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Many healthcare organizations are investing in new approaches to healthcare delivery to meet the digital demands of mobile device-enabled consumers and other stakeholders. Data analytics, software systems, virtual technology such as telehealth, and enterprise network-connectivity platforms typically are early initiatives.
Each organization will have a unique approach to its digital technology strategy, based on its goals and where it sits on the spectrum of desired digital transformation. That spectrum ranges from traditional players that regard technology solely as an IT cost center, to experimenters that use technology with selected business functions to improve operational efficiency, and to innovators that leverage technology constantly to drive revenue and cost optimization.a However, organizations that invest solely in traditional IT to support healthcare delivery with a purely bricks-and-mortar focus can expect their competitive position to slowly erode over time, so remaining a traditional player clearly is not an option for long-term sustainability.
Digital transformation for the experimenter and innovator categories of players may encompass everything from advanced electronic health record (EHR) infrastructure and cybersecurity to software tools for consumer engagement and enhanced access to clinical decision support, care coordination, and population health systems. See related sidebar, which identifies key investment areas for a digital future: Investment Areas for a Digital Future.
The prioritization, sequencing, and monitoring of initiatives require close attention, but underlying these activities is a fundamental question: Where will we raise the required capital? Although investment in digital transformation may be well underway in some organizations, the methods to finance such initiatives in the industry are evolving and expanding, and senior leadership teams should consider applying one or more of these innovative methods.
The funding source for any chosen digital initiative an organization intends to pursue should reflect the organization’s business assets and its underlying risk profile and risk tolerance. Because digital initiatives typically are not fixed assets with long expected lives and steady projected cash flows that can be leveraged, the traditional options (debt, cash, or leasing) will need to be expanded to include more creative partnership financing activities. This is particularly true for not-for-profit organizations that are unable to raise external equity in the public markets.
To identify the most appropriate financing source to meet capital structure goals, leadership teams of for-profit and not-for-profit healthcare organizations require a strategic framework for decision making, as described below.
The fundamental goal of an organization’s overall capital structure is to fund business growth in a way that produces the desired risk-adjusted return, given the organization’s capital flexibility needs and risk tolerance. Capital structures—the combinations of debt and equity that fund organizations’ overall strategic plans—vary widely by industry and business profile.
A close look at a specific measure of overall leverage, such as debt to total assets (i.e., the proportion of the assets that are financed by debt), can indicate a lot about the business an entity is in—for example, whether the sector is light or heavy in fixed assets and how much uncertainty exists in projected cash flows—and its capital flexibility needs and risk tolerance.
Companies that are light on fixed assets or that are accustomed to making high-risk investments as part of their core business—software and energy companies, for instance—tend to have a lower median ratio of debt to total assets (24 to 26 percent), indicating they tend to use a high proportion of equity to fund their technology development or drilling explorations.
Organizations that are heavy on fixed assets and that have more predictable cash flow streams, such as real estate and telecommunications companies, tend to have a higher median proportion of debt to total assets (46 percent), because they expect their buildings and other infrastructure will produce a steady capital return over a long period.
The leverage ratio spread is even broader in the healthcare industry. For example, about 25 percent of healthcare organizations situated at the lower end of the leverage spectrum are large for-profit health insurance companies whose business involves limited fixed assets, but whose assumption (and tolerance) of risk is high by virtue of their core business. At the higher end of the leverage spectrum, 65 to 90 percent are more hospital-centric, for-profit companies that predominantly invest capital in long-dated, depreciating assets (e.g., inpatient facilities and related real estate investments).
Due to their lack of access to external equity markets, among other reasons, the balance sheets of large not-for-profit healthcare organizations have sizeable “internal equity” in the form of cash and investments. The three largest not-for-profit health systems in the United States hold $8 billion to $15 billion in cash and investments, yielding 185 to 260 days cash on hand. By comparison, the largest for-profit healthcare companies hold less than $1 billion in cash and investments, yielding only eight to 15 days cash on hand. Adjusting for the large cash balances on not-for-profit balance sheets, not-for-profits still have lower leverage than for-profit providers—with debt to “adjusted” total assets in the range of 36 to 41 percent.
Looking into the future, as health care moves further into value-based payment, hospital revenue is expected to flatten or decline. A high ratio of debt to assets adds the risk of overleverage to the organizational profile. For access to additional capital, not-for-profits will need to look externally for private-equity or joint-venture partners. Organizations with scale in terms of the number of managed lives will make attractive partners.
Whether an organization is for-profit or not-for-profit, its capital spending for digital initiatives must be funded through appropriate capital sources or channels. Each financing channel can be evaluated across a range of criteria, including cost, how quickly the organization needs the capital, and the level of control required in the capital investment given its degree of strategic essentiality.
Control. Whether the organization should own, either outright or jointly, the financed initiative is the most important, high-level strategic issue. For each investment type in the previously mentioned sidebar, a decision-making framework such as that shown in the exhibit below can be used to determine whether the investment requires a low or high degree of organizational control in its development or management (Y axis), given the extent to which the investment is deemed essential for establishing and maintaining the organization’s strategic essentiality or differentiation (X axis).
Strategic Funding Framework
Consider the lower left quadrant of the framework, for example: If a low degree of organizational control is required for a technology’s customization that has low importance in differentiating the organization from competitors, such investment types will appear in this quadrant. Such a technology product is likely highly commoditized and can be purchased off the shelf in the marketplace. For example, software for revenue cycle management (RCM) is an investment type that is unlikely to differentiate the organization from competitors. Further, development of RCM software systems need not be controlled by the organization but can be purchased or contracted for from an RCM supplier as part of normal operating expenses.
By contrast, the lower right quadrant will be populated with technologies that are strategically differentiating in nature but for which the organization would not require sole control. For example, an organization’s leadership team may view telehealth as integral to the success of consumer access strategies. However, leaders likely will not feel the need to control 100 percent of that business and are more likely to regard a partnership with a telehealth company as a more appropriate option, where the partner has incentives for co-development through upside sharing. External equity, secured via joint ventures or venture capital, could be useful to get the best minds and money to the table.
Appearing in the top two quadrants are investments requiring a high degree of organizational control for customization of the technology, which may or may not be strategically differentiating.
A digital asset’s strategic importance would determine whether an organization would want to have a high degree of governance control over its development. An essential or differentiating investment would be placed in the upper right corner of the framework and would be a candidate for private equity/partnership financing or use of internal cash or retained earnings.
For example, as patient access centers evolve from a fee-for-service model to a value-based model, organizations can view them as critical digital assets that will contribute to strong financial and clinical outcomes by ensuring that the right mode of care is provided—whether from a physician, nurse, advanced practice provider, or telehealth provider, for example.b The organizations therefore would be likely to want to exert a high degree of control over these strategic assets.
Where organizations place digital initiatives in the framework will vary by organization and will drive many of the next-order funding decisions. Funding choices will be based on the organization’s current and desired future strategic-financial position, credit rating, and many other factors.
Cost and speed. Another factor for evaluation that warrants mention is cost and speed to market. The cost of various types of external capital can be compared with traditional financing channels, such as the public debt markets. Use of the organization’s own operating or excess cash to fund initiatives carries an implicit opportunity cost because capital used for one project is not available for another. Debt capital ultimately would be a less-expensive alternative than equity capital, which shares the upside capital appreciation with another entity.
There is an argument for speed given that numerous digital initiatives could offer “first mover” advantages—for example, by attracting customers to a certain specialty or procedure. If the organization needs capital quickly, using its own cash to fund an initiative will be the fastest way to procure the money. The more complex the financing mechanism, the longer the financing implementation time frame. Outside equity arrangements (i.e., venture capital) might take up to a year or longer to secure, but if the organization has the time and patience, such arrangements can be the most appropriate funding source. Capital partners that are willing to take on risk also will share rewards with the health system.
Types of financing strategies for the investment areas shown in the sidebar include both internal and external sources.
Many organizations are establishing internal venture capital funds to invest in start-up businesses or ideas generated by their own clinicians, researchers, or other employees. The investments may yield both monetary rewards as well as products, methodologies, or processes that translate to the bedside to improve quality and customer satisfaction.c
See related sidebar: Case Study: Dignity Health
External capital sources. Use of external capital sources involves seeking investment from an unrelated entity. Options include debt capital, equity capital structures, and philanthropic funds.
As with all capital sources, use of debt capital should be evaluated in the context of the organization’s overall credit position and capital structure, and the terms, covenants, and repayment structure being offered.
Equity capital structures involve co-ownership through growth partnerships and joint ventures with other healthcare organizations, technology firms, private-equity firms, or other entities. These arrangements typically are used to fund ideas, research, and other nondepreciable assets. The partners share investment requirements and upside opportunities, whether generated from care delivery, patents, or other sources.
See related sidebar: Extent of Corporate Venture Funds in Health Care
Philanthropic funds are a benefit many health systems enjoy as a result of their community, academic, or faith-based affiliation, and they require no repayment. If associated with a particular capital initiative, the funds may flow directly to the balance sheet rather than being recorded as an income item.
With digital transformation, innovative, hitherto hospital-centric enterprises will be moving from fixed-asset businesses with substantial bricks and mortar that are financed largely through long-term debt to businesses that are more like technology companies with assets such as licenses and patents that are not easily leveraged through traditional debt financing.
The conventional capital sources for healthcare capital decision making—debt, cash, or leasing—will not be appropriate for many elements of the digital transformation. For example, it will not make sense (or even be possible) to borrow 30-year capital for investment in an analytics-driven population health management platform with indeterminate useful life and uncertain prospects for success.
Internal equity and cash reserves are a limited resource. Most healthcare organizations will find transforming a technology platform to be a capital-intensive undertaking. If an organization wants command and control of a highly strategic and differentiating digital offering (in the upper right quadrant of the previously discussed exhibit), access to outside equity markets likely would be required to grow and scale the initiative. Some innovator organizations can use cash and internal equity to build the capabilities without assistance, but they—like other organizations—can accelerate progress by partnering with another enterprise to do so through joint-equity, risk-sharing arrangements.
Even digital initiatives that do not appear to be scalable at this time (e.g., neural nets, artificial/augmented intelligence, blockchain) deserve consideration by leadership teams. Some forms of financing, as described earlier, may be available for such initiatives. The digital landscape is moving rapidly, and the picture five years from now likely will look considerably different.
Smaller organizations will require partnerships with larger providers and technology companies to be able to make digital progress. A portion of capital budgets will increasingly be allocated to pilot tests of emerging technology.
Transforming an organization in a completely new way requires an enormous amount of capital. In the words of Peter McCanna, president of Dallas-based Baylor Scott & White Health: “Two constant challenges present themselves: sticking with the effort by providing the adequate capital; and resisting the gravitational pull of staying in the past.”d
Creative partnerships can help leadership teams in all organizations expand financing sources to help ensure a successful digital future.
Matt Robbins, CFA, is senior vice president, Kaufman, Hall & Associates, LLC, Boston.
Munzoor Shaikh is director, Healthcare & Insurance, West Monroe Partners, Chicago.
Therese L. Wareham is managing director and a founding partner, Kaufman, Hall & Associates, LLC, Skokie, Ill.
a. For a discussion of these differences, see Fitz, T., and Shaikh, M., “4 Tactics of Effective Strategic Technology Planning for the Digital Future,” hfm, November 2018.
b. Shaikh, M., and Loebig, T., “The Journey to Value-Based Care: A New Value Chain for Patient Access Centers,” West Monroe Perspective, 2018.
c. Arrick, M., “Shifting Competition Leads U.S. Not-for-Profit Health Care Organizations to Accelerate New (and Old) Strategies,” S&P Global Ratings, May 14, 2018.
d. McCanna was speaking as a panelist in a session titled “Meeting Disruption Head On,” 2018 Kaufman Hall Healthcare Leadership Conference, Oct. 17, 2018.
Publication Date: Friday, February 01, 2019
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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.
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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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