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Transformation toward value-based healthcare is reshaping the delivery of care, patient expectations, and payment structures.
Improve your revenue cycle performance through standard metrics, peer comparison, and successful practices.
As the country makes the shift to value-based care, many hospitals and health systems are contemplating how best to start managing population health under risk-based payment arrangements. As part of that equation, some organizations are considering whether their chances of succeeding in the emerging business model would be enhanced by developing, acquiring, or participating in provider-sponsored health plans.
Such plans typically are owned and controlled by one or more hospitals or health systems and can be a significant strategic asset in certain markets. But the decision whether to take on management of a health plan is a complex one. There is great variability from market to market, and careful evaluation, planning, and execution are essential. In many instances, it may be best to decide not to proceed.
For provider-sponsored plans to be successful, they must have appropriate scale and be underwritten, operated, and marketed in a manner consistent with the organization’s overall strategic plans.
Provider-sponsored health plans proliferated in the late 1980s and throughout the 1990s, when several hundred hospitals and health systems entered the health insurance business. The surge was driven by numerous factors, including the anticipated movement to capitation under managed care, a lack of competition among insurer-owned health plans, and the hope of achieving the margins enjoyed by those companies. Most provider-sponsored health plans formed at that time either failed or were sold. Only about 100 to 150 sizeable plans remain.
Today, many of the factors that drove interest in provider-sponsored plans 20 years ago have resurfaced with the implementation of the Affordable Care Act (ACA) and the transition to a value-based payment model. These forces, combined with the advent of health insurance exchanges this fall, have generated even greater interest among providers that want to offer a health plan directly to their patient population.
Several factors contributed to the inability of provider-sponsored plans to succeed in the 1990s, including the failure to achieve enough scale to manage risk, the lack of an adequate provider network, and poor underwriting. Providers currently considering entering into the health insurance market can learn from their predecessors. Past efforts suggest that a provider’s success depends on its ability to:
In addition, for plans to be formed by multiple provider sponsors, the sponsors must be able to both compete and jointly govern a health plan.
Organizations today that are considering whether to move into the health insurance business should carefully consider their options. Seeking outside expertise is recommended to help identify and evaluate existing provider-sponsored health plans in the region, and determine the best path forward based on a solid strategic-financial analysis.
Opportunities may exist either to join an existing multiprovider-sponsored plan or to merge an existing plan with another provider-sponsored plan. Such arrangements allow hospitals and health systems to more quickly achieve the scale required to assume utilization risk. As noted previously, however, the long-term viability of plans with multiple provider sponsors may be uncertain. The chances of success are greatly improved if potential partners serve different patient populations and if they maintain individual control over underwriting decisions and sufficient financial risk for services provided in their respective markets.
Developing a new provider-sponsored plan poses more challenges, and the associated risks likely are too great for most hospitals and health systems. Competition may be formidable from large established commercial health plans that have experience, large capital reserves, and economies of scale. In most cases, it may be advisable to consider partnering with an existing payer to form a narrow network product, or work with an outside firm that specializes in developing health plans. Even so, each opportunity is unique and requires thorough evaluation. Provider-sponsored health plans may be able to gain niche positions in given markets, but controlling out-of-area claim costs will continue to be a challenge.
Organizations that opt to establish new plans should engage in comprehensive planning to mitigate potential risk from the very significant capital investment, actuarial, and management expertise requirements. They should be prepared for losses that could be much greater than investment costs and returns, even in the long term.
Developing an insurance offering for the health insurance exchanges that are opening for consumer enrollment in October under the ACA may be the right-sized playing field for certain provider-sponsored plans due to their defined geographic scale. Again, rigorous planning is required to mitigate financial risk.
Mike Finnerty is a managing director with the mergers and acquisitions practice of Kaufman, Hall & Associates, Inc., Skokie, Ill.
Publication Date: Wednesday, May 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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