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* The shift to an outpatient- and consumer-driven healthcare system
requires traditional providers to strategically respond to these game-changing
* The increasing influence of national physician practices will require
hospitals to contend with agile competitors that innovate both clinically and
* Forward-thinking companies in the primary care and Medicare Advantage
spheres will compel hospitals to reimagine their patient engagement strategies.
The distribution of care delivery to ambulatory sites of care is well
underway, with outpatient and physician revenues for many large health systems
now equaling or exceeding core inpatient hospital and diagnostic payments. Trends
such as the reorientation of the industry towards B2C business, rapidly rising
consumer and employer expectations, and the redistribution of risk from payers
to providers are changing the basis of competition and providing new
opportunities to create value in the ambulatory care market.
In 2016, according
to a recent McKinsey analysis, the shift from inpatient to distributed ambulatory care settings resulted in:
The advent of enhanced clinical digital technology, coupled
with a growing and aging population, will fuel further growth in demand — particularly
in ambulatory settings, where consumer preference for convenience has emerged
as a major factor in provider selection. The so-called “consumerization” of
healthcare requires a service-based strategy designed to meet the underlying
needs of consumers at the time they interact with the system.
More than 80 health systems already hold direct-to-employer contracts. Employers such as Intel and Boeing have
collaborated with providers to pursue risk-sharing, total-cost-of-care care
models for their employees.
medical centers such as Mount Sinai Health System in New York are partnering
with startups such as One Medical to provide concierge-like primary care in a
move to protect and grow their commercial-segment business. Insurers such as UnitedHealth Group, Humana and some Blue Cross Blue Shield plans have
become providers, buying practices and hiring physicians who offer ambulatory
care through retail urgent care clinics, surgery centers and offices in over a
Adding to the disruption are the new vertical integrations
still in their infancy, such as Cigna/Express Scripts and CVS Health/Aetna, and
employer entrants like Haven, the new Amazon/Berkshire Hathaway/JP Morgan Chase
healthcare joint venture led by Atul Gawande, MD. In addition, healthcare
venture investments in 2018 were 50% higher than in 2017 (over $25 billion),
according to a
Silicon Valley Bank report, with major investments in oncology and neuro
drugs, biopharma platforms, cardiovascular and neuro devices, and diagnostic
tools and analytics.
Meanwhile, patients are being expected — fingers crossed —
to act more like “customers,” creating increased motivation for health plans
and providers to address issues of access and affordability.
With this type of transformation looming, healthcare leaders
should be plotting strategy to respond to the following key trends.
While revenue growth in the overall healthcare market has
slowed in the past decade, ambulatory clinical demand is continuing to expand
at a healthy rate. For one provider, Truven
Health Analytics forecast that the
combination of population growth, aging, treatment trends, expansion of
Medicaid and coverage through healthcare information exchanges will produce
growth of approximately 21% over the next decade.
The growth of the older population as a share of the total
population will have a powerful impact on ambulatory services. By 2025, the
percentage of the population over 65 will rise from 15.1% to 18.8%, according
to Truven Health. Adding to this demand is the impact of the roughly 17 million
individuals who have received coverage through state and federal health
exchanges and Medicaid expansion.
National physician practices (NPPs)
— single-specialty, groups of related specialties and multispecialty — have
been somewhat off the radar in most strategy discussions. Because hospitals
tend to partner with NPPs to fill gaps in their clinical staff, they are not
seen as direct competitors. Yet NPPs are the focus of significant venture
capital activity, with competition for physicians driving rapid increases in
practice valuation. Given their scale and specialty focus, NPPs
have advantages in recruiting, particularly for positions such as hospital
intensivists and emergency medicine.
The scale of NPPs facilitates
management practices that better align clinical staffing with hospital and payer
needs and create a more convenient care experience for patients. A number
of NPPs, such as Sound Physicians, have been active participants in Medicare
bundled payment initiatives, creating opportunities for potential joint-venture
partnerships with provider systems seeking to relocate their resources from
inpatient to ambulatory care.
Sidebar: Organizations that are changing the face of the ambulatory market
According to a 2019
Accenture survey, consumers are changing their
expectations about convenience, affordability and quality. As expected, younger
consumers are more dissatisfied with the healthcare status quo —
but consumers of all generations are more willing to try nontraditional
services, with convenience being a top factor in the choice of care. Large
employers, the government and insurers are increasingly looking to enhanced
forms of primary care as the key to improving access, lowering costs and
filling market needs.
The demand for high-quality primary care services, coupled
with the alignment with new value-based payment models and venture capital
investments, is catalyzing the growth of new types of ambulatory care
providers. Telemedicine companies and urgent care centers can fill some of the
needs outside of the ER. But perhaps more transformative in the long term are
primary care corporations featuring a care model that can provide real
engagement, frequent dialogue and joint patient/physician decision making.
primary care providers tend to feature:
Some, but not all, embrace value-based, at-risk contracts
that align physician and care teams with patient needs and outcomes.
in NEJM Catalyst on their
experience in the primary care market, Venrock partner Bob Kocher, MD, and Christopher
Chen, CEO of ChenMed, conclude that "practices that succeed at making the shift from fee-for-service to managing risk are routinely able to increase practice profitability by at least 25%." Although
there is relative safety and predictability in FFS revenue, they argue,
value-based revenue is increasing and likely to be more lucrative because it
allows primary care providers to capture revenue that formerly went to
Such an approach requires a shift
in mindset from maximizing RVU revenue and downstream referrals to managing
total patient health, quality and costs. This trend reinforces the need for
providers to grow their own magnet physician groups and makes acquisition of
remaining independent practices a priority.
The ambulatory business can be viewed as a portfolio
of consumer assets with specific contracting approaches; centralized billing,
collections and financial management; and a unique set of performance metrics
that align incentives of health systems, owners and physicians. Successful joint
ventures require a common vision and common goals, a clear understanding of
what each partner brings to the venture and a process for resolving operational
Organizations should commit to creating
standardized, predictable and effective business processes, maintaining the
agility to accommodate changing consumer purchase patterns, and prioritizing
on-demand access and convenience through investments in innovative technology.
Dudley E. Morris and David G. Anderson, PhD, are
seniors advisers, BDC Advisors.
HealthTrust: A Holistic Approach to Value Analysis
DHG Healthcare: Optimizing CDI for Bundled Payment Arrangements
Kaufman Hall: Five Key Learnings from HFMA’s Financial Analytics Leadership Council
Grant Thornton: Guiding Organizations Through Cloud-Based ERP Adoption
A senior leader at Grant Thornton LLP HealthCare Advisory Services talks about key ways to lay the groundwork for a shift to cloud-based ERP solutions. Insights stem from a presentation given at the HFMA Large System Controllers Council.
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.