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An influential group of healthcare
leaders puts it bluntly: The resources spent on maternity care services are not
leading to the highest value.
Instead, there are too many Cesarean
deliveries, too many preterm births, and too many early elective inductions,
all of which increase the need for neonatal intensive care services. The infant
mortality rate in the United States is higher than in 38 other countries. The maternal
mortality rate has doubled in the last 30 years.
The Health Care Payment and Learning
Action Network (HCPLAN), a collaborative group of private and public
stakeholders convened by the Department of Health and Human Services to advance
the use of alternative payment models, thinks the current payment system is
partly to blame for the nation’s poor track record of maternity and newborn
care. In a white paper issued recently, HCPLAN recommends
the use of episode-of-care (i.e., bundled) payments to incentivize the use of
HCPLAN’s work group includes top
executives from many major health plans, although payers thus far have been
slow to push for maternity care payment reform. Devising a new way to pay for
an episode that may last 10 months or more, involves a wide range of providers,
and starts with one patient and ends with two is a daunting task.
But now that HCPLAN has published
recommendations on how to get started, purchasers intend to jump on them. “We
want to capitalize on the momentum,” says Brynn Rubinstein, senior manager for
the Transform Maternity Care initiative at Pacific Business Group on Health
That group, representing Walmart,
Boeing, and many of the nation’s other largest healthcare purchasers, hopes
regional and national pilots to test episode payment for maternity care will start
soon, because its members are not satisfied with the value they are getting. Combined
maternal and newborn stays account for more than 20 percent of hospital stays—and
the wide variation in costs does not correlate with outcomes.
“PBGH feels it’s the role of the
purchaser and the employer to kind of pound the table and let plans know that
the time is now,” Rubinstein says. “While there are many obstacles to navigate,
they are all challenges that can be overcome.”
Since 2008, Geisinger Health
Plan, based in Danville, Pa., has been proving that the theory behind bundled
payments for maternity care holds up in practice. The plan uses bundled
payments for maternity care delivered at Geisinger Health System, where
standardized care processes have reduced the total cost of care.
“If you decrease your
early elective delivery rate and your C-section rate, you end up decreasing
your NICU days and the other high-end costs that tend to happen to babies born
too early,” says John Bulger, DO, chief medical officer of Geisinger Health
Plan and CMO for population health for the health system.
That said, perinatal bundles
are among the most complex in Geisinger’s suite of ProvenCare episode-of-care
packages. The design team identified 103 unique best-practice measures that are
tracked for every patient; if a mother begins her care with Geisinger in the
first trimester, there are as many as 300 opportunities to deliver those
measures to each patient. By comparison, Geisinger tracks 19 best-practice
measures—and 40 opportunities to deliver them—for patients who receive coronary
artery bypass grafts.
hallmark of care transformation—does work for maternity care, Bulger says. “It
changed the culture in the obstetrics department to focus more on quality and
focus more on processes of care—more on what they needed to do versus what they
did not need to do,” he says. “Our early elective delivery rate has been
essentially zero for six-plus years, and we saw our C-section rate go down
fairly quickly as well.”
Like most maternity care leaders,
Sean C. Blackwell, MD, chair and professor in the Department of Obstetrics,
Gynecology and Reproductive Sciences at McGovern Medical School at UTHealth in
Houston, thinks physicians must be the “accountable entity,” responsible for
designing and directing maternity care and for dividing the payment among
providers in the bundle.
That’s why his
department—roughly 80 OB/GYNs who belong to a large independent physician
practice—is in a two-year pilot with a Medicaid managed care plan that covers
roughly half of all births in the Houston area. Finding the right mix of
quality measures, payment incentives, and care protocols to succeed in a
bundled payment contract is going to take time, and Blackwell, who also serves
as chief of service for obstetrics and gynecology at Children’s Memorial
Hermann Hospital, wants to figure it out.
Through the pilot,
Blackwell (pictured at right) gained access to data about the actual cost of care for a given
pregnancy. The data made clear to him that a truly cost-effective maternity
bundle must also include ancillary costs such as laboratory testing, medication
use, and fetal imaging, all of which have potentially high costs.
Another lesson learned:
The actual spend on physician services may need to increase for avoidable—and
expensive—hospital admissions and readmissions to decrease.
“Even though OB/GYN
physician services may only represent 10 percent of the total cost of maternity
care, the physicians are the captains of the ship who are making not only
clinical care decisions that affect maternal and newborn outcomes but also
decisions regarding utilization of services within the hospital,” Blackwell
says. “Reducing the frequency and/or severity of preterm birth is by far the
number one opportunity to decrease costs of maternity care and improve
Reducing unnecessary Cesarean
deliveries is the second-biggest opportunity for improving health and reducing
“Strategies such as
adopting clinical pathways and managing lengths of stay all require physician
partnership,” Blackwell says. “It is unrealistic to believe hospital leadership
can do this unilaterally. If hospitals are going to successfully decrease the
cost of their care, they must be aligned with their physicians and have shared
incentives related to cost and quality.”
Beyond that challenge,
the data disconnect between payers and providers will take some effort to
resolve. For example, health plans tend to use quality measures that are relevant
to their own reporting requirements but that may be unrelated to physician care
or outside the control of the OB/GYN physician. Thus, physicians and payers
must come to agreement on what constitutes high-quality obstetrical care and
what measures are important. Both sides must compromise, Blackwell says.
of the measures that are feasible to use will be imperfect or suboptimal, and
measures that are more ideal may not be easily obtainable or laborious to
assess and track,” he says.
During the first year of
the two-year pilot, Blackwell’s group did not make substantial changes to care
processes or focus on reducing costs of care. Rather, the year was devoted to
gathering baseline data for quality measures and analyzing the payers’ data to
understand the overall costs associated with maternity and newborn care so that
a better care model could be designed.
“When you think of all
the good things that doctors and midwives and nutritionists and diabetes
educators and lactation consultants can do to improve outcomes, we have got to
redesign the care and the payment model so those things are appropriately
valued and people can invest in them,” he says.
Blackwell is committed to
working through the many challenges associated with maternity bundles because
he believes a bundled-payment approach will be widely adopted. But he doesn’t
think it will be easy.
“The learning curve is
just going to be tremendous here,” he says.
Providence Health &
Services, one of the largest not-for-profit health systems in the country, does
not yet have a bundled-payment contract for maternity care, but it has spent
the past four years getting ready for such an arrangement.
is a very challenging aspect of moving toward bundled payment,” says Laurel
Durham, regional director of perinatal services, Providence Women and
Children’s Services. “We’ve been focused on the clinical pathway as a first
step in addressing payment reform.”
Based in Renton, Wash.,
Providence serves five western states. Midwifery care is offered throughout the
system, but a unique midwifery model has been developed in the Portland area.
Starting in 2012, the Portland midwife clinic began using its product
development methodology to bring the Triple Aim goals to maternity care.
“We found that we could
incorporate group appointments and add doulas and social workers,” says Durham (pictured at right).
“And we could have a team-based model of care that allows everyone to work at
the top of their license. By focusing on the patient experience, we increased
patient satisfaction while reducing cost.”
In 2013, Providence
piloted its “pregnancy care package” in a single clinic in Portland. The
package is designed to coordinate care from prenatal services through labor and
delivery to the postpartum and post-discharge phases. The care team, which is
anchored by certified nurse midwives, includes nurses, doulas, patient
navigators, a consulting OB/GYN physician, and social workers. The pregnancy
care package operates within Providence’s larger footprint in Oregon, giving
patients easy access to the system’s services and resources.
During the pilot year,
women served in the pregnancy care package model had a Cesarean rate of just
over 20 percent, compared to a national average of 32 percent. In its first
year, the pregnancy care package, which gives women options for pain management
during labor, resulted in an epidural rate that was 23 percent below the
national average, and just 1 percent of women had early elective deliveries.
Durham believes the lower
epidural rate can be attributed to two factors. “Rates were lower in part
because these pregnancies were lower-risk and among women who wanted to have
low-intervention births,” she said. “Additionally, the pregnancy care package
provides the support these women need to achieve their birth experience goals.”
The cost of services provided through the pregnancy care package was 15 percent
less than in the traditional care model, while patient satisfaction scores were
in the 98th percentile.
Since then, the pregnancy
care package model has expanded to three women’s clinic locations and two
hospital delivery sites, making it a convenient option for any woman living in
or near Portland. Delivery volume has grown dramatically, and Providence
continues to innovate to make the package attractive. For example, workgroups
defined the scope of practice for doulas to support patients throughout the
continuum of their birth experience, including a Cesarean section when
necessary and postpartum.
Even as they optimize
their care delivery model, Providence leaders see the barriers facing payment
reform. For example, doulas provide support to women who want nonmedicated
births, allowing them to avoid epidurals. Although doula services are bundled
into the pregnancy care package model, some health plans do not cover doula
services outside of this bundled approach.
“We need to find a way to
determine the value of navigators, doulas, and the integration of behavioral
health services in maternity care,” Durham says. “Those are really important
parts of pregnancy care, and it will be challenging for this to spread rapidly
without addressing the value they provide, and subsequently, payment.”
Although the HCPLAN workgroup and others recommend designating OB providers as
the “accountable entity” that accepts a bundled payment for maternity care,
Durham thinks that function can be handled by a health system, with OB
providers leading the process.
“A health system can help
provide the infrastructure many providers would need to manage a bundled
payment model,” she says. “If they are paid and then have to allocate payment
to others who were involved in the care, it becomes really complicated from a logistical
Butcher writes about healthcare business and policy topics for several HFMA
Interviewed for this article: Brynn Rubinstein, senior
manager for Transform Maternity Care, Pacific Business Group on Health, San
Francisco; John B. Bulger, DO, MBA, chief medical officer, Geisinger Health
Plan, and chief medical officer-population health, Geisinger Health System,
Danville, Pa.; Sean Blackwell, chair
and professor in the Department of Obstetrics, Gynecology and Reproductive
Sciences at McGovern Medical School at UTHealth, and chief of service for obstetrics
and gynecology, Children’s Memorial Hermann Hospital, Houston; Laurel Durham, regional
director perinatal services, Providence Women and Children’s Services, Providence
Health & Services, Portland.
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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
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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
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.
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5-Minute Briefing on Accelerating Cash Flow Through HIM WhitePaper Hospitals FS
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Providers Focus Too Much On Revenue Cycle Management
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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
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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.
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Building a Clinically-Integrated Network
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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
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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.
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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
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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
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