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May 2—A newly proposed direct primary care payment model is part of a “fundamental rethinking of provider compensation” by the federal government, said Health and Human Services (HHS) Secretary Alex Azar II.
The Centers for Medicare & Medicaid Services (CMS) recently announced it was putting together a direct primary care (DPC) model, based on some of the 1,000 stakeholder responses it received after asking about new directions for payment models.
CMS has released little information on what the coming DPC model will entail, but Azar described it as allowing Medicare beneficiaries “to receive convenient, accessible primary care from a physician they know at a predictable and affordable cost.”
“Such a model would have the potential to enhance the doctor-patient relationship by eliminating administrative burden for clinicians and providing increased flexibility to provide the high-quality care that is most appropriate for their patients, thus improving quality while reducing expenditures,” a CMS release stated.
To help build DPC models, CMS recently issued a request for information (RFI) on various components, including: provider and state participation, payment, general model design, and program integrity and beneficiary protections.
“It’s another tool in the toolkit where they can try to both induce a focus on primary care but also in a way that’s pretty physician-friendly, which I think is a lot of the motivation,” Susan Dentzer, president and CEO of the Network for Excellence in Health Innovation, said in an interview.
The goal appears to be helping more physician practices remain independent. The share of physicians owning their own medical practice fell below 50 percent for the first time in 2016, according to an American Medical Association study.
The DPC model is just the first of several new Medicare and Medicaid payment models that HHS plans to push out, Azar said at the World Health Care Congress in Washington, D.C.
“These will be significant steps representing the kind of fundamental rethinking of provider compensation that may help us deliver value,” Azar said.
In previous comments, CMS Administrator Seema Verma has said other coming models will include those focused on consumer-driven health care, state-based and local innovation, and behavioral health and opioid addiction treatment.
Among the recommendations from hospital advocates was a dedicated model that tests coverage and payment changes that would lead to more effective and widespread adoption of virtual care strategies, as described in a letter responding to the RFI.
A new hospital requirement to post chargemaster prices online was included in the recently released Inpatient Prospective Payment System proposed rule. Azar said he wanted federal price and quality transparency requirements to go much further and noted the same rule sought comments on possibly requiring providers to inform patients of their out-of-pocket costs for a service before the service is furnished.
Azar described patient access to such information as a “fundamental right” and cited the proliferation of high-deductible health plans (HDHPs) as increasing the need for price transparency. The share of workers covered by HDHPs reached 28 percent in 2017, according to a Kaiser Family Foundation survey.
Azar cited his own experience as an HDHP enrollee who had extensive problems finding the price for a “routine electro-cardio stress test” after his hospital-employed physician ordered one. He eventually found out that his insurer’s negotiated payment for the test was much higher than the average price for the test as displayed by another large hospital system’s price transparency tool.
Another benefit of greater patient access to prices is that many patients likely would seek tests and imaging at cheaper locations, which could reduce “unsustainable” increases in healthcare spending, Azar said. The potential savings were seen in several studies that Azar cited in which employer-sponsored and commercial insurance price transparency programs provided large savings.
“Imagine the savings that would have accrued over the entire system if I could have easily found out where I could get the procedure cheapest,” Azar said.
Healthcare industry professionals have had wide-ranging reactions to the CMS transparency push.
“Could this make a difference in consumer behavior? Yes, in certain situations,” Dentzer said.
Such transparency also could lead providers to cut prices, she said.
The large companies that belong to the Pacific Business Group on Health (PBGH) tried emphasizing price transparency to covered employees in recent years but found little engagement with those tools, said David Lansky, president and CEO of PBGH. Additionally, employers have had a hard time gleaning what information patients actually want, and many HDHP enrollees have resorted to reducing all use of health care, including needed services.
Instead, PBGH member-companies have increased their focus on approaches that encourage providers to deliver high-quality care, such as reference pricing and value-based plan designs, Lansky said.
But Alan Warren, PhD, chief technology officer for Oscar Health, a six-year-old insurance company known for technological innovation, said the company has found continued strong customer interest in knowing provider prices in advance.
“Our customers want to know what things cost; that’s very important information,” Warren said. However, when patients found that estimates Oscar provided did not always match up with what they were charged—due to the addition of unanticipated services—the insurer moved from providing specific price estimates to giving enrollees a range of expected costs.
Amy Compton-Phillips, MD, chief clinical officer of Providence St. Joseph Health, said patients don’t want to know the chargemaster price but instead what they will owe, which is complicated by the difference in negotiated rates with each insurer.
“Trying to have something that’s relevant to that person, who’s trying to understand the price, is really challenging,” Compton-Phillips said.
The system’s orthopedic facility does post the self-pay prices for uncomplicated total knee and total hip procedures. However, charges vary based on whether the procedures are performed in inpatient or ambulatory surgery center settings and also by insurer.
“If we can figure out a way to make it simple, we would be doing the world a huge service,” Compton-Phillips said.
Additional HHS initiatives aimed at overhauling the healthcare delivery system, Azar said, include cutting regulatory burdens. Azar said rules changes already proposed in 2018 would save providers more than 4 million hours a year in compliance work, and changes in the coming months will save providers “billions” of dollars more in compliance costs.
Azar said the administration also is working on a “comprehensive plan” to reduce drug prices. Hospitals and advocates have sued the administration over one cost reduction effort, which cut Medicare payments to many of the hospitals that participate in the 340B drug discount program by nearly 30 percent.
President Donald Trump “wants to go much further,” Azar said.
Azar also detailed the growing amount of federal health program data that the administration has released to researchers and other entities. The Trump administration recently issued the first release of Medicare Advantage encounter data, and Azar said it plans to release similar data from Medicaid and the Children’s Health Insurance Program in 2019.
Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare
Publication Date: Thursday, May 03, 2018
Two senior leaders at R1 talk about the advantages of working with an innovative revenue cycle partner that offers technology-enabled revenue cycle and patient experience services.
Two senior leaders at Grant Thornton talk about the advantages of robotic process automation to improve office efficiency, reduce costs, and mitigate risk.
A senior leader of VitalWare talks about the need to create a comprehensive pricing strategy for consumers and how to get started.
Two of HealthTrust’s senior leaders talk about strategies for optimizing the hospital workforce to improve productivity and reduce waste.
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.
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.
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.
As value-based payment models evolve, providers are challenged to maintain superior clinical outcomes while controlling costs.
Read more about factors contributing to the changes in the post-acute marketplace and what it means for manufacturers, physicians, clinicians, patients, and post-acute facilities as they anticipate the transition to the second curve.
HSG helped the physicians and executives of St. Claire Regional in Morehead, Kentucky, define their shared vision for how the group would evolve over the next decade. As well as, develop the strategic and operational priorities which refocused and accelerated the group’s evolution.
The client was a nine-hospital health system with 14 clinics serving communities in a multi-state market with very limited access to care, poor economic conditions, high unemployment, and a heavy Medicare/Medicaid/uninsured payer mix. In most of these communities, the system was the sole source of care. Though the clinics were of substantial size (they employed 98 physicians) and comprised of multiple specialists, the physicians functioned as individuals and the practices lacked any real group culture.
Clinical integration can be expensive, but it doesn’t have to be, as this four-step road map for developing a CIN proves. Does it have to cost millions to initiate a clinical integration strategy? Contrary to popular belief, we have clients who have generated substantial shared savings and a significant ROI over time, without massive investments. Yes, some financial capital is required for resources the CIN providers can’t bring to the table themselves. But the size of that investment can be miniscule relative to the value it produces: improved outcomes and documentation for payers.
Today’s concerns about physician compensation are the result of the changing healthcare environment. The transition to value is slow, but finally becoming a reality. Proactive hospitals want to ensure that provider incentives are properly aligned with ever-increasing value-based demands. This report focuses on the three big questions HSG receives about adding value to physician compensation; Why are organizations redesigning their provider compensation plans? What elements and parameters must be part of successful compensation plans? How are organizations implementing compensation changes?
Revenue Cycle Management has become an even more complex issue with declining reimbursements, implementation of Electronic Health Records, evolving local carrier determinations (LCD), and payer credentialing [The emphasis on healthcare fraud, abuse and compliance has increased the importance of accuracy of data reporting and claims filing). The efficiency of a medical practice’s billing operations has critical impact on the financial performance. In many cases, patient billings are the primary revenue source that pays staff salaries, provider compensation and overhead operating cost. Inefficiencies or inaccurate billing will contribute to operating losses.
This publication identifies and outlines the necessary characteristics of a fully-functioning clinically integrated network (CIN). What it doesn’t do is detail how hospitals and providers can participate in the value-based care environment during the development process. One common misconception is that the CIN can’t do anything significant until it has obtained the FTC’s “clinically integrated” stamp of approval. While the network must satisfy the FTC’s definition of clinical integration before single signature contracting for FFS rates and contracts can legally start, hospitals and providers can enjoy three key benefits during the development process.
Nearly half of all Medicare beneficiaries treated in the hospital will need post-acute care services after discharge. For these patients, a stay in an inpatient rehabilitation facility, skilled nursing facility or other post-acute care setting comes between hospital and home.
With the proper process, tools, and feedback mechanisms in place, budgeting can be a valuable exercise for organizations while helping hold organizational leaders accountable. Having a proper monthly variance review process is one of the most critical factors in creating a more efficient and accurate budget. Monthly variance reporting puts parameters around what is to be expected during the upcoming budget entry process.
Managing the cost of patient care is the top strategic priority of most hospital CFOs today. As healthcare shifts to more data-driven decision making, having clear visibility into key volume, cost and profitability measures across clinical service lines is becoming increasingly important for both long-range and tactical planning activities. In turn, the cost accounting function in healthcare provider organizations is becoming an increasingly important and strategic function. This whitepaper includes five strategies for efficient and accurate cost accounting and service line analytics and keys to overcoming the associated challenges.
TRENDSETTER
This article takes an in-depth look at how one company is enabling more efficient procure-to-pay processes to streamline healthcare organizations’ financial operations.
This article takes an in-depth look at how one organization is preventing chronic care readmissions through in-home monitoring, patient education, and counseling.
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