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Mark Watson, executive human resources
director for Union County, N.C., likes to tell about a visit to his physician
that took 40 minutes out of his workday, including travel time and a strep
He also likes the story of a Union
County employee who was scheduled for visits to two specialists—a dermatologist
and a surgeon—and then surgery to address a worrisome mole. A few days before
the surgery, he mentioned the procedure to his new primary care physician
during an annual physical. “And the doc biopsied the thing right there, sent it
off to the lab, and got the results back the next day,” Watson says.
“Everything was good, so he canceled his surgery.”
And his favorite is the one about the
deputy sheriff who started feeling sick during an overnight shift. He called
his primary care physician at 1 a.m., drove to the all-night pharmacy for a
non-drowsy prescription that got him through the shift, and visited the doctor’s
office at 7 a.m. to get checked out.
The hero of all three stories, in
Watson’s telling, is direct primary care. The county pays a flat monthly fee to
a direct-care practice that does not accept insurance. The arrangement is
reducing patients’ medical and pharmaceutical costs—and improving employees’
productivity because they spend less time out of the office to go to medical
appointments and recover from illnesses.
Direct primary care (DPC) is a delivery
and payment model that steps completely away from fee-for-service payment and
insurance. Details differ from one DPC practice to the next, but the general
idea is this: The practice charges a monthly retainer—typically $40 to $80—per
patient for unlimited access to primary care, preventive care, and chronic care
management, including after-hours access by telephone, email, or text.
Consumers who join a DPC practice on
their own are encouraged to have an insurance policy to cover emergency care,
hospitalizations, surgery, and other high-cost services. For employer-sponsored
health benefit plans in which DPC is offered, it is bundled with a major
medical and prescription plan to provide a full range of coverage.
With no need for a big back-office
staff, a direct-care practice has much lower overhead than practices that bill
and collect money from insurers and patients. In turn, providers can have
smaller patient panels and spend more time with patients.
“I did this because I wanted to be a doctor
again,” says Jeffrey Gold, MD, who opened a direct-care practice in Marblehead,
Mass., two years ago. “I did not want to be a computer data enterer. I wanted
to have the time to practice ‘relationship medicine’ again, rather than
Gold Direct Care is one of dozens of
DPC practices that have emerged across the country in recent
years. The DPC model has the support of the American Academy of Family
Physicians (AAFP), which regards DPC as an innovation that delivers on the
Quadruple Aim of improved patient experience, better population health, lower
costs, and happier clinicians.
“What I see in talking with these men
and women who have adopted this type of practice is that they are extremely
satisfied with their work environment and their relationships with patients,
both face-to-face and electronically; the patients are very happy; and the
outcomes are quite good,” says Doug Henley, MD, AAFP’s executive vice president
Not to be confused with concierge
practices, in which consumers pay hefty retainers for 24/7 access to their
personal physician, DPC practices tend to use a medical home delivery model
that focuses on efficiency and effectiveness. For example, Gold says, instead
of asking a patient with hypertension to come to the office frequently for
monitoring, he would advise purchasing a blood pressure monitor and reporting the
readings by email.
That level of support is perhaps most
valued by individuals who are trying to manage chronic conditions.
“Trust me, we are not cherry-picking
people,” Gold says. “I have gotten people off opiates, and I have some of the
most complicated patients whom the healthcare system has completely failed and
who are looking for someone to spend time to listen to them.” (Leadership Blog: "Why Direct Primary Care Works for Me," by Jeffrey Gold, MD.)
The prevalence of employer-sponsored
insurance in America is a barrier to the DPC model. Gold’s practice has grown
to 600 patients in two years, but he finds many individuals who are attracted
to the idea of direct care but are not willing to pay for it because they have
Watching DPC gain traction across the
country, however, Gold increasingly is convinced that the delivery model has a significant
role in the future of U.S. health care. “I think the tipping point is
employers,” he says.
John Blanchard, MD, CEO of Salta Direct
Primary Care in suburban Detroit, agrees. He ran a direct-care practice that
targeted individual consumers for more than a decade before launching Salta in
2015. The company’s first contract is with United Shore Financial Services,
which has 1,800 employees.
“Direct primary care is going to
continue to scale in the individual market, but it’s going to take off like a
rocket with self-insured employers,” Blanchard says.
Salta opened a clinic—built and paid for
by United Shore—at the company’s headquarters. United Shore pays Salta $70 per
employee per month for acute care, chronic care, and preventive care/wellness
visits, as well as coaching on positive lifestyle changes such as weight loss
and smoking cessation. Employees pay a $10 copay per visit and have 24/7 access
to a member of the care team, which includes a physician, a nurse practitioner,
and a physician assistant.
“Smart CEOs of companies, especially
self-insured companies, are recognizing that there's no insurance-based,
insurance-centric solution for their healthcare problem,” Blanchard says.
“Their problem is they're footing the bill, in large part, for health care for
their employees, but they have no control over its quality or delivery.”
Contracting directly with a primary care
practice gives employers more control because physicians have a financial
incentive to keep their patients—and their patients’ employers—satisfied. “The model is very simple: We allow our physicians to have more time
with their patients," Blanchard says. "More time allows for more effective communication. More
effective communication allows for a relationship of trust to evolve between
the patient and physician. Now, in the context of that relationship, you can
engage patients to help them take responsibility for their own health and
Meanwhile, the primary care team is
looking for ways to avoid wasteful spending, knowing that every inappropriate
test comes out of the practice’s pocketbook.
To encourage employees to choose the
DPC option, Union County, N.C., officials offer an incentive: Employees who
stick with the traditional health plan are responsible for $750 per year in
out-of-pocket expenses for routine medical services, while those who go with
DPC avoid those fees.
While 16 states have
passed laws affirming that DPC is not health insurance, most have not. “We are
concerned about the potential that some
state insurance commissioners could get a bit overzealous and declare direct
primary care as some kind of an insurance model, and generate a huge amount of
unnecessary regulation,” Henley says.
In addition, the IRS regards DPC contracts as
health plans and thus prohibits individuals with consumer-directed health plans
from using money in a health savings account to pay for DPC. The
AAFP and others are lobbying for the Primary Care Enhancement Act, which would
reverse the IRS’s position.
“If those two things were clarified, I
think direct primary care will get greater traction,” Henley says.
Butcher writes about healthcare
business and policy topics for several HFMA publications.
John Blanchard, MD, CEO, Salta Direct Primary Care, Troy, Mich.; Jeffrey
Gold, MD, owner, Gold Direct Care, Marblehead, Mass.; Douglas E. Henley, MD, executive vice president and CEO, American
Academy of Family Physicians, Leawood, Kan.; Mark
Watson, Union County
(N.C.) executive human resources director, Monroe, N.C.
Cedar: Reimagining the Patient Financial Experience
Cedar’s CEO and co-founder tackles the topic of patient payment and the importance of having an innovative patient financial management system.
TRIMEDX: Moving Healthcare Providers Toward Mature Clinical Asset Management
This article includes a discussion by TRIMEDX leaders about the best ways to mature a clinical asset management program.
HealthTrust: Optimizing Purchased Services
Andrew Motz, assistant vice president, supply chain consulting at HealthTrust, discusses the value of a data-driven approach when procuring purchased services.
Change Healthcare: Accelerating Revenue Cycle Transformation
Jason Williams, vice president for strategy and business analytics, Change Healthcare, discusses the importance of technology and technology-enabled services in reinventing the revenue cycle.
6 Patient Revenue Cycle Metrics You Should Be Tracking (and How to Improve Your Results)
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.
Orlando Health Gains Insight into Denials, Reduces A/R Days with RelayAnalytics Acuity
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
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.
Streamlining the Patient Billing Process
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.
Wallace Thomson Hospital Automates to Maximize Limited Resources
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.
7 Steps for Building and Funding Sustainability Projects
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.
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
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.
Trend Watch: Providers adapt as value-based care moves from hype to reality
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
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.
Reforming with a New 50-Bed Acute Care Facility
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.
5-Minute Briefing on Revenue Integrity Through HIM WhitePaper Hospitals FS
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.
5-Minute Briefing on Accelerating Cash Flow Through HIM WhitePaper Hospitals FS
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.
5-Minute Briefing on Reducing the Cost of RCM WhitePaper Hospitals FS
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.
Providers Focus Too Much On Revenue Cycle Management
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.
Lucille Packard Children’s Hospital Stanford Case Study
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.
Using Predictive Modeling To Detect Meaningful Correlations Across Claims Denials Data
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.
ZOLL and Emergency Mobile Health Care Case Study
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.
Maximizing Medicare Reimbursements White Paper
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.
Denials Deconstructed: Getting Your Claims Paid
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.
Automation and Operational Improvement Drive Sustainable Results
Physician practices must improve organizational efficiency to compete in this era of reduced reimbursement and escalating administrative costs.
Revenue Cycle Management Resolves Migration Implementation Issues
Many healthcare organizations are pursuing next-generation health information systems solutions. Learn more about Navigant's work with University of Michigan Health System.
Partnering For Success – Provider Achieves Strength in Stability
The proper implementation of healthcare information technology systems is crucial to an organization’s financial health.
Building a Clinically-Integrated Network
As value-based payment models evolve, providers are challenged to maintain superior clinical outcomes while controlling costs.
Winning in the Post-Acute Marketplace
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.
Building A Common Vision with Employed Physicians
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
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.
Adding Value to Physician Compensation
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?
Effective Revenue Cycle Management in Your Network
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.
Succeeding in Value-Based Care
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.
Therapy: Benefits at All Levels of Care
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.
Does Your Budgeting Process Lack Accountability?
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.
Cost Accounting: the Key to Cost Management and Profitability
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.