Healthcare providers or physicians in the US have lately been facing an increasing number of challenges on multiple fronts; from unresolved insurance issues to juggling the administrative and medical aspects of their work. Some of these issues are more pressing than the others, and directly impact the health care provider’s productivity, cutting down on the quality time that needs to be given to their patients. Thus, physicians find it hard to cope with the recent changes introduced on the national level in the medical health sector.
Some of the major challenges that have put healthcare providers in hot water have been discussed below:
Seeking Reimbursement for Provided Services
Getting paid for services from insurance companies has emerged as one of the major challenges in the recent past. The problem is all the more vexing when it comes to filing claims to seek their due payment. Claims often get denied on the pretext of not being supported with enough documentation, rendering the claims weak to be accepted. This issue has forced some providers to opt out of accepting health insurance altogether, moving to the simple ‘pay as you get treated’ method.
Moreover, the passing of Affordable Care Act or Obamacare on a national level implies a shift to value based compensation to the health care providers, instead of the straight method of payment. The problem escalates for physicians working with patients on Medicaid right now.
Losing Time in Administrative Concerns
Many of the health care providers, because of privacy breach concerns, control the patients’ record keeping and sensitive information in their own hands; handling which requires a huge amount of time. This involvement and handling of all the administrative work becomes challenging as it impacts their ability to tend to the actual work that they’re qualified for; being a doctor and treating the patients. Moreover, a major chunk of what’s left after sorting out the administrative concerns is spent in preparing prior authorizations which are instrumental to having important procedures; getting hold of crucial drugs and medicines while improving the overall value of the treatment of the patients.
The patients that have registered themselves under the Obamacare/ACA are entitled to an extra time frame of three months to pay the cost of their treatments, as part of the act. Healthcare providers find it increasingly challenging to keep up with these patients and recover premiums from them. One of the major problems that many complain about is the ultimate inability of ACA covered patients to pay the premiums, which the doctors then have to forego completely. This is a major blow to their earnings. On one hand, they cannot deny patients the extra time; while on the other hand, the inability of patients to pay premiums is completely out of their control.
Other than the major ones briefly discussed here; operational expenses, tough decision making between independent practice and being employed by another, keeping consistency between staff members and rising costs, and the reins of control being handed over to the patients gradually are some of the other challenges that healthcare providers perpetually face.
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 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.
By Jackie Birmingham, RN, MS, vice president, emeritus, of clinical leadership, Curaspan.
The Affordable Care Act calls for provider quality to be publicly reported and widely shared. As a result, the Centers for Medicare and Medicaid Services (CMS) extended star ratings to home health agencies (HHAs) on Home Health Compare (HHC) in 2015 to provide home health care beneficiaries with a summary quality measure in an accessible format.
By supporting consumer choice and encouraging provider quality improvement, public reporting will remain a pillar for improving healthcare quality. Currently, CMS reports 27 process, outcome and patient experience of care quality measures on the HHC website to equip patients and their families with the right tools to make choices about home healthcare.
Calculating the Two Types of Star Ratings
1) The Quality of Patient Care Star Rating – This rating probes nine specific evidence-based process and outcomes measures for each home health agency such as timely initiation of care, improvement in patients’ functional status and hospital readmissions. The measures are calculated into a composite score and star rating, which are typically calculated on a quarterly basis and include:
CMS rankings of all HHA providers reporting which is then divided into 10 ranked deciles for each measure.
Each HHA receives a score (.5 to 5) based on its ranked decile.
Each score is compared to a national agency average on that measure, and if there is a statistical difference, the score will be adjusted.
For each agency, adjusted scores are averaged to reach a composite score which are then translated into stars.
2) Patient Survey Star Ratings –These ratings incorporate the patient experience of care measures based on Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS). These surveys reflect patients’ views on a variety of issues including whether the staff checked patients’ prescriptions for side-effects and properly explained dosing instructions.
Guest post Ken Perez, vice president of healthcare policy, Omnicell.
Soon after passage of the Affordable Care Act (ACA), the Congressional Budget Office, the Obama Administration and private research firms, such as Health Policy Alternatives, concluded that the health reform law would generate budget surpluses over the 10-year period of 2010-2019 of $124 billion to as much as $150 billion.
However, according to the CBO’s report, “The Budget and Economic Outlook: 2016 to 2026,” released in January of this year, the divergence between past rhetoric and current reality has widened, at least in terms of the coverage expansion initiative of health insurance exchange subsidies.
According to an April 22, 2010, memorandum from Richard S. Foster, chief actuary for the Centers for Medicare and Medicaid Services (CMS), the ACA’s health insurance exchange subsidies were projected to total $153 billion from 2014-2019. However, arguably because of the higher-risk pool of individuals participating in the exchanges, the recent CBO report projects $347 billion in federal outlays for health insurance exchange subsidies for 2014-2019, leading to a deficit just for the subsidies of $194 billion for that period, outweighing the previously projected budget surplus.
Even worse, the higher health insurance exchange subsidies aid a significantly smaller exchange enrollment population, down about 40 percent from 21 million to 13 million individuals for 2016, per the CBO. Moreover, the CBO projects exchange enrollment to peak at 16 million in the next decade, a third less than the 24 million it predicted in March 2015.
Guest post by Ken Perez, vice president of healthcare policy, Omnicell.
Under the authority of Section 3021 of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) has launched a variety of accountable care organization (ACO) initiatives, including the Pioneer ACO Model, the Medicare Shared Savings Program (MSSP), the Advance Payment ACO Model, and the Next Generation ACO Model. ACOs continue to be the most aggressive of the healthcare delivery reforms mandated by the ACA.
Notably, none of the aforementioned ACO models has a disease-specific focus. During the past few years, DaVita Inc., the nation’s second-largest dialysis provider, lobbied CMS diligently for a renal-specific ACO or at least creation of a framework that would allow for a disease-specific approach. DaVita formed the Accountable Kidney Care Collaborative to prepare the nephrology community to participate broadly in general ACOs and/or in disease-specific renal ACOs.
An ACO Program Focused on Renal Disease
On Oct. 7, 2015, the Center for Medicare and Medicaid Innovation (the Innovation Center) made a groundbreaking announcement, launching the Comprehensive ESRD Care (CEC) Model, with its sole focus on end-stage renal disease (ESRD), also known as kidney failure. This disease afflicts more than 600,000 Americans. These individuals require life-sustaining dialysis treatments several times each week. In 2012, ESRD beneficiaries comprised 1.1 percent of the Medicare population and accounted for $26 billion or 5.6 percent of total Medicare spending.
The CEC Model’s first three-year agreement period began on Oct. 1, 2015, with 13 ESCOs in 11 states: Arizona, California, Florida, Illinois, New Jersey, New York, North Carolina, Pennsylvania, South Carolina, Tennessee, and Texas. All except one of the 13 ESCOs are owned by a large dialysis organization (LDO), defined as an organization that owns 200 or more dialysis facilities. Dialysis Clinic, Inc. (DCI), the nation’s largest non-profit dialysis provider, owns three of the ESCOs, as does DaVita. Fresenius, the largest dialysis provider, owns six of the ESCOs. The lone non-LDO is the Rogosin Institute in New York City.
As with all Medicare ACO programs, the CEC Model has both quality measures and expenditure-reduction targets which impact the model’s payment arrangements.
The CEC Model features 26 quality measures—14 outcome and 12 process—for both LDOs and non-LDOs. The quality measures span five domains: patient safety, person- and caregiver-centered experience and outcomes, communication and care coordination, clinical quality of care, and population health.
This is the reason that the Affordable Care Act is not going away, despite the continuing conversations about its demise: In its first five years, the Affordable Care Act (ACA) has already left an indelible mark on the $2.9 trillion health sector. By energizing five fundamental shifts, the law has accelerated the rise of a new health economy predicated on value, according to a new report from PwC’s Health Research Institute (HRI), “Five Trends to Watch as the Affordable Care Act Turns Five.”
“Although the ACA will continue to face crosswinds, it has already had a profound impact on the healthcare business,” said Kelly Barnes, PwC’s U.S. health industries leader. “The ACA has catalyzed major changes in an industry historically slow to change. Our report provides a roadmap that outlines what industry leaders should be doing as these shifts continue over the next five years.”
“Most striking, the five trends have led to the creation of more than 90 new companies that have entered the sector since 2010,” said Ceci Connolly, managing director of PwC’s Health Research Institute. “The ACA has opened gates for savvy investors and startups to take a piece of the $2.9 trillion industry.”
According to the report, although much groundwork was laid in advance of the law’s enactment, health industry business models and imperatives will likely never be the same post-ACA. These five key trends fueled by the ACA have ignited sector-wide transformation:
Risk Shift: Raising the stakes for all healthcare players. The ACA added force to new payment models that reward outcomes and penalize poor performance such as high rates of readmission and hospital-acquired conditions.
Primary care: Back to basics. Experimentation in new payment models and expansion of insurance coverage are making primary care once again the critical touch point.
New entrants: Innovators in the New Health Economy. New entrants are rushing into the market to meet the demand for lower-cost, consumer-oriented care options in the post-ACA era. More than 90 new companies have been created since 2010, according to HRI analysis.
Health insurance: From wholesale to retail. Rapid enrollment in the ACA’s public exchanges has demonstrated the potential of retail-style health insurance and spawned renewed interest in private exchanges.
States: Reform’s pivotal stage. States have emerged as key players in the reconfigured healthcare landscape, as the ACA gave states notable discretion in how the law could be implemented.
Guest post by David Cooper, CEO and co-founder, Medical Mime.
As most of us involved in the healthcare industry already know, the Affordable Care Act calls for providers to adopt secure, confidential, electronic health information systems. Why? Because most experts agree that by using these electronic health records, we can collectively reduce paperwork and administrative burdens, cut costs, reduce medical errors and, most importantly, improve healthcare outcomes. But reality has had a funny way of challenging those expectations.
Yes, financial incentives have motivated doctors to get on the bandwagon, and many – if not most – office-based physicians have adopted some form of electronic health records. A study published in the journal Health Affairs reported that 78 percent of doctors working in office-based environments had implemented an electronic health record.
However, only about 48 percent of doctors had an EHR system with advanced functionality, according to the same source. Only 39 percent reported they had used their system to share medical data with other providers, and a stark 14 percent reported sharing data with providers outside their own practice. In short, the adoption of EHRs has not resulted in the promised integration of patient data that we hoped for. In fact, the use of electronic medical records – so far – may actually be having a negative impact on the quality of care doctors deliver.
According to a Northwestern University study published in the spring of 2014 in the International Journal of Medical Information, doctors who use electronic health records in their exam rooms spend one-third of their time looking at their computer screens. By comparison, physicians who rely on paper charting spend about 9 percent of their time looking at a patient’s records during an encounter. The study also asserts that because physicians spend so much time looking at their EHRs, they miss out on nonverbal communication cues from patients, thus affecting the quality of the care they’re delivering.
Twenty eight states, three territories and the District of Columbia will receive more than $665 million in Affordable Care Act funding to design and test healthcare payment and service delivery models that will try to improve healthcare quality and lower costs, Health and Human Services Secretary Sylvia M. Burwell announced.
Together with awards released in early 2013, more than half of states (34 states and three territories and the District of Columbia), representing nearly two-thirds of the population are participating in efforts to support comprehensive state-based innovation in health system transformation aimed at finding new and innovative ways to improve quality and lower costs.
The State Innovation Models initiative supports states in planning or implementing a customized, fully developed proposal capable of creating statewide health transformation to improve health care. Example initiatives include:
Improving primary care through patient centered medical homes, building upon current Accountable Care Organization models or integrating primary care and behavioral health services.
Providing technical assistance and data to healthcare providers and payers that are working to advance models of integrated, team-based care, or transition to value-based payment models.
Creating unified quality measure score cards that health care payers and providers can use to align quality improvement and value-based payment methodologies.
Expanding the adoption of health information technology to improve patient care.
Fostering partnerships among public, behavioral and primary healthcare providers.
Strengthening the healthcare workforce through educational programs, inter-professional training, primary care residencies and community health worker training.
Health spending continued to grow at a slow rate last year the Office of the Actuary (OACT) at the Centers for Medicare & Medicaid Services (CMS) reported today. In 2013, health spending grew at 3.6 percent and total national health expenditures in the United States reached $2.9 trillion, or $9,255 per person. The annual OACT report showed health spending continued a pattern of low growth—between 3.6 percent and 4.1– percent for five consecutive years.
The recent low rates of national health spending growth coincide with modest growth in Gross Domestic Product (GDP), which averaged 3.9 percent per year since the end of the severe economic recession in 2010. As a result, the share of the economy devoted to health remained unchanged over this period at 17.4 percent.
“This report is another piece of evidence that our efforts to reform the health care delivery system are working,” said CMS Administrator Marilyn Tavenner. “To keep this momentum going, we are continuing our efforts to shift toward paying for care in ways that reward providers who achieve better outcomes and lower costs.”
Total national health spending slowed from 4.1 percent growth in 2012 to 3.6 percent in 2013. The report attributes the 0.5 percentage point slowdown in health care spending growth to slower growth in private health insurance, Medicare, and investment in medical structures and equipment spending. However, faster growth in Medicaid spending helped to partially offset the slowdown.
Other findings from the report:
Medicare spending, which represented 20 percent of national health spending in 2013, grew 3.4 percent to $585.7 billion, a slowdown from growth of 4.0 percent in 2012. This slowdown was primarily caused by a deceleration in Medicare enrollment growth, as well as net impacts from the Affordable Care Act and sequestration. Per-enrollee Medicare spending grew at about the same rate as 2012, increasing just 0.2 percent in 2013.
Spending on private health insurance premiums (a 33 percent share of total health care spending) reached $961.7 billion in 2013, and increased 2.8 percent, slower than the 4.0 percent growth in 2012. The slower rate of growth reflected low enrollment growth in private health insurance plans, the continued shift of enrollees to high-deductible health plans and other benefit design changes, low underlying medical benefit trends, and the impacts of the Affordable Care Act.
Medicaid spending grew 6.1 percent in 2013 to $449.4 billion, an acceleration from 4.0 percent growth in 2012. Faster Medicaid growth in 2013 was driven in part by increases in provider reimbursement rates, some states’ expanding benefits, and early Medicaid expansion.
Out-of-pocket spending (which includes direct consumer payments such as copayments, deductibles, spending by the insured on services not covered by insurance, and spending by those without health insurance) grew 3.2 percent in 2013 to $339.4 billion, slightly slower than annual growth of 3.6 percent in both 2011 and 2012.
Among health care goods and services, slower growth in spending for hospital care and physician and clinical services contributed to slower growth in national health care spending in 2013. However, faster spending growth for retail prescription drugs in 2013 partially offset the overall slowdown.
Hospital spending increased 4.3 percent to $936.9 billion in 2013 compared to 5.7 percent growth in 2012. The lower growth in 2013 was influenced by slower growth in both price and non-price factors (which include the use and intensity of services). Growth in private health insurance and Medicare hospital spending decelerated in 2013 compared to 2012.
Spending for physician and clinical services increased 3.8 percent in 2013 to $586.7 billion, from 4.5 percent growth in 2012. Slower price growth in 2013 was the main cause of the slowdown, as prices grew less than 0.1 percent. Growth in spending from private health insurance and Medicare, the two largest payers of physician and clinical services, experienced slower spending growth in 2013, while Medicaid growth accelerated as a result of temporary increases in payments to primary care physicians.
Retail prescription drug spending accelerated in 2013, growing 2.5 percent to $271.1 billion, compared to 0.5 percent growth in 2012. Faster growth in 2013 resulted from price increases for brand-name and specialty drugs, increased spending on new medicines, and increased utilization.
In 2013, households accounted for the largest share of spending (28 percent), followed by the federal government (26 percent), private businesses (21 percent), and state and local governments (17 percent).