Though many Medicare and private payer reimbursement programs that require practices to begin moving to value-based compensation already have set sail, most small practices are still treading water near the shore when it comes to this new wave of payment models.
While admirable in their care goals, these quality care-based reimbursement programs can pose some insurmountable challenges for small providers. In fact, they require a whole new way of providing care for some practices, as well as creating new documentation of integrated data analysis, development of care coordination with other providers, payer reporting applications, and often times new technologies that can support these new provisions.
What’s more, all this change also can be quite expensive for small practices and wreak havoc on current business practices.
Set the course
No doubt about it, though, the move to value-based care is on. According to the 2015 Physician Compensation Survey, conducted by Physicians Practice magazine, 63 percent of physician compensation is currently tied to productivity; 37 percent to value metrics and 29 percent to patient satisfaction scores.
The Centers for Medicare and Medicaid Services (CMS), however, has expressed its goals of having more providers participating in value-based plans each year, with a goal of 50 percent by 2018. And it has further incentivized physician participation by specifying increasing reductions in payments for non-participation that began in 2013.
So unless they want to start leaving money on the table, practices have no choice but to take the plunge into such new compensation programs.
Lift the Anchor
Before diving in and potentially draining money and resources to participate in such programs, physicians need to look around and assess their current situation to determine how the new reimbursement model might work in their practice. For example, they need to evaluate current technology, vendors, resources and physician support to determine what changes they need to make, as well as what internal infrastructure they can use.
The long awaited road to true healthcare IT system interoperability is being implemented at Good Samaritan in Indiana, enabling the 232-bed community healthcare facility to better deliver on its commitment to delivering exceptional patient care. The system will also enable the hospital to substantially increase their practice’s revenue while containing healthcare system integration costs.
“We strive to be the first choice for healthcare in the communities that we serve and to be the regional center of excellence for health and wellness,” said Rob McLin, president and CEO of Good Samaritan. “We are proud to be the first hospital in the country to implement this great integrated health record system that will allow us to provide a much higher level of continuity of care for our patients, as they are our top priority.”
The integration is being made possible with Zoeticx’s Patient-Clarity interoperability platform that will integrate WellTrackONE’s Annual Wellness Visit (AWV) patient reports with Indiana’s Health Information Exchange (IHIE) and the hospital’s Allscripts EHR. IHIE is the largest HIE in the US, serving 30,000 physicians in 90 hospitals serving six million patients in 17 states.
Revenue Generator for the Hospital
WellTrackONE and Zoeticx will enable patient’s AWV data to flow from the application to Allscripts EHR and the IHIE system. With Zoeticx’s Patient-Clarity platform and WellTrackONE’s software, the healthcare IT integration passes on increased revenue from the Centers of Medicare & Medicaid Services (CMS) and decreased IT costs for medical facilities.
Medicare pays medical facilities $164.84 for each initial patient visit under the AWV program and $116.16 for each additional yearly visit. With the AWV integration in place, the hospital is now able to meet CMS’s stringent requirements for patient reimbursements.
It is estimated that the Good Samaritan will be able to generate $500 to $1,200 per AWV patient from follow up appointments for additional testing and referrals for approximately 80 percent of the Medicare patients that are flagged by the AWV for testing, imaging and specialty referrals within the hospital.
This subscriber number is expected to trend upwards into 2050 and will create billions in new healthcare revenue through the US as the population ages. The hospital is not charged any costs for the system until it is reimbursed by CMS.
Overcoming Healthcare System Limitations
The hospital began offering Medicare’s AWV’s a few years ago, but had to develop its own tracking protocols, which impacted its budget and staff resources. The system it had created also operated poorly, allowing hospital staff to only view about 10 percent to 15 percent of patient data.
Good Samaritan medical teams were also constrained by interoperability, having to enter new illness findings and other medical info manually and fax PDFs to other facilities where they would have to again be entered into a different system. The hospital also had all of the data contained in WellTrackONE and Allscripts’ system, but no way to integrate the two, let alone achieve that integration with IHIE. Providers were also spending valuable patient face time trying to find specific patient data buried in the EHR system.
“Our systems were working fine, independently of each other,” said Traci French, director of business development and revenue integrity. “But we could not achieve true interoperability between the two systems. The best we could do was basically reshuffling PDF documents. The next challenge was to integrate that data with the exchange. We needed to get data to providers where they needed it, when they needed it.”
Guest post by Robert S. Oscar, R.Ph. CEO and president, RxEOB.
Prior authorization exists to reduce drug costs, to manage appropriate brand medication prescribing, and to curb medication abuse. Despite its good intentions, this extra step to determine whether or not a drug is appropriate for a patient’s symptoms has gained a reputation of inconvenience for both physicians and consumers.
In a 2013 study by SUNY Upstate Medical University, it was revealed that U.S. primary care physicians and their office staff have experienced significant increases in time consumption as a result of prior authorization and its associated requirements. For consumers, hours can be wasted waiting to find out whether or not they are allowed a particular prescription under the conditions of their health plan.
Reducing this negative aspect of prior authorization is paramount for the betterment of overall health costs and medication adherence. By streamlining the time spent between medical record lookup and prescription delivery, healthcare organizations and consumers can begin to experience more efficient prior authorization. If efforts made toward better big data advancements, mobile health (mHealth) and health IT are prioritized, doctors can confirm drug eligibility faster to help their patients recover faster.
Below are five reductions that can come from implementing electronic prior authorization (e-PA):
Reduced Labor Costs: When a doctor pulls up a patient’s medical records he must sift through numerous data points to determine which drugs are approved and which drugs are going to require prior authorization. The hours spent processing this data is costly for healthcare staffing, but lost time can be reduced by moving the process online and implementing electronic methods. This can allow physician offices and PBMs the ability to review, submit and determine authorization almost immediately.
Reduced Consumer Delays: A consumer will typically experience the unattractive side of prior authorization at the pharmacy. If a doctor issues a prescription without knowing the patient’s medication history or pushes a popular name brand drug without suggesting a generic, the consumer will likely get sidelined with prior authorization processing at the point of sale. Having an e-PA process that can review and determine which drugs a patient is already approved for before they head to the pharmacy can reduce customer wait times and greatly increase consumer satisfaction.
Guest post by Lucy Doyle, Ph.D., vice president, data protection, information security and risk management, McKesson, and Karen Smith, J.D.,CHC, senior director, privacy and data protection, McKesson.
Today there are opportunities and initiatives to use big data to improve patient care, reduce costs and optimize performance, but there are challenges that must be met. Providers still have disparate systems, non-standard data, interoperability issues and legacy data silos, as well as the implementation of newer technologies. High data quality is critical, especially since the information may be used to support healthcare operations and patient care. The integration of privacy and security controls to support safe data handling practices is paramount.
Meeting these challenges will require continued implementation of data standards, processes, and policies across the industry. Data protection and accurate applications of de-identification methods are needed.
Empowering Data Through Proper De-Identification
Healthcare privacy and security professionals field requests to use patient data for a variety of use cases, including research, marketing, outcomes analysis and analytics for industry stakeholders. The HIPAA Privacy Rule established standards to protect individuals’ individually identifiable health information by requiring safeguards to shield the information and by setting limits and conditions on the uses and disclosures that may be made. It also provided two methods to de-identify data, providing a means to free valuable de-identified patient level information for a variety of important uses.
Depending on the methodology used and how it is applied, de-identification enables quality data that is highly useable, making it a valuable asset to the organization. One of the HIPAA- approved methods to de-identify data is the Safe Harbor Method. This method requires removal of 18 specified identifiers, protected health information, related to the individual or their relatives, employers or household members. The 18th element requires removal of any other unique characteristic or code that could lead to identifying an individual who is the subject of the information. To determine that the Safe Harbor criteria has been met, while appearing to be fairly straightforward and to be done properly, the process requires a thorough understanding of how to address certain components, which can be quite complex.
The second de-identification method is the expert method. This involves using a highly skilled specialist who utilizes statistical and scientific principles and methods to determine the risk of re-identification in rendering information not individually identifiable.
We need to encourage and support educational initiatives within our industry so more individuals become proficient in these complex techniques. At McKesson, we are educating our business units so employees can better understand and embrace de-identification and the value it can provide. This training gives them a basic understanding of how to identify and manage risks as well as how to ensure they are getting quality content.
Embracing Social Media and New and Improved Technologies
One of the challenges we face today in de-identifying data is adapting our mindset and methodologies to incorporate new emerging technologies and the adoption of social media. It is crucial to understand how the released data could potentially be exposed by being combined with other available data. New standards are needed.
While de-identifying data can be challenging and complex, the task is made easier when we remember and adhere to our core directive to safeguard data. With this in mind incorporating new technologies is part of an ongoing process of review.
When done properly, de-identification enables high quality, usable data, particularly when the expert method is used. De-identification should not be viewed as an obstacle to data usage, but rather as a powerful enabler that opens the door to a wealth of valuable information.
For decades, the use of paper medical records was the “norm” and the sharing of those records with another provider typically involved a photocopier and a briefcase for the patient to carry them to the next doctor. Today, electronic medical records are becoming the standard, but the exchange of health data between disparate networks and software systems has remained elusive.
While some data exchange is taking place in health care today, it’s only occurring in isolated pockets, typically within one region or health system, making it largely ineffective. Solving this challenge requires transparency, collaboration and innovation for continued success–attributes CommonWell Health Alliance embodies.
Transparency across the Industry
Competition in almost every sector thrives on keeping information separate and technologies proprietary. However, for many industries – like banking, telecom and internet, working across competitor lines to exchange data has enriched and expanded their reach. Health care needs to take a lesson from these industries.
Working in data silos will not improve the exchange of health data; rather, it will create friction in the industry. Patients expect their doctors to have the information they need to provide them with the best treatment. Doctors struggle to access this important data outside their four walls. The industry has an opportunity to step up and make it possible for providers to access a three-dimensional view of the patient’s health history, and in turn, create a new wave of opportunities for the health IT industry.
Collaboration among Health IT Industry Players
Collaboration throughout the IT industry is essential to creating a ubiquitous nationwide interoperable Health IT Infrastructure. This focus on infrastructure will drive standard adoption and open up the gates to national record sharing. Electronic health record (EHR) vendors offering services across the healthcare continuum are a key piece of this puzzle, which is why CommonWell formed to join forces with all health IT stakeholders dedicated to the vision that patient data should be accessible no matter where care occurs.
Collaboration with the public sector is also crucial. The government plays a strong role in narrowing the technical standards in health IT, but the bar must be raised on leveraging real-world data exchange. Additional ONC activities are complementary to the existing Federal Advisory Committees (FACAs) as noted below:
Bipartisan legislation known as the 21st Century Cures Act—which passed in the U.S. House of Representatives this past July—includes mandates that systems be interoperable by the end of 2017 or face reimbursement penalties.
In early October, the Office of the National Coordinator for Health IT (ONC) released its final draft of “Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap.” The three overarching themes of the roadmap including:
Giving consumers the ability to access and share their health data
Ceasing all intentional or inadvertent information blocking
Adopting federally-recognized national interoperability standards.
The ONC has also formed a Health IT Policy Committee and Health IT Standards Committee which each include smaller workgroups that meet to ensure ongoing collaboration among the private and public sector. In fact, many members of CommonWell and other private-sector interoperability initiatives participate and/or lead these committees and workgroups.
The days of life science companies focusing on physicians and medical professionals as their main “customers” are numbered. Larger healthcare market trends, better access to real world data and increasing costs are driving the shift to a new customer – the patient.
As total spending on medicines globally reaches the $1 trillion level annually, payers are, not surprisingly, placing greater emphasis on ensuring they are receiving value for their investments. Payers are bringing closer scrutiny to all parts of the healthcare system they are funding. Patients, too, are spending more in today’s system and in turn are changing their expectations about value and outcomes. As a result, we are seeing a new focus on real world evidence as payers and patients seek proof that the medicines are contributing to improved patient outcomes, reduction in hospital admissions or re-admissions, and more efficient use of resources.
In response, life science companies are seeking new and more effective ways to leverage data and analytics across the clinical-commercial continuum and to adapt their go-to-market strategies to reflect their focus on patient outcomes. Capturing results-oriented data and making it usable is critical for this new model to work and for the patient to receive the most appropriate care.
With this shift to outcomes-based results and real world evidence, many questions arise around the data and analytics. Who defines “value” and what does success look like? Is it long-term value or short-term results? Additionally, how should this information be distributed to and evaluated by the various stakeholders? How do we achieve a level of consistency when data sources are not yet fully interoperable?
As the pharma industry starts to work through the answers to these questions and begins to redefine go-to-market strategies and commercial models, effective utilization of data and analytics will prove to be one of the greatest competitive advantages.
Defining Value in the New Healthcare Era
This focus on patient outcomes has broader implications for the industry with data sources now being aligned with the patient to enable decisions across the enterprise including drug development, market access, and commercial performance.
This article is part of the “Think Further” series sponsored by Fred Alger Management. For more “Think Further” content, please visit www.thinkfurtheralger.com.
There is almost nothing I’m certain of except that life is an uncertain thing and that it seems to change a lot. Even in the most predictable of settings, even the minutest changes in detail can have a lasting and overwhelming effect on nearly everything in its atmosphere. In healthcare, a space seemingly immune to the status quo, things seem to get a whole lot more complicated. The same can be said of life and death, health and well-being. On their own, they are not so difficult to understand and often, in most cases, predictable and redundant; until the final days, of course, then things begin to get a little more complicated. When we’re fine, we’re fine. Life is good and most of our concerns seem trivial.
Then health gets involved and the minutest change in detail can send our lives in a spiral so much so that we barely recognize our place in it let alone who we are and where we belong. When such an occurrence arises, we begin to rely on beeps and buttons, software and technology in ways never before imagined for the intersection of our lives.
Clearly, the health IT landscape will be completely different five years from now. From where we stand today to where we’re headed, we’ll likely look back on this moment and wonder how we survived such archaic times. Just a couple years removed from the age of the electronic health records, technology that already seems dated and antiquated, is no longer monolithic and domineering to the space as it likely seemed in 2010.
Our future selves might stand on the threshold of 2020 and say that we were being single minded. The technology — EHRs were supposed to save healthcare and are now nothing but foundational. The technology was supposed to simply aggregate information collection, provide for the ability to quickly share information system wide and around the world; and give us the capability accessing all of a patient’s information at the tips of the proverbial finger.
When the promise of those solutions faded (yes, their stars have faded) and as our attention forced us into new technologies (primarily because of consumers’ desire) we are now seeing developments in technology creating touch points that impact patients “where they live” and has become the new force behind healthcare technology.
Consumers will drive healthcare’s future. Probably not a secret at this point, but a point that is hard for the old guard. They’ve had enough of being left out of the ownership process regarding their own health. They’re tired of being locked out of their own records, and kept access to their own information. Such data would not exist without those helping produce it. New consumer technologies have and will further level the field. Consumer tech will continue to spur innovation, at light speeds. Data will flow between healthcare parties and its consumers; HIPAA protections will be waived and open access for the social good will become the norm. Standard and traditional approaches when dealing with patients, in a generation or so, will be completely different and far less segmented, as they are now.
The Centers for Medicare & Medicaid Services (CMS) and Office of the National Coordinator for Health Information Technology (ONC) today released final rules that simplify requirements and add new flexibilities for providers to make electronic health information available when and where it matters most and for health care providers and consumers to be able to readily, safely, and securely exchange that information. The final rule for 2015 Edition Health IT Certification Criteria (2015 Edition) and final rule with comment period for the Medicare and Medicaid Electronic Health Records (EHRs) Incentive Programs will help continue to move the health care industry away from a paper-based system, where a doctor’s handwriting needed to be interpreted and patient files could be misplaced.
“We have a shared goal of electronic health records helping physicians, clinicians, and hospitals to deliver better care, smarter spending, and healthier people. We eliminated unnecessary requirements, simplified and increased flexibility for those that remain, and focused on interoperability, information exchange, and patient engagement. By 2018, these rules move us beyond the staged approach of ‘meaningful use’ and focus on broader delivery system reform,” said Dr. Patrick Conway, M.D., M.Sc., CMS deputy administrator for innovation and quality and chief medical officer. “Most importantly we are seeking additional public comments and plan for active engagement of stakeholders so we take time to get broad input on how to improve these programs over time.”
HHS heard from physicians and other providers about the challenges they face making this technology work well for their individual practices and for their patients. In recognition of these concerns, the regulations announced today make significant changes in current requirements. They will ease the reporting burden for providers, support interoperability, and improve patient outcomes. Providers can choose the measures of progress that are most meaningful to their practice and have more time to implement changes to program requirements. Providers are encouraged to apply for hardship exceptions if they need to switch or have other technology difficulties with their EHR vendor. Additionally, the new rules give developers more time to create user-friendly technologies that give individuals easier access to their information so they can be engaged and empowered in their care.
As part of today’s regulations, CMS announced a 60-day public comment period to gather additional feedback about the EHR Incentive Programs going forward, in particular with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which established the Merit-based Incentive Payment System and consolidates certain aspects of a number of quality measurement and federal incentive programs into one more efficient framework. We will use this feedback to inform future policy developments for the EHR Incentive Programs, as well as consider it during rulemaking to implement MACRA, which we expect to release in the spring of 2016.
Health IT’s most pressing issues may be so prevalent that they can’t be contained to a single post, as is obvious here, the third installment in the series detailing some of the biggest IT issues. There are differing opinions as to what the most important issues are, but there are many clear and overwhelming problems for the sector. Data, security, interoperability and compliance are some of the more obvious, according to the following experts, but those are not all, as you likely know and we’ll continue to see.
Here, we continue to offer the perspective of some of healthcare’s insiders who offer their opinions on health IT’s greatest problems and where we should be spending a good deal, if not most, of our focus. If you’d like to read the first installment in the series, go here: Health IT’s Most Pressing Issues and Health IT’s Most Pressing Issues (Part 2). Also, feel free to let us know if you agree with the following, or add what you think are some of the sector’s biggest boondoggles.
The healthcare industry has undoubtedly become a bigger target for security threats and data breaches in recent years and in my opinion that can be attributed in large part to the industry’s movement to virtualization and the cloud. By adopting these agile, effective and cost-effective modern technological trends, it also widens the network’s attack surface area, and in turn, raises the potential risk for security threats.
We actually conducted some research recently that addresses evolving security challenges, including those impacting the healthcare industry, with the introduction of cloud infrastructures. The issue is highlighted by the fact that the growing popularity of cloud adoption has been identified as one of the key reasons IT and security professionals (57 percent) find securing their networks more difficult today than two years ago.
Paul Brient, CEO, PatientKeeper, Inc. No industry on Earth has computerized its operations with a goal to reduce productivity and efficiency. That would be absurd. Yet we see countless articles and complaints by physicians about the fact that computerization of their workflows has made them less productive, less efficient and potentially less effective. An EHR is supposed to “automate and streamline the clinician’s workflow.” But does it really? Unfortunately, no. At least not yet. Impediments to using hospital EHRs demand attention because physicians are by far the most expensive and limited resource in the healthcare system. Hopefully, the next few years will bring about the innovation and new approaches necessary to make EHRs truly work for physicians. Otherwise, the $36 billion and the countless hours hospitals across the country have spent implementing electronic systems will have been squandered.
Email security is one of healthcare’s top IT issues, thanks, in part, to budget constraints. Many healthcare organizations have already allocated the majority of IT dollars to improving systems that manage electronic patient records in order to meet HIPAA compliance. As such, data security may fall to the wayside, leaving sensitive customer information vulnerable to sophisticated cyber-attacks that combine social engineering and spear-phishing to penetrate organizations’ networks and steal critical data. Most of the major data breaches that have occurred over the past year have been initiated by this type of email-based threat. The only defense against this level of attack is a layered approach to security, which has evolved beyond traditional email security solutions that may have been adequate a few years ago, but are no longer a match for highly-targeted spear-phishing attacks.
Dr. Rae Hayward, HCISPP, director of education and training at (ISC)²
Dr. Rae Hayward
According to the 2015 (ISC)² Global Information Security Workforce Study, global healthcare industry professionals identified the following top security threats as the most concerning: malware (77 percent), application vulnerabilities (74 percent), configuration mistakes/oversights (70 percent), mobile devices (69 percent) and faulty network/system configuration (65 percent). Also, customer privacy violations, damage to the organization’s reputation and breach of laws and regulations were ranked equally as top priorities for healthcare IT security professionals.
So what do these professionals believe will help to resolve these issues? Healthcare respondents believe that network monitoring and intelligence (76 percent), along with improved intrusion detection and prevention technologies (73 percent) are security technologies that will provide significant improvements to the security posture of their organizations. Other research shows that having a business continuity management plan involved in remediation efforts will help to reduce the costs associated with a breach. Having a formal incident response plan in place prior to any incident decreases the average cost of the data breach. A strong security posture decreases not only incidents, but also the loss of data when a breach occurs.
Guest post by Steve Tolle, chief strategy officer and president of iConnect Network Services, Merge Healthcare.
Sooner than later, payers will demand meaningful interoperability to determine the true cost of quality healthcare outcomes. While they may not have a preference for which electronic health record (EHR) platform a doctor or health system uses, they will understand that a platform’s ability to communicate with other EHR platforms will affect the cost and quality of the care provided.
Payers are already implementing bundled payments for some types of costly care, such as full hip replacements. Conventional assumptions aside, physician fees and facility charges are not the leading drivers of joint replacement cost variability. Instead, wide cost disparities frequently seen between Joint Replacement Procedure A and Joint Replacement Procedure B are the product of unpredictable charges for supplies, anesthesia, and medical imaging. When payers start bundling reimbursements for common procedures, risk will shift to providers who will be challenged to closely manage cost fluctuations. In preparation for this transition, healthcare organizations must proactively assess their imaging strategies to keep their business running smoothly, continue providing quality patient care, and ensure they maximize revenue for the services they deliver.
What Providers Must Evaluate
Medical imaging is a $100 billion industry that drives $300 billion in healthcare spending. It accounts for nearly eight percent of U.S. healthcare spending, according to the Journal of the American College of Radiology — a costly component of care that must be effectively addressed as the industry readies itself for the shift from volume to value-based reimbursement.
The U.S. Department of Health and Human Services recently set an ambitious goal that by 2016, 85 percent of healthcare payments will be tied to quality and value of care. Successful healthcare organizations will need to manage two key factors closely — appropriateness and efficiency.
CMS and private payers will increase their vigilance around quality measures such as readmission rates and unnecessary diagnostic imaging. Medically unnecessary or redundant imaging is already on Medicare’s radar, showing up in legislation that mandated decision support for imaging and extended the deadline for ICD-10 conversion. If providers begin to correct course now, downstream risk of lost revenue and decreased patient satisfaction can be mitigated, if not avoided.
Take Stock of Current Assets
To stay ahead of the curve, providers should evaluate all aspects of their image management programs. Many are looking for new solutions that simplify and digitize outdated, paper-based procedures for patient orders, automate insurance payment authorization, and move images from point A to point B in real time, regardless of file format.