In this tier, the health information systems are equipped to transmit and receive data, but the HIT system on the receiving end may not be decked up to interpret that information.
2) Structural: The middle level, structural interoperability defines how the data exchange will take place. Structural interoperability is all about how data should be presented in pre-described message standards. This tier is critical to interoperability as it allows a uniform movement of health information from one system to another, avoiding the alteration and promoting the security of data.
3) Semantic: Semantic interoperability is the third tier, and at the top of the communications pyramid. The highest level of interoperability, it provides the systems the ability to exchange data and make use of the information. The message is received in an encoded format and which is later normalized. This normalization of data pushes health IT systems to close in on the technology gaps and create a common platform for secure, uninterrupted machine-to-machine communication.
Scope of Interoperability
There has been a dramatic increase in population, and with that came the need to manage population health. The amount of information increased exponentially with the use of EMRs. They helped in storing the increasing information, but sharing was still doubtful.
In 2005, only about 30 percent of the entire group of office-based physicians and hospitals used basic EHRs which increased to 75 percent for hospitals by the end of 2011. The state of Indiana now connects more than 10 million patients across 80 hospitals, and about 18,000 physicians use this data.
How long until 100 percent interoperability?
It has been accepted that health care, as a single entity, faces challenges in the exchange of information. Even the pioneer EHR vendors admit that although they have some complex connections established, not all of them were successful. According to a report, less than half the providers were satisfied with the way their information exchange was taking place. Stakeholders involved have always been concerned that EHRs, even the ones for Meaningful Use 2, are unable to share data effectively.
In the latest ONC report, it was mentioned that if all the providers were to come down to a common consensus, there happen to be two barriers on the road to complete interoperability. One, discord on how data should be transmitted. Second, a lack of proper infrastructure which is equipped enough to transmit data nationwide. It is very critical that the technology being used is updated and standardized to ease the flow of patients’ vital information to avoid any probable mishap.
Persisting Problems in the Path of Interoperability
1) Inadequate Standards
More often than not even after collecting patients’ data, it cannot be passed on to the members of the healthcare community because of lack of the appropriate standards. Most of the times it happens that two systems trying to exchange data are using a different version of standards. This is because there are varying standards and numerous version for which providers aren’t equipped.