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Providers increasingly are sharing with payers the financial
risks associated with patient populations. Beyond specific treatments, this
model requires them to focus on the entire continuum of care for their patients.
As risk has shifted, providers have found that an effective way to manage risk
is via care management programs that target patients who are likely to be high-volume
users of healthcare services.
In a series of case studies published by the Commonwealth
Fund in 2013, effective care management of chronic conditions such as asthma
and heart failure and a program targeting a Medicare-Medicaid dual-eligible
population resulted in significantly lower hospitalization rates. Average time
between hospital encounters increased for those enrolled in the asthma program,
while heart failure patients and dual-eligibles reduced 30-day hospital
readmissions by 46 percent and 21 percent, respectively.a
Successfully developing and utilizing care management
programs requires providers to think both big and small. They must develop a
sound population health strategy while also having effective care coordination
and communication with patients on a one-to-one basis.
“When you start taking on risk or a shared-savings
arrangement, you start to think about a population health strategy, and that
requires a different set of tools,” says Vanessa Pratomo, MD, medical director
for ACO quality improvement and chronic illness management at Montefiore Health
System in the Bronx, N.Y. “It requires not just providing that direct clinical
care, but also looking at the group of patients you are servicing and trying to
understand who is at high risk—who do I think is going to be really sick?—so I
can get ahead of that need and provide this person with the services that can
keep them healthy.”
According to Clemens Hong, medical director of community
health improvement at the Los Angeles County Department of Health Services,
care management programs typically target a relatively small subset of a
healthcare organization’s patient base: those with complex chronic conditions.
These complex care management programs appear promising, but many have not
shown definitive results.
“High-risk care management allows you to provide, in a very
tailored way, high-quality care to a subset of your patients who have complex
sets of needs,” Hong says. “You tend to see improved quality of care and
improved experience for those individuals who are perhaps your sickest and most
vulnerable. You may see reduced utilization of emergency departments and
hospitals, but it’s harder to return the money you invest in the program.”
Although reported financial results appear mixed, Hong
thinks “the problem often is not in the concept, but in how the concept was
Common implementation errors include not adequately
leveraging internal data and the claims data of payers in the organization’s network,
and as a result not accurately identifying the cohort of patients most likely
to be high-volume users of services. But Hong points out that selecting which
patients to actively manage is not simply an exercise in data analytics.
The most effective programs, he notes, also consider
qualitative approaches—information that physicians can provide based on their
knowledge of individual patients. Such observations may include a patient’s
temperament, his readiness for treatment, and his ability to follow treatment
Hong thus recommends a hybrid approach to patient selection
for care management, one that combines quantitative evaluation of patient data
with qualitative information based on firsthand knowledge about patients from
their primary care provider.
“Data is critically important, but it doesn't provide you
with all the information you need,” Hong says. “Once you have generated a list
from the data, you put those lists of patients in front of the doctors and ask
them to choose, based on the structure of the program and their knowledge of
the patients, which ones they think are most likely to benefit.”
A major challenge to implementing care management is the
deep-rooted influence of fee-for-service at all levels of health care. “If you
think about the average physician, a patient is scheduled, then comes to see
you,” says David Wennberg, MD, former CEO of Northern New England Accountable
Care Collaborative and currently chief science officer at Quartet Health, a New
York-based startup that uses advanced analytics and clinically guided
technology to improve the integration of behavioral and physical health care.
“What providers don’t have is proactive population approaches to managing patients
at risk. One reason is they are accustomed to transactional activity only. My advice is that they should be as concerned
about the patients they aren’t seeing as those who are in their office.”
Michael Hunt, DO, interim president and CEO of St. Vincent’s
Health Partners, the first URAC-accredited integrated health network in the
country, says the Bridgeport, Conn.-based physician-hospital organization effectively
codified this broader view of patient care by requiring physician practices participating
in the network to be certified as patient-centered medical homes.
“Our strength is that we designed our model to enhance and
support the physician who takes care of the patient,” Hunt says. “We put the
focus on the primary care provider, so they can be the captain of the
therapeutic plan for their patients.”
To ensure the primary care physicians stay informed and
engaged in managing the health of their patient panels, St. Vincent’s care
coordinators have a clinical background and meet at least monthly with the
physicians and care teams. The purpose of these meetings is to present
actionable data on patients while also building trust.
“It is a collaborative relationship between the care
coordinators and the providers,” Hunt says. “We expect them over time to get to
the point where the physicians and their office staff view our coordinators as
a part of their care team.”
Although St. Vincent’s spends considerable resources to keep
primary care physicians informed and engaged, the physicians are expected to
play a central role in managing the health of their patient populations. This philosophy
includes a care management model that comprises all the tenets of a patient-centered
medical home. “We are asking them to be responsible for patients in a way they
have never been held responsible,” Hunt says. “When the patient is discharged
from the hospital, the hospital team 'owns' that patient until the patient is in bed at the
skilled nursing facility. When the patient moves back home or back to the hospital,
they own that patient until they move to the next level of care.”
Gaining access to information on all the care that patients
receive is a significant benefit of care management. As Wennberg notes, even in
smaller markets in the Northeast that feature a single, dominant health
network, between 25 percent and 50 percent of care is delivered outside the
network. So developing data systems and processes and having access to payers’
claims data—then providing the relevant data to care teams—enhances the quality
of care delivered and reduces overutilization of services.
“If you think of it from a risk standpoint, which is moving
away from a transactional payment to some kind of performance-based payment, having
people not go immediately to the emergency room or not self-referring to
specialists is really important,” Wennberg says. “And while a primary care
provider can help encourage that, it is my opinion that they can’t do that
alone. They need true team-based care to do that, and part of that team is the
care management component.”
Chris Anderson is a freelance
writer and editor who covers payers, new care models, healthcare IT, and
Interviewed for this
article: Vanessa Pratomo, MD,
medical director for ACO quality improvement and chronic illness management,
Montefiore Health System, Bronx, N.Y.; Clemens
Hong, medical director, community health improvement, Los Angeles County
Department of Health Services; David
Wennberg, chief science officer, Quartet Health; Michael Hunt, DO, interim
president and CEO, St. Vincent’s Health Partners, Bridgeport, Conn.
a. McCarthy, D., Cohen, A., and Bihrle Johnson, M., “Gaining
Ground: Care Management Programs to Reduce Hospital Admissions and Readmissions
Among Chronically Ill and Vulnerable Patients,” The Commonwealth Fund, January
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Change Healthcare: Accelerating Revenue Cycle Transformation
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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.
10 Ways to Reduce Patient Statement Volume (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.
Reduce Patient Balances Sent to Collection Agencies: Approaching New Problems with New Approaches
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.
The Future of Online Patient Billing Portals
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.
Payment Portals Can Improve Self-Pay Collections and Support Meaningful Use
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.
Large Health System Drives 10% UP (Patient Payments) and 10% DOWN (Billing-related Costs)
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.
ICD-10: Managing Performance
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Clarity Drives Collections
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.
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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.
Revenue Cycle Payment Clarity
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Streamlining the Patient Billing Process
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Wallace Thomson Hospital Automates to Maximize Limited Resources
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7 Steps for Building and Funding Sustainability Projects
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Key Capital Considerations for Mergers and Acquisitions
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.
Key Capital Considerations for Mergers and Acquisitions
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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 case study
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Reforming with a New 50-Bed Acute Care Facility
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Providers Focus Too Much On Revenue Cycle Management
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Lucille Packard Children’s Hospital Stanford Case Study
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ZOLL and Emergency Mobile Health Care Case Study
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Denials Deconstructed: Getting Your Claims Paid
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Automation and Operational Improvement Drive Sustainable Results
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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.
Practice Performance Improvement
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 Without Spending a Fortune
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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.
Adding Value to Physician Compensation
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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?
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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.
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