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When a patient visits Kevin Bozic, MD, MBA, to seek relief from longstanding knee pain, the surgeon looks at two key pieces of information: images of the knee and the patient’s self-reported pain, functional status, and quality of life.
Bozic, chair of the Department of Surgery and Perioperative Care at Dell Medical School, The University of Texas, and his colleagues are pioneers in the use of patient-reported outcome measures (PROMs) for shared decision-making, an important element of high-value healthcare services.
PROMs are validated instruments that use a patient’s response to questions to create a quantifiable measure of a health outcome or health status. PROMs allow a physician to understand a patient’s specific symptoms—for example, depression, anxiety, or
pain level—from the patient’s perspective.
“It’s giving the patient a voice in their health care,” says Judith Baumhauer, MD, MPH, associate chair of the Department of Orthopaedic Surgery at the University of Rochester Medical Center (URMC) in Rochester, N.Y. “We used to tell them how they’re doing. Now,
they’re telling us.”
When a patient’s baseline PROMs are compared with those of other patients with a similar condition, both patient and physician can
understand whether proceeding with surgery is worthwhile. Likewise, seeing the post-surgery PROMs for other patients helps the patient set realistic expectations for pain and functional ability in the weeks and months after surgery.
“We can tell from patients’ baseline pain, functional status, and mental health scores how likely they are to achieve a successful result from surgery,” Bozic says.
Shared decision-making, a major tenet of high-value health care, has been shown to reduce the nation’s healthcare tab. Up to 20 percent of patients who participate in a shared decision-making process
choose less-invasive surgical options. In a 2012
study published by Group Health, the use of decision aids to help patients who were considering hip and knee replacements resulted in 38 percent fewer surgeries over six months.
Shared decision-making empowers patients to choose treatments based on their values and preferences, but patients often have inadequate information to make fully informed decisions—for example, exactly how does my current pain level compare to the pain I will
likely experience during rehabilitation or after full recovery? PROMs allow a physician to show how a patient’s individual scores compare with those of similar patients to facilitate shared decision-making conversations.
Sample PROM Score Report
At URMC, PROMs have been collected for the past two years during every outpatient visit—about 17,000 a month—to the orthopedic surgery department. The medical center uses the
Patient-Reported Outcomes Measurement Information System (PROMIS), one of many measurement options.
Each patient’s appointment is linked to a QR-code reader that imports the appropriate PROMIS questions to a Wi-Fi-enabled computer tablet, which is given to the patient upon arrival at the clinic. Patients answer an average of four to seven questions. Physicians can immediately see the patient’s PROM scores in the
electronic health record (EHR) and compare them to scores from similar patients treated at URMC in the past two years.
That allows Baumhauer (pictured at right) and her colleagues to advise patients on how they can expect to fare after a given procedure.
“When a patient says, ‘Do you think I’m going to get better from having the surgery?’ I can look at their [PROM] scores and tell them with pretty good probability—94 percent probability in some cases—that they might not benefit from surgery and we ought to do something different,” she says. “That’s the
Holy Grail—having the vision to see the result ahead of time so the patient doesn’t have to try something that isn’t going to work.”
Traditionally gathered for research purposes, the idea of using PROMs for clinical decision-making has long held allure for physicians. But progress has been slow.
Dartmouth-Hitchcock Medical Center has been collecting PROMs for both clinical and research purposes for two decades. Today, those thousands of data points feed a calculator that lets patients see the outcomes of surgical versus nonsurgical interventions for
patients similar to them, as
reported recently in the New England Journal of Medicine. Partners HealthCare in Boston introduced PROMs in 2012 and has collected 1.2 million scores in 21 specialties, including urology, orthopedics, psychiatry, and primary care. After starting with orthopedic surgery PROMs in 2015, URMC has expanded collection
to 30 departments and divisions.
PROMs are at the center of a shared-decision making process that has been implemented in the Musculoskeletal Institute at UT Health Austin, where Bozic and his colleagues are working on ways to improve the value of care delivered to patients with arthritis.
Although PROMs are collected more widely for orthopedic surgery patients than for any other service line industry-wide, Bozic (pictured at right) says PROMs are rarely used in clinical decision-making even in that specialty. He estimates that perhaps 5 percent of orthopedic
specialists are collecting PROMs for the majority of their patients, mostly for research purposes.
“What percentage are collecting PROMs for every patient at every encounter and using them in clinical decision-making? I would say it’s far less than 1 percent,” he says.
He expects growth in the use of PROMs for shared decision-making to remain slow until value-based health care becomes more widespread. Although value-based payments are beginning to catch on for joint replacement surgeries, most new payment methodologies incentivize improvements
in the quality and efficiency of surgery—and do nothing to help patients decide whether surgery is their best course of action. Currently, most health plans and patients are not yet demanding the use of PROMs as an indicator of high-value medical practice. “Adoption is going to depend on how much the payer
community is willing to say, ‘This is important and we are going to start incentivizing this,’ and on patients being informed that this is important information that influences their treatment decisions,” Bozic says.
Medicare provides a quality incentive for hospitals in the Comprehensive Care for Joint Replacement program to report pre- and postoperative patient-reported functional outcomes, although the hospitals are not required to use those scores in any way.
As patients come to understand how PROMs can inform their decisions about major surgery, they are likely to gravitate to institutions that use such measures. Thus, value-oriented health systems should start preparing for the day when using PROMs for shared
decision-making becomes a competitive advantage. Pioneers such as Partners have found that gearing up for PROMs to become a seamless part of decision-making takes years.
“We certainly have the battle scars you’d expect from such a complex endeavor—asking people to do yet one more thing, to incorporate yet one more piece of technology,” Neil Wagle, MD, MBA, Partners’ associate quality officer, said in an
NEJM Catalyst article.
Like most important initiatives, the collection and use of PROMs requires a wide range of resources and, thus, support from top leaders. At URMC, implementing PROMs is an element of the institution’s strategic plan, Baumhauer says. “That’s how important our leaders think this
is, which is fantastic,” Baumhauer says. “It’s hard to get that level of institutional support, and we do have it.”
Those at the forefront identified issues that need early consideration:
Technology. Ensuring a 100 percent reliable wireless network in every location where PROMs will be collected is an important first step. PROMs are generally collected using computer tablets when patients first arrive at an outpatient clinic (unless patients
have used an online portal to answer questions in advance of their visit). Unreliable wireless connections wreak havoc: Patients get frustrated with the devices, PROM data does not get relayed to the patient’s EHR in time for the appointment, and the technology problem becomes a new source of physician stress
and, potentially, burnout.
Choosing the right technology platform is also an important early step. At Partners, PROMs are integrated into the EHR. Patients can answer their PROM questions at home using the patient portal or in the clinic. URMC, in contrast, uses a third-party platform
that sits outside the EHR, although PROM data flows into patients’ electronic records for physicians to view. Each system has advantages and disadvantages that should be carefully weighed.
Physician support. The physicians in Bozic’s department at Dell Medical School have chosen to use PROMs for shared decision-making, but that perspective is not necessarily universal. At first, the use of PROM data seems like another task placed
on an already overburdened clinician. It takes a while for physicians to learn how to read the data quickly and incorporate it into a shared decision-making conversation.
That’s why the PROM journey should start with a physician champion in a specialty where PROMs are validated and understood to be of value in clinical decision-making. The champion should be able to convince his or her peers that using PROMs is good for their patients—the
only message that is likely to get them on board.
Patient buy-in. Patients are already burdened with tasks—providing insurance information, signing HIPAA forms, filling out health histories—before their physician appointment, and they are not eager to take on more. At URMC, every department asks patients to report on three things—physical
function, pain interference, and depression—in a questionnaire that takes an average of 2.4 minutes to complete. Some departments add extra domains such as anxiety, fatigue, or social isolation when those are relevant to the patients they treat.
“Every time you add in an additional domain, it takes about a minute,” Baumhauer says. “We have a philosophy of trying to decrease patient burden, so we want to keep it under five minutes.”
Unless patients see exactly how the physician is using PROM data, the response rate on the questionnaires will be low, Bozic says. However, patients expect to put in considerable effort to get an X-ray—arriving early, waiting, exposing themselves to radiation, even hand-carrying a CD—because they
understand its relevance to the physician’s understanding of their condition. That’s why Bozic’s protocol is to use a patient’s PROM data just as he uses an X-ray image, showing it to the patient and explaining how it informs treatment decisions.
Despite the challenges associated with collecting and using PROMs for clinical decision-making, pioneers believe these measures will become the standard of care in the foreseeable future.
Researchers at Partners recently conducted
qualitative interviews with 25 physicians and non-physician providers to learn how PROMs affect providers and patients. Less than five years after a robust PROM program was initiated at that health system, some providers have evolved from skeptics to cheerleaders.
“Our interviews suggested that use of PROs can improve physician satisfaction, enhance physician-patient relationships, increase workflow efficiency and enable crucial conversations,” the authors wrote. “Despite [the] challenges, we believe PROs have the
potential to reengage patients and physicians in the care delivery process.”
Lola Butcher writes about healthcare business and policy topics for several HFMA publications.
Interviewed for this article:
Judith Baumhauer, MD, MPH, is professor and associate chair of the Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, N.Y.;
Kevin Bozic, MD, MBA, is professor and chair of the Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas, Austin.
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.
Ensemble Health Partners: Driving Revenue Cycle Innovation
Judson Ivy, president of Ensemble Health Partners, discusses the value of revenue cycle outsourcing and the importance of selecting the right partner.
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
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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
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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.