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Children's Hospital Boston has found a way to dramatically improve the lives of children with asthma-and significantly reduce the total costs of care for these patients. The results say it all: a 64 percent reduction in emergency department (ED) visits, a 79 percent reduction in hospitalizations, and a 41 percent reduction in missed school days.
The hospital's approach does not involve a new state-of-the-art treatment for pediatric asthma-which, ironically, might be covered by government and private payers under the current fee-for-service system.
Instead, the centerpiece of the hospital's Community Asthma Initiative (CAI), which primarily enrolls inner-city children, is a comprehensive asthma education and case management program that includes home visits by a nurse case manager or community health worker.
See related article: Children's Hospital Boston Cuts Asthma ED Visits by 64 Percent
Some CAI approaches-such as increasing patients' access to asthma specialists-are billable to payers. But many CAI interventions do not fall on the list of "covered services" traditionally paid for by Medicaid and private insurers.
For instance, CAI staff often give families HEPA vacuum cleaners, bedding encasements, and other products to help rid homes of pests, mold, and other asthma triggers. None of those products are covered by payers. In addition, only one of Massachusetts' five Medicaid plans covers home visits delivered by community health workers; yet, about 78 percent of CAI patients are on Medicaid.
This means that Children's Hospital Boston has had to rely on a combination of fundraising expertise, financial wisdom, and sheer persistence to pay for the program. Since the CAI program launched in 2005, the hospital has used grants and its own dollars to cover costs, while simultaneously pushing for bundled payment funding via Medicaid.
"I think Children's Hospital has very strategically and consciously said we need to figure out where kids should be cared for and how best to do that in a cost-effective manner," says Joshua Greenberg, vice president of government relations. "In the long term, doing the right thing for kids and advancing the knowledge of clinical care delivery is how we're going to succeed in our business."
The CAI clinical budget is roughly $443,000 per year, according to Marc Proto, director of financial management. Roughly 81 percent is currently funded via grants from the Centers for Disease Control and Prevention (CDC; $317,000) and the Healthy Tomorrows Partnership for Children Program ($42,000).
Children's Hospital Boston invests the remaining money-roughly $84,000 of its own revenue-in the CAI program, says Proto. In the early days of the program-before landing the CDC grant-the hospital investment was much higher. When the CDC grant expires in September 2012, the hospital may once again be footing a larger bill. While the hospital will pursue other potential grant opportunities, few may be as large as the CDC grant.
Although the CAI investment is charitably focused, the monies also help the not-for-profit Children's Hospital demonstrate that it is meeting community health needs-which is an Internal Revenue Service (IRS) requirement for tax-exempt status. As required under the Affordable Care Act, not-for-profit hospitals must prove they provide a true social and financial benefit to their communities. The IRS now requires not-for-profit hospitals to conduct a needs assessment every three years to identify specific health needs in their communities-and then pinpoint strategies to meet those needs.
These new federal requirements actually reflect voluntary community benefit guidelines that Massachusetts put in place about 17 years ago. Children's Hospital has been assessing community health needs and pinpointing strategies to meet those needs for many years.
On its website, the hospital posts a detailed accounting of its financial benefit to the community. After charity care, the hospital points to a $7.3 million investment in community health improvement in FY09-which includes the money the hospital puts toward the asthma program. Childhood asthma was a high-priority health need among those identified in Children's Hospital's 2003, 2006, and 2009 community needs assessments.
"In the pediatrics space, childhood asthma will always emerge as a very significant chronic disease that requires a population health-based approach," says Greenberg. "So community-based asthma programs are a natural fit with IRS community benefit requirements. Most medical providers should be able to readily track service utilization and expenditures for asthma-related care and the impact of developing programs like the CAI on clinical and quality-of-life outcomes."
Tracking clinical outcomes and costs are also crucial to obtaining grant funding for programs like this, adds Greenberg. It is particularly important in pediatric programs for which there's a dearth of reliable outcomes measures and tracking, says Proto.
Asthma is the No. 1 admitting diagnosis at Children's Hospital and makes up roughly 3.8 percent of the hospital's total admissions. Theoretically, the CAI-which reduced repeat hospitalizations among CAI patients by 79 percent-could put an unwanted dent in volumes and revenues.
Fortunately, as a tertiary care and teaching facility, Children's Hospital has been able to skirt this potential financial loss, and is finding a strategic benefit in having more beds available. "Children's Hospital Boston serves a broad group of patients, including regional, national, and international patients," says Proto. "As our utilization among less acute asthma cases decreases, we are backfilling that care with higher acuity-type cases."
The hospital's census has been high and the case mix is increasing. "The higher acuity business that flows in from around the region and nation is what we really want to keep at the Longwood hospital site in Boston," he adds. "We are able to do that by moving asthma care to the outpatient and community setting."
After years of community advocacy and political lobbying, Children's Hospital and other Massachusetts providers and advocates are claiming a large victory for asthma patients: The state's Medicaid program, MassHealth, is preparing to roll out a bundled payment program for high-risk pediatric asthma patients.
Providers from across the state-hospitals, community clinics, pediatric practices-that participate in the Medicaid pilot will be encouraged to use a community-based asthma approach modeled on Children's Hospital's CAI program. The bundled-or lump sum-payment is expected to cover some of the cost of caring for asthmatic children on Medicaid, including home visits and asthma education. In contrast, Medicaid typically reimburses on a fee-for-service basis for specific services, such as physician visits.
"We've got enough positive results from the CAI program to help guide how asthma care should be delivered statewide," says Greenberg. "But we need to figure out how to do this in multiple different kinds of settings in the most cost-effective way. We are a big teaching hospital, and it may well be the case that we're not as cost effective as, say, a community health center would be. There are things that we can learn by taking this to scale. For example, there may be a way to share the home visit responsibilities collectively across a number of different organizations within a geographic area, rather than a hospital owning it all."
MassHealth is expected to post a request for proposal (RFP) on its website in the near future, which will provide specifics for providers that want to participate in the bundled payment pilot, says Greenberg. Phase 1 of the project is currently scheduled for early 2012.
The state convened a workgroup to help inform the development of the RFP for pilot sites to implement the program, says Greenberg. "It is anticipated that patients in the pilot program will be selected based on the fact that their asthma is poorly controlled-for example, they have been seen in the ED or have been hospitalized as a result of an asthma attack-and that funding will be available to flexibly cover all of the components of the CAI protocol," he says. "RFP applicants will be primary care settings that will work to integrate CAI-type services."
The pilot will, hopefully, help shed light on how to handle bundled payment approaches for chronic diseases like asthma-as well as how to cost-effectively deliver quality asthma care to children. "One issue is to figure out how to pay for things that Medicaid doesn't normally pay for, such as home visits, asthma education outside the physician's office, and environmental mitigations like HEPA vacuums and integrated pest management," says Greenberg.
Other questions include how the bundled payment will be appropriately divided among the various providers that care for a defined population of pediatric asthmatics on Medicaid-from physicians and hospitals to community clinics and integrated pest management experts.
Children's Hospital Boston is optimistic that providers that do the right thing for patients-whatever the setting-will soon be financially rewarded by payers. "I think that health reform is increasingly going to push us to deliver the right care in the right setting," says Greenberg. "How long are payers going to tolerate having preventable admissions flowing into hospitals when there are increasingly well-understood ways to prevent these admissions?"
In addition to pushing for the Medicaid bundled payment pilot, Children's Hospital Boston is arranging pay-for-performance payment contracts for asthma and other patient populations with Blue Cross Blue Shield of Massachusetts and other private payers. CAI's robust evaluation framework-which has demonstrated positive clinical and financial results over a multiyear period-has helped Children's Hospital at the negotiating table with private payers and in lobbying efforts with the state legislature.
The hospital also worked with other Massachusetts providers and groups to create an asthma business case.
"Our asthma initiative has reduced hospitalizations and ED visits, and that's a cost savings to society," says Proto. "It proves the program works, and this approach can be applied to other diseases and other diagnoses."
Interviewed for this article:
Joshua Greenberg is vice president of government relations, Children's Hospital Boston (firstname.lastname@example.org).
Marc Proto is director of financial management, Children's Hospital Boston, and a member of HFMA's Massachusetts-Rhode Island Chapter (email@example.com).
Publication Date: Tuesday, September 20, 2011
In this business profile, Amy Gross, senior vice president of Key Government Finance, discusses the benefits of private placement transactions to support large-scale financing projects.
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.
In this business profile, Doug Polasky, executive vice president at Xtend Healthcare, explains the importance of having sound workflow processes in a consolidated business office to ensure optimal performance and reduce costs.
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.
TriMedx helps health systems control costs and uncover savings opportunities by optimizing the clinical engineering function.
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.
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.
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.
Emad Rizk, MD, president and CEO of Accretive Health, discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management.
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.
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.
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.
Steve Scibetta, senior director of channel sales for Ontario Systems' healthcare product line, shares insights into effectively managing receivables.
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
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.
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.
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.
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.
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.
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.
Greg Burgess, Founder and Chief Product Officer at Burgess Group shares insights and opportunities for payment integrity in the rapidly changing healthcare IT landscape.
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.
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.
Copyright 2016, Healthcare Financial Management Association.
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