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Transformation toward value-based healthcare is reshaping the delivery of care, patient expectations, and payment structures.
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As the United States migrates to a value-based healthcare system, one that is measured on improvements in quality and service while controlling costs, federal and state payment policies are needed to support the use of technologies and services that help to achieve these goals. Simple analysis, such as comparing payment amounts per procedure by site of service are not very helpful in efforts to bend the overall cost curve.
Physician offices have been targeted for reimbursement reduction for imaging services at levels not seen by hospitals, with 13 separate cuts in reimbursement rates since 2006.
This trend now also poses a concern for hospitals. Hospitals have struggled with how to accurately reflect the equipment costs of imaging services on their cost report to the Medicare program, with the result that many imaging services have been under-valued in the hospital outpatient setting. This issue is only now starting to be addressed by the Medicare program. Hospitals have very different overhead costs, due to several factors such as uncompensated care obligations, teaching and training activities, and the need to provide 24/7 emergency care for their communities. Yet policy organizations and researchers continue to compare the reimbursement rates for physician and hospital sites of service as if they are both apples, versus as an apple and an orange.
In its March 2014 Report to Congress, the Medicare Payment Advisory Commission (MedPAC) proposes aligning hospital outpatient department payment rates with physician office rates for some ambulatory services. MedPAC evaluated about 450 ambulatory payment classifications (APCs) and found 66 that did not require emergency standby capacity.
Aligning the payments for these 66 outpatient APCs would mean major cuts if this policy were to go into effect. Although the negative impact on hospital margins under the proposal would average 0.6 percent, the impact would be more onerous for rural, smaller, and specialty hospitals, which stand to lose as much as 0.9 percent because they have a larger share of their overall Medicare revenues coming from outpatient care.
Two of the 66 APCs would capture ultrasound services that have been shown to improve quality and reduce cost significantly. The proposed policy ignores the specific benefits of its use in a hospital setting, such having rapid access to the operating room and avoiding costly complications in surgeries. If the proposal were adopted, an unintended consequence might be the decision of some hospitals to shift from ultrasound to more cumbersome and time-consuming, but also higher-paid, radiation-dependent modalities, which pose the risk of radiation to patients. Because ultrasound poses no radiation risk to patients, it is one of the most useful tests in terms of balancing diagnostic needs with patient safety.
If payments are driven down for hospitals, the reality is that hospitals will need to respond. Management consultants might be called in to show administrators which procedures would keep their Level 1 trauma centers afloat, after which centers would shift their priorities accordingly. If quality is adversely affected, it ultimately will be the trauma centers, and potentially their vulnerable populations, that will suffer. A large proportion of the nation’s compassionate, uncompensated care is delivered in trauma centers. These centers and those they serve could be the victims of a well-intended but poorly considered policy change.
In short, making it more and more difficult to perform important procedures in the hospital setting—a conceivable result if their reimbursement is threatened—ultimately could lead to greater costs to Medicare and greater risks to patients, not to mention more limited access to care, which goes against one of the central tenets of healthcare reform. Healthcare finance leaders should advocate strongly against MedPAC’s proposal, bringing these compelling perspectives to bear.
Paul R. Sierzenski, MD, RDMS, FAAEM, FACEP, is medical director, point-of-care ultrasound, and director, Emergency, Trauma & Critical Care Ultrasound, Christiana Care Health System, Wilmington, Delaware.
Publication Date: Wednesday, April 23, 2014
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.
Copyright 2016, Healthcare Financial Management Association.
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