Get the E-newsletter
The Center for Medicare and Medicaid Innovation (CMMI) finalized several new mandatory payment models in December 2016, including three for providers treating cardiac patients.
Bundled payments for cardiac care will hold approximately 1,120 acute care hospitals in 98 markets financially accountable for the cost and quality of all care for a 90-day episode of care for acute myocardial infarction (AMI) and coronary artery bypass graft (CABG). About 1,320 hospitals in 45
geographic areas are expected to participate in a separate model for cardiac rehabilitation.
Originally slated to kick off on July 1, these new models have been delayed until Jan. 1, 2018.
Despite mixed signals on the issue from the Trump administration, Billy Wynne, JD, a managing partner with the Washington, D.C.-based government relations firm TRP Health Policy, expects payment innovation to move forward because it’s a rare issue that has bipartisan
“On the government side historically, delivery reform, payment reform, trying to encourage value, trying to incentivize value over volume, have been bipartisan priorities,” he says. “It’s only with the Affordable Care Act and the hyper-partisanship of it that the
bipartisanship got lost.”
The delay of the start date for the new models gives providers an opportunity to prepare for what many see as inevitable change in payment approaches. Health systems around the country have found the following elements to be essential for structuring cardiac bundle
programs to optimize performance.
clear and achievable goals. Many providers make the mistake of entering cardiac bundled
payments without a clear purpose or defined goal, says Zenobia Brown, MD, medical director of advanced illness management and bundled payments with Long Island-based Northwell Health Solutions.
“There are so many different points of entry on how you can redesign care that those points are going to designate what your outcomes are,” Brown (pictured at right) says. “Without crystal clarity, you end up doing lots of different things, any number of which may or may not be successful.”
For example, is the goal to solve a clinical problem, such as high readmission rates or lengths of stay, or is it to make money? If improving readmission rates is a priority, then a provider may implement systems to achieve that goal and to improve clinical outcomes, which doesn’t guarantee a particular
financial outcome, Brown says.
“If the thing that you really were interested in is making money in your bundle, that [approach] is probably not where you’re going to find the funds,” Brown says.
Focus on inpatient costs and reducing care variation. With cardiac bundled payments, in contrast to the Comprehensive Care for Joint Replacement program, most spending is on inpatient care.
“In cardiac bundles, you typically have much lower post-acute spending compared to joint replacement bundles,” says Rocky Edmondson, senior director of bundled payment consulting with XG Health Solutions, a spinoff of Geisinger Health System.
In fact, hospitalization accounts for about half of all spending to treat AMI and about three-quarters to treat CABG.
“Understanding your spending patterns during the inpatient stay is key,” Edmonson says.
With cardiac bundles, that means focusing on reducing costs and improving quality by reducing readmissions and unnecessary variations in care.
“When you look at a major complication like a stroke or prolonged ventilation, you could be raising potential costs to the delivery system by 90 percent or more,” says Matthew Ducsik, director of cardiovascular clinical program services with Providence Health & Services. “So, being
able to engage the providers, the physicians, the nurses, around best practices and evidence-based care quality initiatives also facilitates that strategic purpose of cost reduction.”
Let data be the guide. Brown advises providers to be very careful about where they focus when evaluating care variability.
“Very often clinical people will go for the most exciting aspects of care redesign, such as readmissions, which are not necessarily areas that need attention or any care redesign at all,” she says.
“Until you understand whether your performance varies from a benchmark standard, you might think that number [of readmissions] is high, but really, there is no opportunity there to see a savings or see a delta if you’re already performing either at or better than a standard.”
This analysis requires a robust way of measuring compliance with standards and best practices, along with an honest evaluation of the organization’s ability to build the infrastructure to accurately track data that is needed to understand the relationship between an activity and its outcome.
“Most places make the mistake of thinking they’re going to measure their compliance through their outcome—we have a better readmission rate, so that means that we were compliant with our best-practice protocol,” Brown says. “The two things are true but unrelated. There is a lot of assumed causality in care redesign
that many places don’t have the infrastructure set up to know.”
Focus on medication management and
compliance. Hannah Berg, product manager with Providence Health & Services’ Heart Institute in Oregon, says much of her work focuses on making sure not only that physicians are prescribing the appropriate medications but also that patients are taking those medications once they go home.
In Oregon, Providence CABG patients receive a bedside visit from a pharmacist for consultation on their medications, Berg (pictured at right) says. Advanced practice providers, such as physician’s assistants or nurse practitioners, prepare patients before discharge. Patients who have undergone heart surgery get a phone call from a nurse to make
sure they’re on track with their medications.
Reorganize to manage post-acute spending. Avoiding readmissions is paramount, which makes a robust care management program essential.
“There are a lot of touch points in a CABG, for example, both internally and externally,” Edmondson says.
Following patients through their hospital stay is not enough. Someone also must make sure they’re getting to follow-up appointments and that the care they receive at skilled nursing facilities or through home health providers meets the quality standards of the hospital.
For the subset of patients who are readmitted to the hospital, it’s necessary to understand exactly why and to closely track all skilled nursing and home health discharges, the quality of care that patients receive while being treated by another provider, and their length of stay.
Establish a strong post-acute provider
network.Essential to managing post-acute spending is the ability to establish and rely on a performance network of providers that meet expectations based on quality and length of stay.
Patients also need immediate access to clinics to avoid unnecessarily seeking care in the emergency department (ED). Are patients heading to the ED, for example, because when they called their doctor’s office for an appointment they were told they’d have to wait two weeks?
“Lack of access is probably the No. 1 driver of readmissions,” Edmondson says. Successful providers, he says, have set up immediate-access clinics that allow same-day appointments for patients who can be treated for follow-up issues by advanced practice providers or physicians.
Heart failure clinics monitor patients in an office setting before they’re sent home, and mobile paramedics travel to patients’ homes and evaluate them on the spot or direct them to the most appropriate site rather than automatically taking them to the ED.
Gain stakeholder buy-in. Finally, the best data and most efficient process redesign are unlikely to succeed without the buy-in of clinical staff.
“It has to be provider-driven,” Ducsik says. “We’re very fortunate in the cardiovascular world that we have lots of data, especially around cardiac surgery and interventional cardiology, but I think it really has to go to those clinical caregivers to determine what those areas of opportunity are.”
Ducsik adds that clinicians should be involved in the design of those interventions. “They’re the ones at the bedside, providing the care.”
Lisa Zamosky is a healthcare journalist who covers health insurance, healthcare policy, the Affordable Care Act, Medicare, Medicaid, and consumer health and finance concerns.
for this article:
Hannah Berg, product manager, Providence Heart and Vascular Institute, Portland, Ore.;
Zenobia Brown, MD, medical director of advanced illness management and bundled payments, Northwell Health Solutions, Long Island, N.Y.;
Matthew Ducsik, director of cardiovascular clinical program services, Providence Health & Services, Renton, Wash.;
Rocky Edmonson, senior director of bundled payment consulting, XG Health Solutions;
Billy Wynne, JD, managing partner, TRP Health Policy.
Grant Thornton: Helping Organizations Embrace Robotic Process Automation
Two senior leaders at Grant Thornton talk about the advantages of robotic process automation to improve office efficiency, reduce costs, and mitigate risk.
VitalWare: Creating a Transparency Strategy: Meeting the Mandate to Post Standard Hospital Pricing
A senior leader of VitalWare talks about the need to create a comprehensive pricing strategy for consumers and how to get started.
HealthTrust: Solving Workforce Management Challenges
Two of HealthTrust’s senior leaders talk about strategies for optimizing the hospital workforce to improve productivity and reduce waste.
Grant Thornton: Optimizing the Ambulatory Workforce
One of Grant Thornton’s senior healthcare consultants addresses the topic of workforce management and the importance of a data-driven approach.
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.