For many practices, the focus this year has been on ICD-10 and preparing for an effective transition. As a result, a growing problem has been slipping under the radar—patient collections.
Today, patient due amounts make up 30 percent or more of practice accounts receivable. And the longer it takes the practice to collect from a patient, the less they get paid. According to Mary Pat Whaley, after 60 days the percentage collected drops to below 60 percent.
ICD-10 will likely remain a key focus for practices through the end of 2015 at least. But don’t let that stop you from taking some time to look at the state of your patient collections. This infographic shows how the landscape is changing and what practices can do to ensure they get paid.
Although life in rural communities offers many advantages, the rural healthcare system in America faces challenges not seen in urban areas, for obvious reason: population loss, poverty and access to healthcare have been problematic in recent years.
Taking a look at Pennsylvania, which is the sixth most populous and ninth most densely populated state in the US, based on information from the United States Census Bureau from 2010 and 2013, as a state it hosts a significant amount of rural areas. According to the Pennsylvania Rural Health Association, 48 of its 67 counties classified as rural, and all but two counties have rural areas. More than one quarter of Pennsylvanians live in rural counties.
Thus, it’s as good a place as any to examine some of the unique issues facing rural communities, who even though they may be within driving distance to some of the best medical care in the world, they are unable to access it each day without some sort of life altering obstacle.
In general, residents of rural communities in the U.S. are less healthy than those in urban environments. According to Unite for Sight, “rural residents smoke more, exercise less, have less nutritional diets and are more likely to be obese than suburban residents.” Already against the odds, residents in rural Pennsylvania face several specific problems that jeopardize the state of healthcare in the area.
Population Loss
Between 2000 and 2010, the Pittsburgh Post-Gazette reported that rural Pennsylvania counties grew by 2.2 percent while urban counties grew by 3.9 percent. However, the small increase in rural counties was only because of the eastern counties. Western rural counties decreased by 0.9 percent, and by another 0.5 percent from 2010 to 2012.
In some places, the situation is bleak. The newspaper highlights the population loss in Taylor Township, a part of Lawrence County that experienced a 13.6 percent population loss from 2000 to 2010. “Of its 1,052 residents, more than twice as many are over age 65 as under 18. That ratio is practically unheard of among municipalities and doesn’t bode well for the township’s future.”
Guest post by Gillian Christie, health innovation analyst, Vitality Institute
Gillian Christie
“Everyone I knew was on drugs for depression, drank too much and had severe sleeping problems.” – former Amazon employee
Jess Bezos’s beloved Amazon.com is the latest company facing criticism for its workplace practices. Jodi Kantor and David Streitfeld’s recently published article in the New York Times depicts Amazon as relentlessly pushing the boundaries of white-collar workers to achieve its sky high ambitions. While evidence suggests that a degree of stress can motivate employees to improve productivity in the short- and medium-term, demanding work cultures like Amazon’s contribute to poor physical and mental health among employees in the long-term.
Chronic diseases – diseases of long duration and slow progression like cardiovascular disease, type 2 diabetes and various cancers – now represent the leading cause of death and disability worldwide. These diseases further contribute to poor workforce productivity and threaten economic competitiveness. A majority of these diseases are largely preventable by modifying underlying risk factors, including physical activity and nutrition, minimizing excess alcohol intake, and avoiding tobacco use. Personalized health technologies – wearables, smartwatches, and mobile health applications – have emerged to empower individuals to track and modify their health behaviors, both inside and outside the workplace. These technologies connect a consumer with a device, a central data hub, and at times a healthcare professional and social network.
The proliferation of personalized health technologies has contributed to consumers engaging in healthier behaviors, but concerns have also emerged regarding the data generated by these devices. Is personal health data accurate, reliable and trustworthy? Is it being reused for marketing or advertising purposes? How do we know that data is secure and protected from cybercriminals? Consumers too often remain in the dark on how their data is used, stored, secured, and shared with others – be it their healthcare provider, employer, or unbeknownst third parties.
Consumers are expected to use more devices in coming years, meaning that more information on habits and preferences will become available to businesses. The global consulting firm Accenture contends that organizations focused on building a reputation based on offering superior services while respectfully using data will emerge as dominant market leaders. Accountability will ensure that companies comply with traditional regulation while proactively practicing self-regulation. “Digital trust is the currency of today,” according to Accenture.
To proactively address consumer concerns associated with personalized health technology, Vitality has launched a global public consultation on a draft set of guidelines running from July to October 2015. The six points addressed are:
Guest post by Greg Mancusi-Ungaro, CMO, BrandProtect
Greg Mancusi-Ungaro
Since 2009, the personal health information of almost 30 million Americans has been compromised. From Partners Healthcare and Anthem to the UCLA Health System and Children’s National Health System, it’s clear that healthcare organizations are a hot target, especially as medical records include exactly the kind of valuable data cyber criminals want to get their hands on. And, since information like social security numbers and birthdates can’t be “turned off” in the ways that stolen credit card numbers can, once cyber criminals get ahold of such records, they can do significant damage with them like counterfeiting patients’ identities.
It is crucial that the healthcare industry be vigilant when it comes to cyber security. From hospitals and insurers, to medical groups and individual practices, health-related organizations must ensure they are taking all possible measures to keep the personal information of their patients – not to mention their own brand reputation and business – safe. That begs some questions: Why are healthcare organizations such a hot target? How are they (and their patients) being targeted, and, and what can the industry do to stay one step ahead of cybercriminals and mitigate the ensuing risks?
What Makes Healthcare a Prime Target?
Healthcare organizations are a large target for many reasons. First and foremost, they possess extremely valuable assets, including the personal, family and billing information of their patients. It isn’t the blood type or cholesterol reports that make electronic health records the most valuable records on the cybercrime black market; it is the virtually complete personal identity information, including social security numbers, parents, maiden names, addresses, emails, children names and, in some cases, complete information of close friends. They are the holy grail of the identity theft world.
Second, the available attack surface in the healthcare industry is very complex. The healthcare industry contains many different organizations that have, over the past few years, moved to electronic systems, but not to a truly centralized electronic system. The reality of today’s healthcare records infrastructure is that there are many networks, data formats, communications protocols, passwords and access points all patched together. Not only is this amalgamated network challenging to maintain, it creates massive opportunities for compromise. Cybercriminals know this.
Healthcare is in the Cybercrime Crosshairs
Doctors are at the center of the healthcare universe. They interact and interface with patients, insurers, services providers and hospitals. Their office networks and smart devices connect with practically every network that affects their business. But doctors are not information technology or security experts. Less than 40 percent of doctors based in the U.S. feel that their cybersecurity processes are above average. Their lack of technical savvy and security knowledge makes them easy pickings for sophisticated cybercriminals. They need education and protection.
Patients are also prime targets. The Affordable Care Act (ACA) has accelerated the dramatic shift of health insurance and medical services to a digital transaction model. With the emergence of affordable individual policies, not tied to employer offerings, and online markets for health insurance, many more individuals are using online recourses to evaluate insurance options, enroll and manage their healthcare. Patients also go online to update their records, view and manage results and appointments, and make payments. Insurers and hospitals use email to communicate and confirm transactions, or to flag issues with accounts or with payments. This is where cybercriminals see their opportunity. Additionally, the ACA has introduced healthcare options – requiring online healthcare management — to many families who are not as familiar with online risks, so they are easy prey for phishing and other cyberattacks.
Reducing the Risk of a Successful Attack
Almost all cyber events start out the same way, with a successful attack on a single individual (an employee, doctor or patient) or device. This initial incursion, whether through malware, social engineering or another means, can lead to illegal network access and records theft over the course of weeks or months. But if a healthcare organization can successfully reduce the risk of a successful first attack, they make it harder for cyber criminals to gain this access.
Keeping your practice fiscally healthy while you keep patients physically healthy can be tricky. Medical practices work hard, offices get busy, people need attention and everyone on staff does their best to provide the immediate goal of helping people feel well. But we also know that the only way you can continue to help your patients feel well is if you maintain a healthy business that sustains your overhead, staff costs and profit.
Your ability to collect maximum reimbursement can make or break your ability to provide excellent healthcare to your patients. Without steady, high levels of reimbursement your practice will likely suffer from low cash flow and minimal profitability. It can also impact your staffing choices, ranging from running with too few employees to underpaying critical staff members, resulting in poor care. The stress level in a practice that is under-reimbursed can damage your practice from the inside out.
One way to keep a practice in the black is to minimize claims denials — that’s not as easy as it sounds. A recent American Medical Association study sought to calculate just how much reworked claims can cost a practice and found that medical offices waste as much as $14,600 each year on correcting denied claims via appeals, trouble-shooting and countless phone inquiries.
But you already know all about this — your billing staff or outsourced billers probably tell you all the time how many obstacles stand in the way of successfully submitting claims.
Here are some tips to help you avoid leaving $14,600 on the table each year:
Guest post by Timothy “Dutch” Dwight, vice president of business development, Medullan, Inc.
Timothy “Dutch” Dwight
Will today’s pioneer ACOs share the same demise as the HMOs of the 80s and 90s? It’s certainly starting to look that way.
Like HMOs, ACOs (Accountable Care Organizations) were created to reign in excessive fee-for-service arrangements and provide an incentive for capitating costs. The premise was that under the umbrella of an ACO, providers and payers would share in the responsibility for quality, cost and coordinated care for a defined population of patients.
If an ACO saved money for the payer without compromising quality, providers — defined as physician practices, hospitals, group practices, physician-hospital alliances and networks -–would share in the savings. And the savings were projected to be significant. Early forecasts from the Congressional Budget Office estimated that the 32 pioneer ACOs could save more than $1.1 billion in the first five years. On the other hand, if the ACO failed to meet capitation limits while providing care, the group shared in the losses.
To offset the risk and encourage membership, the early ACOs were supposed to receive multi-year compensation. However, that financial support disappeared after the first year and most provider groups did not have the business margins to carry them through a long-term investment approach. In addition, the ACO model requires a draw on scant resources from all parties to create another layer of program oversight – further cutting in to margin.
So where does the ACO model stand today? Nineteen of the 32 pioneer ACOs have left the program over the last two years, resulting in considerable wasted taxpayer dollars. As CMS moves towards the Next Generation program, can it succeed?
What will it take to save the ACO?
I believe ACOs can be saved, but significant changes must be enacted.
The fundamental problem with the pioneer ACO is that it manages the care of an unhealthy population without having sufficient oversight of that population. This leads a risk-adverse industry to hold their cash and cling to old processes.
Two years ago, Clayton Christensen rightly pointed out that the provider community must make major process and procedural changes in order for the ACO model to work. “No dent in costs is possible until the structure of healthcare is fundamentally changed.” I couldn’t agree more.
To survive, ACOs need to align with the Patient Centered Medical Home (PCMH) model, which is continuing to thrive and grow. PCMH is designed to align more holistic care management with a consumer incentive to prevent high-spend patients from seeking services from the more costly care centers such as emergency rooms. The payer, or insurance company, rewards the consumer for making smart choices by reducing deductibles and other fees if they use lower cost service centers such as primary care physicians, nurse practitioners, and urgent care centers. PCMH models use a combination of fee-for-service, value based payments to providers and align consumer incentives to reduce the cost of care. Comparatively, the ACOs capitated, “value based” payment model, intends only to lower the cost of care without having the proper procedures, tools and feedback loops in place to account how that care is provided. In other words, a visit to a PCP or ER makes no difference in the ACO model. On their own, ACOs do not have enough process control(s) and sufficient incentives to change patient behavior.
However, in combining the ACOs and PCMH model, the healthcare industry stands a much greater likelihood of meeting its goals — to improve the quality of care while containing or lowering the costs.
What needs to happen?
It starts with patient education – consumers need to be educated about their options and when and how to best use them. The next step is employing financial incentives. In short, money talks and will be key in changing old habits. When there is financial reward for going to one’s PCP or an urgent care center instead of an ER, consumers will make smarter choices. And ACOs will have an easier time capitating costs.
Guest post by Daniel Schwartz, content strategist, CureMD.
Daniel Schwartz
On Oct. 1, 2015, the 10th revision of the International Classification of Diseases, or ICD-10, will go into full swing, requiring that all healthcare institutions and organizations covered by the Health Insurance Portability Accountability Act comply as such. This will mark a transition from the previous classification of diseases, called ICD-9. The Centers for Medicare and Medicaid Services (CMS) has already released several documents and other mediums of information to help answer questions and concerns about this upcoming change and to provide avenues of approach to handling the upgrade, and you might find that, if you’ve waited until now to begin preparation or even so much as to begin thinking about this major coding change, you’ve waited far too long.
In a recent survey done by the Workgroup for Electronic Data Interchange (WEDI), 25 per cent of physicians stated that they are not going to be ready when the ICD-10 compliance date arrives, and another twenty five per cent stated uncertainty. Marcia Frel lick, author of the article on Medscape that represents this statistic, writes that Robert Tennant, vice chair of the WEDI group, says that “the physician side of the provider community [is] really struggling,” and, judging by the numbers in their survey, he seems to be largely correct.
Exactly a year ago, Aug. 10, 2015, the first phase of the recommended transition process, suggested and published by aafp.org in early 2014, would be less than two months away. This debut entry into the process would begin October 1 and end in December, and would include necessary tasks such as scheduling hard-date meetings with committees and personnel, conducting large inventories of coding, becoming vastly familiar with the ICD-10 coding itself, budgeting for the transition, learning your implementation plan, and much more. After the completion of the first phase, the second phase would then begin in January of 2015 and last until April, demanding the passing of tasks like completing ICD-10 training on all levels, reviewing insurance contracts, evaluating your current cash flow, and determining the impact quality initiatives, such as PQRS and Electronic Health Records, had in 2014 for your institution. These are only two of the five total phases aafp.org suggests you complete, and if you’re just now starting to look over what needs to be done, you’ll be cramming all of this scheduling, monitoring, determining, and preparing while you’re already integrating ICD-10—specific workflow plans, processes, and claim submission resources; in other words, you’ll be doing far too much within a miniscule time period, leaving too much room for error, failure, and dissatisfaction.
ICD-10 will provide more than 14,400 distinctive code sets and the ability to track many new diagnoses for hospitals and other practices. Such a large database of higher-echelon information does not demand proper transition, but requires it. Since the current ICD-9 codes are being used in almost all current healthcare processes, rather significant and grandiose substitutions and reincarnations are going to have to take place. This large-scale implementation is required so as to ensure that the codes will be put into place and used correctly, because of the improvements they carry for features such as service reimbursement, coverage qualifications, population health management and reporting, and more.
If you’re already feeling concerned about waiting too long, there are other concerns you should be worried about that would have been your only concerns if the proper preparation-phasing would’ve taken place much earlier in the year. A lot are worried that the translations from the previous ICD-9 to the current ICD-10 will not be straightforward or easy to follow, and some of these translations are indeed not directly correspondent. They include disproportionate changes that go both ways, from ICD-9 to ICD-10 and vice versa. In spite of this, there have been tables and crosswalks published to make this transitional process more painless, but it’s going to take more study and observation in order to properly determine how the coding will completely change. Practices and institutions of healthcare that have not been preparing sufficiently for these new and complex implementations and upgrades ICD-10 will bring will be maniacally wishing they had when the date of compliance arrives.
Guest post by Tom S. Lee, Ph.D, CEO and founder, SA Ignite
Tom Lee
The Value-Based Payment Modifier (VBM) is one of the most impactful yet least understood components of the portfolio of value-based programs under Medicare Part B. Provider organizations widely know that their Physician Quality Reporting System (PQRS) quality measures must be reported to CMS in order to avoid significant VBM penalties. Yet, few organizations understand the value-based payment modifier rules well enough to know how to improve their value-based payment modifier quality and cost scores, which directly impact Part B reimbursement. And, the stakes are high as the 2015 VBM can have a +/-4 percent or greater impact on Part B, and starting in 2017, value-based payment modifier comprises 60 percent of the reimbursement impact of the newly-passed Merit-Based Incentive Payment System (MIPS). MIPS rolls up value-based payment modifier, meaningful use and other value-based programs into a single score for each provider that can impact Part B reimbursement up to approximately 30 percent based upon cost and quality performance relative to peers.
One way to understand the growing importance of VBM is to compare the rules and metrics of the 2013 program to those of CMS’ proposed 2016 program. The rise is stunning and reminiscent of the rapid expansion of other game-changing programs, such as meaningful use, but where the financial and reputational impacts are even greater.
The growing number of providers subject to VBM penalties
VBM penalizes providers falling into the lowest tier of quality performance among peers nationally, as determined by PQRS and other quality measures. In 2013, approximately 30,000 providers were subject to value-based payment modifier quality-performance penalties. In 2016, CMS projections and proposals taken together indicate that 1.25 million providers will be subject to such value-based payment modifier penalties, representing a 40-fold increase in the span of 4 years.
Why the growth? It’s all about regulatory change. In 2013, this quality-performance penalty only applied to groups with more than 100 providers, which opted into quality tiering, and it excluded organizations in the Medicare Shared Savings Program (MSSP), Pioneer ACO Model, or the Comprehensive Primary Care Initiative (CPCI). Furthermore, penalties were only applicable to Part B payments to physicians (MD, DO), not payments to non-physician providers (nurse practitioners, physician assistants, etc.) In 2015, CMS cast the net wider by expanding quality-performance penalties to apply to all groups down to only 10 providers in size and including participants in MSSP ACOs, Pioneer ACO Model and CPCI. For 2016, CMS is proposing that the size threshold be removed entirely such that all groups and solo physicians be subject to quality-performance penalties and that the penalties should be applied to Part B payments to non-physicians as well, not just physicians.
The amplification of VBM incentive and penalty dollars
The sizes of the maximum incentives and penalties in 2013 were 9.8 percent and -1.0 percent, respectively. The national incentive pool is set to be equal to the national penalties assessed in order to keep value-based payment modifier as an overall budget-neutral program. Hence, the “winners take from the losers,” where “losers” also include those providers who simply did not meet the minimum PQRS reporting requirement imposed by value-based payment modifier. This non-reporting percentage was about 30 percent of eligible providers in 2013, and CMS projects about the same percentage for the 2016 performance year. Hence, assuming that the proportion between winners and losers remains about the same in 2016 as compared to 2013 (about 13 percent), and factoring in the proposed 2016 value-based payment modifier rules, the maximum value-based payment modifier performance-based incentive could rise to as high as 20 percent, while the maximum penalty would be -4 percent, respectively representing 2 times and 4 times increases from 2013. As mentioned above, MIPS further increases the potential financial impact to 30 percent or even more of Part B payments.
Although life in rural communities offers many advantages, the rural healthcare system in America faces challenges not seen in urban areas, for obvious reason: population loss, poverty and access to healthcare have been problematic in recent years.
