Guest post Ken Perez, vice president of healthcare policy, Omnicell.
Ken Perez
A recent poll conducted by Monmouth University concluded that “fully 70 percent of American voters say that this year’s presidential campaign has brought out the worst in people.”
Undoubtedly and sadly, in this era in which fact-checking of candidate statements is essential, a majority of Americans believe that all politicians lie or at least that they lie often.
That prevailing sentiment is what made former President Bill Clinton’s candid riff about the Affordable Care Act at an Oct. 3 Democratic rally in Flint, Mich. so extraordinary. He stated, “…the current system works fine if you’re eligible for Medicaid, if you’re a lower-income working person, if you’re already on Medicare, or if you get enough subsidies on a modest income that you can afford your healthcare. But the people who are getting killed in this deal are small business people and who make just a little bit too much to get any of these subsidies. Why? Because they’re not organized. They don’t have any bargaining power with insurance companies. And they’re getting whacked. So you’ve got this crazy system where all of a sudden 25 million more people have healthcare, and then the people out there bustin’ it sometimes 60 hours a week end up with their premiums doubled and their coverage cut in half. It’s the craziest thing in the world.”
Unlike the ACA’s expansion of Medicaid, which has been blocked by 19 states that have declined to go along with the law, the health insurance exchanges have been operational for a number of years in all fifty states and the District of Columbia.
So how are the health insurance exchanges of this “crazy system” really doing and, to Clinton’s point, what’s happening to people who don’t qualify for subsidies?
Clinton was generous in saying that the “system works fine” for those who get subsidies. State regulators have used terms such as “near collapse,” “emergency situation,” “meltdown,” and “financial death spiral” to describe the condition of their exchanges. In total, the health insurance exchanges are way over budget, serve fewer people, and show signs of being unsustainable, which pushes health plans to cost shift by raising premiums for non-exchange insurance policies, especially employer-sponsored health insurance. The population paying for those policies include the people Clinton described as “bustin’ it sometimes 60 hours a week.”
Originally, the federal government was supposed to spend $136 billion from 2015-2019 on health insurance exchange subsidies. However, as more states than expected opted to have the federal government run their exchanges and because of the higher-risk pool of individuals participating in the exchanges—which led to premium hikes—the Congressional Budget Office (CBO) in August projected $278 billion in federal outlays for health insurance exchange subsidies for that period, leading to an overspending or budget deficit just for the subsidies of $142 billion for 2015-2019, a staggering amount, considering that it would basically cancel out the projected 10-year budget surplus for the entire health reform law. With even greater average premium hikes expected for 2017—24 percent for the non-group market—the CBO’s projection is clearly conservative and will certainly be revised upward.
Many states are reporting individual market rate hikes in 2017 well above the aforementioned national average. Minnesota’s approved increases range from 50 to 67 percent. Blue Cross Blue Shield of Tennessee will raise its rates by 62 percent. Golden Rule Insurance Co. in Kentucky received approval for a 47.2 percent rate increase, while Wellmark in Iowa will raise its rates by 42.6 percent. In Delaware, Highmark Blue Cross Blue Shield received approval for a 32.5 percent average rate increase, and Utah’s individual exchange health plans will rise on average 30 percent.
Did you hear the one about the disbarred lawyer who embezzled more than $1.2 million from a hospital in Kansas City over four and one-half years? This is not the start of a joke; it is unfortunately all too true. The long-trusted attorney supposedly served the hospital by collecting past-due payments from patients. Money collected was to go into a trust account. However, his fingers were more than a little sticky when checks were mailed back from patients and found their way into his personal account.
Slow-/no-pay patients have become a much more important aspect of hospital financial management as high deductible health plans (HDHP) become the norm across America. What once was considered little more than an annoying write-off, keeping bad debt to an absolute minimum is very much a priority. Gone are the days when more than 90 percent of revenue came from the insurance companies. Hospitals must look to patients for 50 percent, or more, of that revenue now. My bet is the number of checks embezzled by the attorney has only recently become material, which is why it took so long to catch him.
We can criticize the hospital for not staying on top of its account receivables. Certainly, payment plans, offered at the time of service can help keep A/Rs down as can reminders emailed to the slow-poke-paying patients. But that’s misses the larger point.
Unfortunately, any time checks are directed to third-party services, the potential for maleficence exists. Any point in a process where the payment can be touched, there is an opportunity for a redirection of those funds as in the case of the hospital in the city of fountains.
A significant portion of this could have been avoided if the hospital used an online paperless solution to bill their patients. It cuts off those sticky fingers, figuratively speaking. A paperless method keeps out crooked collectors because there is no reason or way for them to get their hands on the funds since they are not deposited directly into the hospital’s bank account and reconciled nightly. There’s nothing to touch or divert.
I am of the opinion that this crime in Kansas City is not all that unusual or isolated. Perhaps a perpetrator is uncovered and reparations are made under the cover of a sealed agreement, but it happens entirely too often.
In the past year I’ve seen reports of CEOs, CFOs and directors shown the door for embezzling millions from healthcare facilities in Alabama, Idaho and Wyoming, among others. The Alabama case involved a whopping $14 million.
Cash flow has become a top priority for all segments of healthcare, but especially hospitals. As I already suggested, the presence of HDHPs has made it so. But the manner in which these institutions bill for services rendered and go about seeking payment, is opening them to the same fate as these other organizations who were robbed and so the time to change is now.
Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
Abhinav Shashank
The digitization of healthcare was a much-needed change brought after years of hard work and effort. One might wonder how could one justify the expenditure of $10 billion in a span of five years just on digitization. The problem intensifies when after several studies we find out that EHRs only reciprocate around 30 to 35 cents on a dollar and sometimes the figure dips to 15 cents.
Why have we digitized healthcare when the efforts required to get the desired result is still too much? I think we haven’t used the available technological aids appropriately. It is like driving a car at midnight and not knowing that you have headlights. You can have a clear view of your path, you can get to your destination fairly fast but can’t because you don’t know what is going to help you and in what way, your performance is reduced to a great extent to be able to achieve what you desire
Justified use of EHR could create the needed ecosystem
According to a report, 10 percent to 20 percent of savings are possible if a value-focused healthcare organizations capitalize on EHRs and interact with their patients better through technology. The amount that could be saved annually per bed is in between $10,000 and $20,000.
Meaningful Use
There are incentives for meaningful use of EHRs, but the truth is that the return through meaningful use incentives is somewhere around 15 or 20 cents on a dollars. There have been implementation, stabilization and optimization problems that have made it hard for healthcare organizations to extract the best out of EHRs. Practices will have to start using data as a source of innovation and come up with solutions that’ll not provide them better incentives but assist them in providing even better patient-centric care.
There are certain key points one can work on to make their healthcare ecosystem more efficient and patient-centric. Only judicious data usage from data disparate sources can help in so many ways, imagine what else is possible with advanced solutions. The integration of EHR with different disparate sources could be really beneficial in understanding the factors that drive value-based care. For instance, with the help of various data one can perform:
Population Health Management: With the help of data collected from different sources, impact at a population could be created and analyzed. Once you have the data of millions of patients, imagine all the things that are possible. Identification of at-risk patients, stratification of patients on the basis of various disease registries, better decision making, and a lot more. According to a study, due to disease management programs the cost of care were reduced by $136 per member per month because of reduction in admission rates by 29 percent.
Variations in Care Delivery: Efficient analytics and data management can help answer many questions. The medication process could be streamlined on the basis of past cases, and identified opportunities could be capitalized. Also, a thorough data-driven analytics could provide substantial insights on the performance of various facilities and how they differ when it comes to care delivery process.
Guest post by Todd Greenwood, PhD, MPH, director of digital strategy, and Benjamin Dean, digital and business strategist, Medullan.
Todd Greenwood, PhD, MPH
Once upon a time, all that pharmaceutical companies had to do to get their drugs on formulary was to package their clinical data and convince payers that their products performed better (or better enough) in clinical trials. Contracts were struck and the revenues flowed. For most new specialty drugs, those days are now history.
With the average retail price of a specialty drug used on a chronic basis exceeding $53,000 (according to an AARP study), nearly 200 times the average price of generics, payers are demanding that pharmaceutical companies make data-driven, value-based cases before access is granted. Even when payers are convinced , they build stipulations into value-based contracts that require manufacturers to prove that outcomes are being met with their covered lives, or else the pharmaceutical company will face additional penalties or further restrictions.
This all means that the data that manufacturers have used to drive regulatory approval are insufficient for garnering payer formulary access. Companies are being required to prove that their drugs work in the real world – not just within the carefully controlled environment of a clinical study. Across therapeutic areas from osteoporosis to oncology, payers have and are currently using real world evidence studies to define their formularies. Payers want to know how expensive specialty drugs will perform as patients adhere to (or in most cases don’t adhere to) their medications, and outside of the rarified air of a traditional clinical trial.
Benjamin Dean
Equally importantly, payers want to know how drugs affect the most important (and most expensive) health outcomes. Clinical data showing that a drug performed some percentage better than either a category leader or a placebo is now insufficient for new specialty drugs. Instead, payers need to know how health outcomes improved and how effective the drugs were at keeping patients out of the hospital and away from the catastrophic costs.
While it may sound easy, providing this kind of data is far from simple. Clinical trial data is controlled, clean and contained. Surveillance data (AKA real-world data) is a different beast, because patients are complicated. We have multiple conditions, take multiple medications, and we are inconsistent, rarely complying with our doctors’ orders. Moreover, the outcomes that payers care about – hospitalization, disability and death – can be difficult to distill. The data needs to be compiled from a variety of sources: medical and prescription drug claims, electronic health records, the lab (genomic and pathology data) and directly from the patient. Compounded with this, different populations of patients have different risks, and comparing one to another is fraught with difficulty. Finally, real world data can take time to accumulate. In order to know if a drug is working “in the wild”, researchers need to follow enough patients, for long enough, to observe negative health events of interest.
Take, for example, the new class of hyperlipidemia drugs, PCSK9-inhibitors. These injection drugs have been shown to cut LDL cholesterol levels in half, compared with about a 20 percent reduction for statin-class drugs like Zetia. But given the high price of these drugs ($14,000 per year in the US) plus their potential to be prescribed to a significant percentage of the population, payers have largely refused an access foothold. Payer organizations in the US and around the world are asking the same question: how well do these drugs work in real patient populations and to what end? Given that these drugs will be sanctioned for high-risk patients (many of whom will continue to use statin class drugs as combination therapy), payers are concerned about adherence, and ultimately if there is lower cardiac risk and fewer related cardiac events in patient populations. Many economists are asking: can’t we achieve the same ends for far less money by getting patients to adhere more faithfully to their statins?
The need is clear: pharma companies who have invested significantly to develop and launch new specialty drugs have to prove their worth with real world data. But in markets like the US, where providers are typically siloed and disconnected, it’s challenging to capture patient-level condition and drug utilization data, and effectively append it with hospitalizations, other outcomes evidence and costs in order to develop a complete picture.
But there’s hope. As the specialty drug market begins to shift to a value-based model, new ways of tracking real-world usage and connecting it to outcomes are emerging. This is where digital health is poised to play a critical role.
Whether you’re a student in school to become a medical assistant or already working in the field, we can bet that you’ve had a question or two that wasn’t easily answered by an instructor or coworker. The beauty of education and training today is that when that happens you needn’t spend hours flipping through books and manuals to find the information.
While it’s always best to have your questions answered “from the horse’s mouth,” these free medical apps can help put your mind at ease and get you an answer in a pinch.
Epocrates is the #1 medical reference app and go to mobile tool for U.S. physicians and medical providers. It’s hard to believe that it’s free with all of the features it offers. Through the app you can:
Look up OTC and name/brand drug information
Identify potential drug interactions
Access news and up to date research
Perform drug calculations
athena text messaging
athenatext messaging might be the most interesting feature of this app. You can set up a texting service within your care group to share images and communicate with people in your office about patients while still adhering to HIPAA laws.
Medscape is a similar alternative to Epocrates that has many of the same features in an easy to use design. One thing that sets it apart from Epocrates is that it is not just one app but a family of three that each serves a slightly different purpose.
Medscape
Look up OTC and name/brand drug information
Identify Interactions
Perform Drug Calculations
Medscape Medplus News App
Get up to date news related to your field of specialty
Follow medical trends and share information with your followers
Search topics and personalize what’s shown to you
Medscape CME and Education App
Earn CME/CE credit directly from the app
Train with a variety of formats including video and audio
Guest post by Tatsiana Levdikova, copywriter, Effective Soft.
Tatsiana Levdikova
Hospital managers want to be sure that hospital staff constantly improve their skills and share relevant information with their colleagues. Automated solutions cannot become a substitute for a discussion where healthcare professionals can exchange their knowledge and share their ideas, but routine tasks can be arranged in the form of a workflow portal.
Usage of such a portal has a number of advantages:
It will help employees to save their time;
It will enable hospital managers to assign different access privileges to users, thus restricting access to medical data;
The portal can automatically create and send out reports like the ones covering employee performance.
This portal can be used to create its own medical knowledge base for the hospital.
A hospital is a place where like-minded people work and spend much time together. Not to lag behind other healthcare professionals, hospital staff must keep abreast of the latest trends and developments in medicine. However, being extremely busy during their working hours, the personnel has not time to discuss medical trends and developments on the fly: according to the National Center for Health Statistics the mean wait time in U.S. emergency departments increased 25 percent, from 46.5 minutes to 58.1 minutes from 2003 through 2009.
A hospital communication portal seems to be the right choice in this case. However, it should be noted that developers of custom hospital software and such portals in particular must pay close attention to the specifics a medical organization has.
The portal will enable the personnel to share valuable medical information, such as aspects of people, companies, news and other things of interest in a convenient, efficient, and fast way. Besides, it is important to give users an ability to comment.
Users would have their own profiles enabling them to connect directly with each other. The profiles could also include basic information on departments where users work, room numbers, working hours, specializations, and more.
Capabilities of the portal could be extended further by adding elements of social networks by making it possible for users to upload videos and images, tagging other users to them, etc. A general chat or forum could also be launched. All in all, the portal could become an important part of the HRM reporting system and assist hospital managers in managing sources and personnel.
Such a portal has the potential to become much more than a communication tool. It could become an effective hospital automation tool:
Guest post by Dave Willsey, CEO and co-founder, Integrify.
David Willsey
Data security is a top concern of every healthcare provider today. And for good reason. A recent news story from The Wall Street Journal reported that healthcare is “frequently cited as one of the industries most exposed to cyberattack due to large networks with numerous access points and vulnerable, legacy computer systems.”
If there is an industry more vulnerable to hackers today than healthcare organizations, you’d have to search far and wide to find it. Healthcare hacking is a growing problem. It is a trend that will not change course anytime soon.
Unfortunately, hospitals and other providers present a target rich environment for criminals and malicious hackers. And, to make matters worse, a recent study by researchers at three leading universities concluded that additional threats are coming from within “the house” as clinicians and other staff are taking shortcuts and finding workarounds to security measures in an attempt to deliver better patient care.
The federal government response to this growing threat is two-fold: mandatory reporting of data breaches and financial penalties that sting when violations of protected health information occur.
When it comes to reporting and ensuring continuous improvement to guard against future risk to data security, the number-one best practice today is a well-conceived, executable and automated incident response plan (IRP).
The good news is seven-in-ten providers have an IRP in place. The not-so-good-news is most of those plans are based on manual, labor intensive, error-prone processes. What’s needed to step-up the game for healthcare providers is an automated IRP workflow process. Automation is the only way to protect your data as the threat continues to evolve in the future.
Secure data and information is the chief reason to automate IRP workflow. But ROI is another major business driver to invest in automation. Here’s why – you’ll get quick payback from more accurate information about threats and breaches sooner in the process before they get out of hand; your teams will be able to execute with rapid response times that lead to fast resolution when compared to manual processes; and, finally, automation will bring your leadership team and other key stakeholders a unique capability to apply analytics and intelligence to support and measure continuous improvement in critical processes against future threats.
Automated IRP can provide all users with a simple incident reporting tool across the healthcare ecosystem – if a doctor or nurse or someone in the pharmacy formulary, for example, notices a potential security issue, that user can immediately trigger an automated IRP process. This action would notify the front line responder teams who can then escalate a response if needed.
Effective incident response planning addresses three key areas – people, process and data. With people, it’s very important that the roles of each person handling patient data are well identified and this would include all clinical staff, billing and administrative personnel, insurance agents, IT personnel, outside vendors, contractors, and others.
Guest post by John Squire, president and COO, Amazing Charts.
John Squire
Why do so many small medical practices give up a significant portion of their earnings to outside billers? Depending on its geographic location, volume of billing, and other factors, a practice will pay an average of seven percent of its total revenue to a biller, which could be the difference between profit or loss, maybe even success or failure.
In many cases, the reasons given are that no one in the office has experience with medical billing and the physician doesn’t believe a small staff can handle the added burden of work. But if you dig a little deeper, these assumptions are often wrong.
As a developer of electronic health record (EHR) and practice management (PM) software for small practices, my company hears a lot about billing directly from physicians and staff. We’ve learned exactly who does the billing and how they do it once a practice starts using a PM system for the very first time.
In one case, a medical assistant was able to learn everything he needed to know about billing from the PM product training alone. That’s because the physician specializes in podiatry, so the practice uses a limited set of billing codes. With a relatively light patient workload, this Medical Assistant has more than enough time to handle billing functions during normal office hours.
At another practice, when a gynecologist questioned her staff, she learned that her receptionist was eager to start doing something else, preferably from home so she could care for young children. The receptionist became certified in medical coding at a local community college on her own time, and now uses the PM system remotely and visits the office once a week every few weeks.
In a third practice we know, the pediatrician himself shares the work of billing with two of his part-time staffers, who welcomed the extra hours of pay. One staffer had knowledge of billing from a past job, while another was eager to learn. They all handle billing together as a team, so there’s no burden on any single person.
