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An interview with Jon Kingsdale
Three years from now, the Affordable Care Act is posed to usher in the creation of state-based health insurance exchanges designed to enable consumers to easily compare qualified health insurance options and select plans that best meet their needs. These exchanges are expected to support choice in the healthcare market, as well as make health coverage more affordable by providing premium and cost-sharing subsidies to low and moderate-income individuals, according to a Kaiser Family Foundation issue brief.
A Congressional Budget Office factsheet estimates that more than 24 million people will enroll in a health plan purchased through a state-based health insurance exchange by 2019.
Jon Kingsdale, managing director, Wakely Consulting Group, has unique insight into health insurance exchanges. He helped set up the exchange for the state of Massachusetts when he served as the executive director of the Commonwealth Health Insurance Connector Authority, an independent authority established under Massachusetts' landmark health reform legislation of 2006.
In the following Q&A, Kingsdale discusses some of the benefits and challenges of these exchanges-as well as how hospitals and health systems can prepare for them.Access related tool: Questions to Ask as Hospitals Prepare for Health Insurance ExchangesWhat are the biggest benefits the exchanges offer to hospitals and health systems?
Kingsdale: By themselves, the exchanges will probably not have a huge impact on hospitals and health systems. However, when you consider the exchanges in the context of the Affordable Care Act-which is also expanding Medicaid and providing insurance subsidies-then clearly, the big advantage for healthcare providers is that there will be millions and millions more insured patients.
By improving access to insurance, the exchanges will enable many patients to obtain care they may not have been able to afford previously. That has some pretty significant business implications in terms of increased volumes for physicians, hospitals, and other providers.Are there any other business implications for hospitals and health systems?
Kingsdale: Yes, I think another possible benefit will be more payer-provider alignment around value-based plans and business propositions.
The exchanges will give individuals (including employees of small employers) the ability to shop for insurance. Individuals tend to make different choices than groups or employers buying on behalf of a group.
The majority of private insurance sold today is group insurance, purchased by employers. Typically, employers want a health plan that has every provider in the book. Employers don't want to buy a select network that forces employees to give up their current providers.
The downside to offering broad networks is that it is difficult to judge a health plan-and the individual providers in that plan-in terms of quality and costs. When a health plan offers access to thousands of physicians and dozens of health systems, the behavior of any one of those providers doesn't really have any major ramifications for the health plan.
For instance, let's say Health Plan ABC includes 50 hospitals, including Hospitals 1 and 2. Hospital 1 is inefficient and has low quality scores. But Hospital 1's poor performance doesn't really affect the ranking of Plan ABC. Conversely, Hospital 2 is doing a tremendous job at improving quality and efficiency. Yet, Hospital 2 is kind of lost in this broad network of hospitals that are offered by Plan ABC.
The introduction of the exchanges should add more individual purchasers into the insurance market, which will begin to change the dynamic and the financial incentives of the market. Entering this new insurance store will be newly insured individuals who may not have a provider or are willing to switch providers-if they can save on their own premium dollars. These patients will be "in play," if you will, and if they see that they can get a lower premium and good quality scores from a limited network plan, then they will likely go with that plan.
This gives hospitals and health plans a new business opportunity. Hospital finance leaders will no longer just be thinking about, "How much can our hospital extract from every health plan?" They will also think about, "How can we partner with a payer around a select network that's effectively marketed to individuals, so we can attract more individuals to our delivery system?"
A health system might approach a health plan and say, "Let's get together and offer a lower cost, higher quality alternative on the health insurance exchange. Let's offer a better value proposition. It won't appeal to everybody, but we don't have to appeal to the whole group to attract value-conscious individual shoppers."
Moreover, the small-group and individual insurance markets that exchanges are required to serve will have risk-adjustment mechanisms to help balance the premiums. Thus, some select-network health plans might even target sicker enrollees-if the health plan gets more premium dollars for them, and its select provider network excels at managing care for sicker patients in a cost-effective manner. You can save a lot more on good care management for a 40-year old diabetic than for a perfectly healthy one-if you can get more premium dollars through risk adjustment.
Now, of course, this vision is going to play out very differently from geography to geography.What markets do you think are most likely to see a shift to more value-based select networks?
Kingsdale: I think this change will come most rapidly to more competitive markets, versus ones that have one dominant health plan or provider system.
I've not seen as much change in the Massachusetts market in 30 years as we've seen in the last two years here. It's unbelievable. We're seeing provider systems align with health plans around a whole new value proposition for patients, which is pretty exciting.
All sorts of network-dominated health plans are popping up. For example, Partners bought Neighborhood Health Plan, which is a relatively small HMO. Steward, an old Catholic hospital system converted to for-profit, is partnering with Tufts Health Plan to offer a limited network called Steward Community Choice.What are some challenges that you see associated with these exchanges for hospitals and health systems?
Kingsdale: The exchanges will be like retail stores. The shelves are stocked by insurance companies that manufacture health plans. Somewhere between 80 percent and 90 percent of the cost of those health plans represent covered services purchased from medical providers.
The logic is that if the store is a big store, it'll have a significant impact on providers. If the exchange isn't very big, who cares?
If there's not a lot of volume to your state's exchange, then it may be business as usual for your hospital or health system. However, if there is a lot of demand on your state's exchange, if it affects competition among payers, if it starts to create new kinds of relationships between health plans and providers, then providers risk being "left behind" if they are not anticipating and responding to these changes.Do you think that hospitals are going to see their payments decrease from payers as a result of the exchanges?
Kingsdale: Yes, I think providers will experience some downward pressure. The exchanges do tend to emphasize price competition, and they will introduce more price transparency. Price-based comparisons are the easiest ones to make for individual consumers.How do you think the Supreme Court's decision on the individual mandate may affect the launch of the exchanges? If the Supreme Court votes down the individual mandate, do you think the exchanges will still happen?
Kingsdale: I'm not a lawyer, but what I read suggests a high probability that the individual mandate will be upheld. If so, health plans and hospitals had best be prepared.
If not, there are at least two possibilities. The first possibility is that much of the rest of Title I of the Affordable Care Act, including exchanges, remains intact, meaning that some other "fix" (than the mandate) will need to be found for the "free-rider" problem of folks waiting to get sick before they buy insurance. In this case, hospitals and health plans will still need to prepare, but I expect that any fix will not even receive serious Congressional consideration before we learn the national election results of November 2012. The second possibility is that much of the insurance reform-government exchanges included-will be invalidated along with the individual mandate because the mandate is a keystone of reform.
Almost as much uncertainty hangs over health care as over our financial markets. In such uncertainty, leaders can focus on necessary change in anticipation of likely long-term developments. These are relatively safe "bets." For example, we are going to repay the Chinese, which means the ever-escalating trend of government spending on health care will be cut. So it is not too soon to figure out how to run a leaner operation. Whether through exchanges and select-network plans or otherwise, the cost and quality of hospital services will be made transparent, so it is not too soon to focus on systematically improving both.
Interviewed for this article: Jon Kingsdale is managing director, Wakely Consulting Group, and the former executive director of the Massachusett's Commonwealth Health Insurance Connector Authority (firstname.lastname@example.org)Access related article and tool:
Publication Date: Tuesday, November 29, 2011
In this Business Profile, Shawn Yates, director of healthcare product management at Ontario Systems, discusses the growing challenge of managing self-pay accounts and provides insight on how providers can successfully collect patient payments.
In this business profile, Cathy Smith, leader of the revenue transformation consulting practice at The Claro Group discusses how the organization helps hospitals and medical groups reimagine their revenue cycle.
In this business profile, Deloitte & Touche LLP executives Anne Phelps, principal and U.S. healthcare regulatory leader, and Daniel Esquibel, senior manager, explain ways health systems, health plans, and physician practices can prepare for MACRA.
In this Business Profile, Bruce Haupt, president and CEO of ClearBalance, discusses how a patient loan program can increase patient collections, reduce bad debt, and speed cash flow.
In this Business Profile, Jerry Bruno, principal with Deloitte Consulting LLP, discusses the importance of choosing revenue cycle solutions that help an organization meet the challenges of a quickly evolving healthcare environment.
In this business profile, Lane Jackson, a partner in the Grant Thornton LLP Health Care Advisory Services practice, with extensive experience in overseeing system implementations and revenue cycle reorganizations, discusses best practices for elevating revenue cycle performance during an EMR implementation. Grant Thornton LLP is a sponsor of the Large System Controllers Council Affinity Group.
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.
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.
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.
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.
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.
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.
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
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.
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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.
Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.
Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities.
Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.
Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.
As the critical link between patient care and reimbursement, health information enables more complete and accurate revenue capture. This 5-Minute White Paper Briefing shares how to achieve cost-effective revenue integrity by your optimizing HIM systems.
Speedier cash flow starts with better CDI and coding. This 5-Minute White Paper Briefing explains how providers can improve vital measures of technical and business performance to accelerate cash flow.
Qualified coders are getting harder to come by, and even the most seasoned professional can struggle with the complexity of ICD-10. This 5-Minute White Paper Briefing explains how partnerships can help improve coding and other key RCM operations potentially at a cost savings.
The point of managing your revenue cycle isn’t just to improve revenue and cash flow. It’s to do those things effectively by consistently following best practices— while spending as little time, money, and energy on them as possible.
How Lucile Packard Children’s Hospital Stanford increased payments received within 45 days by 20% and reduced paper submission claims by 70% by using ZirMed solutions.
The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.
Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.
Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.
Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.
Physician practices must improve organizational efficiency to compete in this era of reduced reimbursement and escalating administrative costs.
Many healthcare organizations are pursuing next-generation health information systems solutions. Learn more about Navigant's work with University of Michigan Health System.
The proper implementation of healthcare information technology systems is crucial to an organization’s financial health.
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