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Transformation toward value-based healthcare is reshaping the delivery of care, patient expectations, and payment structures.
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Congress passed the Patient Protection and Affordable Care Act (ACA) in 2010 to broaden availability of healthcare insurance coverage and to control spiraling premiums and underlying costs. The legislation was an indicator of the pain caused by our expensive and inefficient healthcare system. The reality is that healthcare costs have continued to outpace other sectors of the economy, and as the government’s share of this cost burden increases, the way that we pay for and deliver healthcare in this country will have to change.
One payment model that’s gaining steam as a means to realign incentives toward better health outcomes at lower cost is bundled payment. In fact, a group of industry experts convened by the Center for American Progress and including former CMS director Don Berwick, former Obama Administration healthcare advisor Ezekiel Emanuel, and former Senate Majority Leader Tom Daschle has urged the federal government to accelerate the adoption of bundled pricing. It’s becoming increasingly clear to stakeholders across the industry that when properly designed, bundled payment strikes the right balance in avoiding both the overutilization seen under fee-for-service payment (i.e., by motivating efficient care) and the underutilization of capitation (i.e., by giving providers incentives to order tests and treatments when necessary).
Despite the window dressing, when you get right down to creating change in any industry, it’s all about the money—who pays, for what, and how. Economic incentives work in a nuanced way, both consciously and subconsciously, and drive decisions. As long as healthcare delivery continues down the path of fee-for-service payment without regard to outcomes, the tendency to do more to make more will remain strong.
The downsides of fee-for-service payment are well known. In fact, CMS has attempted to deal with the problem for decades, as evidenced by efforts such as DRGs in the 1980s. Unfortunately, CMS never connected prospective payment to outcomes, and predictably, quality problems increased along with continuously rising costs.
What has long been recognized in other industries is that quality and cost must be addressed together, and consumers need to have line of sight to the value they receive to make informed choices. Even seemingly low-hanging fruit, like reducing readmission rates, will require realignment of incentives toward more efficient health care.
By promising to deliver a standardized set of services for a fixed price with specific quality commitments, providers will effectively be given incentives to contain underlying cost drivers, without incentives for underutilization, as were seen with HMOs and capitation in the 1980s. Taking action on such issues as overutilization, technology choices, and inadequate coordination across the care continuum can drive meaningful change in quality and outcomes if providers are uniformly focused on these outcomes without the distortions caused by the current fee-for-service approach. A simultaneous focus on developing a differentiated clinical value case will ensure a balanced approach that doesn’t forgo quality and safety for the sake of economic efficiency.
Moreover, payers—both public and private—are increasingly seeing the appeal of this model. Under the gun to slow cost growth, they are looking for a solution, and the opportunity to offload financial risk is an added plus. Because of its fixed price and quality commitments, bundled payment provides a mechanism to accomplish both objectives; providers that exceed their budget or fail to deliver what they’ve committed to will bear the consequences (as they would in any other industry). Creating a predictable cost structure for a defined set of services with a desired outcome can also be a powerful mechanism for differentiation at the provider level.
Looking beyond the short-term competitive appeal to payers, healthcare delivery organizations that wait too long to develop bundled pricing may not have a choice—bundled payment may become a competitive requirement, imposed by payers. So the decision facing providers today is whether they would rather build bundled prices on their own terms, or wait for payers to force bundled payments on them.
Finally, offering bundled prices for episodes of care will move the healthcare delivery system to a more consumer-oriented model. The customer of the future wants comparable evidence of health outcomes delivered for a set total price. As in any other market, the winning provider will have the best answer to “What am I getting for my money?”
So when providers develop a bundled price, what next? How can they make sure that their bundles are better than anyone else’s? The answer is that the care that’s offered has to be differentiated, delivering more value as defined by payers and consumers.
The market share winners in this environment will be those providers that can define and deliver on better health outcome metrics. And these metrics need to go beyond traditional mortality and morbidity measures. Competing with a bundled price requires considerable transparency of information, responsive to the needs of a more engaged, value-conscious consumer. It will also require providers to develop a better understanding of cost drivers within the boundaries of a bundle of care. Every unnecessary or suboptimal resource used means a hit to the bottom line when the organization is committed to a fixed price. Finally, it will require providers to routinely monitor utilization and outcomes, by diagnosis and by physician, with processes and infrastructure to address unnecessary variation. That is a step that is long overdue. Despite these challenges, bundled pricing offers a promising means to reform our healthcare delivery system, realigning incentives for better health outcomes at lower cost.
Michael N. Abrams, M.A. is managing partner, Numerof & Associates, Inc., St. Louis.
Rita E. Numerof, PhD, is president, Numerof & Associates, Inc., St. Louis.
Publication Date: Tuesday, January 29, 2013
A leader from McKesson discusses how healthcare reform is forcing hospitals and health systems to take a different approach to capacity management and patient flow.
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
Emad Rizk, MD, president and CEO of Accretive Health, discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management.
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
Jim Bohnsack, vice president, solution & corporate development for Conifer Health Solutions, explains how the company helps healthcare providers leverage data to deliver better outcomes while optimizing reimbursement for all payment arrangements.
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
Steve Scibetta, senior director of channel sales for Ontario Systems' healthcare product line, shares insights into effectively managing receivables.
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Elena White, vice president of risk, quality, and network solutions for Optum, discusses how healthcare providers can leverage data and technology as they enable risk in their organization.
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Somnia President and CEO Marc Koch, MD, MBA, explains how hospitals can drive transformative change in the perioperative experience for outstanding clinical and financial outcomes.
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
PMMC President Roger L. Shaul discusses the effects of healthcare reform on revenue cycle management and how PMMC's products help clients adapt to a changing financial environment.
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Greg Burgess, Founder and Chief Product Officer at Burgess Group shares insights and opportunities for payment integrity in the rapidly changing healthcare IT landscape.
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
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