Ali Hochreiter and Lauren Knieser from Audacious Inquiry, a PointClickCare company, discuss disaster preparedness for patients outside hospital walls.
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Erika Grotto: Preparing for preparedness, today on HFMA’s “Voices in Healthcare Finance” podcast. Hello, and welcome to the podcast. I’m your host, Erika Grotto. Today we have the first of two episodes that deal with disaster preparedness. My guests are going to share some great lessons learned as well as things leaders should be doing now to ensure continuity of care for patients. But first, let’s check in with our news team. Here’s HFMA Senior Editor Nick Hut and HFMA Policy Director Shawn Stack.
Nick Hut: Hi, everyone. We’ve been doing these segments for about a year now, and I would save we’ve talked about the new surprise billing regulations probably more than any other topic, and that’s just because they really represent almost a sea change in many aspects of providers’ business operations. The latest big news is the issuance of a final rule governing the arbitration process to determine out-of-network payments for scenarios when patients are no longer allowed to be balance billed and the health plan and the provider can’t agree on an amount amongst themselves during negotiations. So last year, an interim final rule with comment period was released, and providers were kind of up in arms because it seemed like it was going to tilt the balance of power quite a bit in the favor of health plans. But Shawn, this final final rule seems to be somewhat more favorable to hospitals and physicians. Would you say that’s the case?
Shawn Stack: I think the final rule has added some more clarity around the court proceedings and the court rulings that came out earlier this year—well, actually, I think it was last year, right?—addressing the QPA recognized amount, and it kind of solidified that in the final rule. So I think that’s a good piece as well as some other, you know, factors, Nick, that I know you’ve observed too. A lot of FAQs came out with this rule, a lot of tip sheets for providers for the IDR process came out with this rule adding clarity.
Hut: Yes, indeed. And you know, just some context on why the big changes were made. There was litigation decided in February with a federal judge ruling that using the qualifying payment amount as the dominant benchmark represented too much of a deviation from legislative intent under the No Surprises Act, and therefore arbitrators should have to assess other specified factors if submitted by either party as long as they deem the information to be credible. So that really kind of forced HHS’s hand, and again, for those who aren’t totally up on this technical jargon, the qualifying payment amount is defined as the median contracted rate for a particular service in a given market. But Shawn, you’ve mentioned one or two things that maybe still need to be ironed out. More than one or two things, but what are a couple of things that stand out to you that really still need to be addressed?
Stack: Co-providers and providers are still very much struggling to get an accurate 835 back. That’s kind of like a remit back from the payer, an electronic remit, showing exactly what the QPA is supposed to be, what the patient’s out-of-pocket, in- and out-of-network charges actually are. That clarity is still very fuzzy, and payers and health plans aren’t always reporting that back on the claim as specified. So I think there needs to be more clarity rolled out there of what those expectations on the health plans and the payers are. I’d like to see that still beefed up a little bit.
Hut: Yeah, that makes sense, no doubt. Perhaps the clearest advantage that providers got from this final rule relative to last year’s rule was a requirement for health plan transparency about the qualifying payment amount. In early cases, it’s emerged that health plans, at least here and there, have been downcoding billed claims for the purposes of establishing a QPA, and that gives them a significant leg up in arbitration. Shawn, what do you make of that? It’s possibly a big win for providers.
Stack: Yes, it is a big win for providers. Unfortunately, it just applies to those claims that are subject to NSA provisions, but at least it’s starting somewhere. But yeah, this is an issue that’s been around for years, either health plans and payers downgrading ED levels of care or changing modifiers on claims or diagnosis codes. This has been happening for years and years and years, and now what the agencies are saying is, if it’s a claim that applies to the No Surprises Act, before the health plan or as the health plan recodes that claim, changes the modifiers, modifies them, changes the codes, modify them, they need to disclose why they’re doing that to the provider so they can review that. And no more of this just automatic downcoding or downcoding levels of care in the ED. That’s very good news, I agree.
Hut: Absolutely. And what I said is happening, at least here and there, for people whose sarcasm detector wasn’t turned on, that was met with some sarcasm because it certainly happens rather extensively and rather frequently. Anyway, Shawn, thank you as always for the insight, great stuff. There’s a lot to digest with this new rule and so much about the No Surprises Act, so keep an eye on our news coverage as way, and as Shawn mentioned, CMS is issuing a lot of tip sheets, FAQs and other tools to make this all hopefully a little easier to understand. Thanks, everybody.
Erika Grotto: When we talk about disaster preparedness in healthcare, the conversation typically goes toward the hospital: making sure patients and staff are safe, preparing for an onslaught of new patients. But with hospital at home programs on the rise as well as the prevalence of patients managing chronic conditions, continuity of care in times of disaster becomes even more crucial for patients outside the hospital walls. Since September is National Preparedness Month, I invited two people from Audacious Inquiry, a PointClickCare company, to discuss their best practices. Here’s my interview with engagement manager Ali Hochreiter and senior director Lauren Knieser.
How can healthcare organizations engage in disaster preparedness to ensure continuity of care for those patients who aren’t under their roof?
Lauren Knieser: Great, Erika, I can start, and then I’ll have Ali kick in after that. The first thing that comes to mind for me is that disaster preparedness is really all hands on deck. And the term healthcare organizations should encompass everyone across the spectrum of care. It’s not just hospitals and long-term care facilities, which we tend to hear about the most. And it’s funny, in my career, I’ve been doing this for about 15 years. When I say I work in disaster medicine, people usually think that, you know, it’s all trauma care and tourniquets and duct tape. But in reality, in most disasters, you’re right, the greatest need for medical care is continuity of chronic care. And so addressing the healthcare needs for people who are not currently inpatients of a hospital is super important. There’s a few things that healthcare organizations can do. First and foremost, you do want to plan for a surge into the hospital, and you need a way to triage who really needs to be in a high acuity setting like that versus who can be treated elsewhere. And when you do that, you should make sure that those lower acuity settings are part of the planning process and they’re equipped to handle an influx of patients who have chronic care needs. One way to do that is to work with pharmacies to ensure that they are able to stay open and that they do advance outreach to patients before disaster comes if there’s a warning, like for a hurricane. And remind them to refill their medications. It’s a really simple thing but can make a very big impact after disasters. And actually, over the last couple of years, we’ve seen lots of the larger pharmacy chains doing this and doing proactive outreach to their patients, which is amazing. And I also think we need to recognize that it’s not always medical needs that people need after disasters. They may be displaced from their home. Their home may have been damaged. Roads can be damaged or washed out. And they might just need simple, basic needs like water and food and other resources. And so healthcare organizations and community partners can help to bring those basic needs to their patients using things like the 211 program through United Way and other organizations that can provide wraparound services that are not specifically clinical care.
Ali Hochreiter: I’ll jump in now if you don’t mind, Lauren.
Hochreiter: Want to touch on how healthcare organizations can connect with their local and state response authorities to be included in jurisdictional emergency management plans. So there is a national response infrastructure, and depending on the size of the organization, they may or may not be aware that their town and city and state and county have existing emergency management structures, and it’s really important for them to be aware of that and to make those connections ahead of time. So for example, healthcare falls under emergency support function number 8, which is a common language used in emergency management, emergency support functions. This is usually at the national level, Health & Human Services leads this. At the local level, it could be Department of Health. It could be Health & Human Services at a state level. So it’s important to know where your healthcare organization falls in terms of that emergency support function and the people that are going to be doing that emergency work when something occurs. Additionally, hospitals aren’t always the first place people go to seek help, so there could be community centers or schools, community hubs that are natural gathering places. After Hurricane Harvey, we saw that schools in many Texas communities were the places that people went because it was the place that they knew, it was where their friends went, it was where their family friends and those connections already were. The gymnasium became sort of a de facto community center for sharing resources and helping people recover. So the more that you can be connected into these local organizations and sort of the local infrastructure that exists already, the faster recovery can happen after the fact. There’s a saying in emergency management, too: Disasters are always local, which means that the people affected are always going to work together to try to solve a problem as a community first. You know, you never hear people say, well, our community’s not really resilient. You always hear people saying, “We are gonna work together and we’re gonna recover. We’re really good at this. We’re gonna come out stronger.” So being plugged in at that local level through those relationships can make a tremendous difference in the aftermath of a disaster. And finally, as a technology company, I suppose we should say you should use technology. There are many, many ways, an increasing number of ways that you can use technology to assist patients: Using mobile platforms, telehealth services. It’s been really cool over the last couple of years to see how that has expanded. And you can advocate for your shelters to be equipped with tools that ensure that people with less urgent needs or lower acuity patients get the care that they need and can stay out of the hospitals.
Grotto: How can healthcare organizations be planning for and looking out for their staff during these times?
Hochreiter: It’s a really good question, and I think especially with Covid, we saw a lot of healthcare organizations really contemplate this because it wasn’t as simple as getting someone to show up for work. It was putting people at a certain amount of risk and then sending them back to their families. So there were a lot of innovations around housing staff members or running them for a certain number of days in a row and allowing them to stay on site so that they weren’t going back home to their families, making adjustments to schedules. I mean, Covid was unprecedented in our lifetimes, so there were a lot of things that were done on the fly, and I think the biggest piece of advice we would have is, start thinking about that now. You don’t want to be making those plans during the emergency. So what are the things that your facility is most at risk for? What are the things that your area is most likely to experience? Is it hurricanes, is it tornadoes, is it likely to be a notice or a no-notice event? And then what are the resources that you can offer your staff? Can you provide hotel rooms? Do you have housing on site? Is there transportation that you need to arrange for or vendors that you need to have agreements with now so that if something happened and you need staff to stay for longer or you need the ability to transport them from place to place or you need to feed 100 extra people every night, how are those plans going to get into place? What are the agreements you need? Are there memorandums of understanding that you can have in place? Are there vendor agreements? All those questions. And then in terms of communicating them, it can be challenging, I think. And setting the expectation for staff members to go above and beyond in an emergency is always a bit of a challenge. And people should account for a certain amount of attrition in those cases because you can’t expect someone to give up caring for their family and show up to work if their home is also being washed away or they have also lost electricity and they have someone who’s ill at home or who needs extra care at home. So what shift changes can we make? What emergency arrangements do you need to make in the case that you only have 40% of your staff available at any time or for a week at a time? And then, it’s great timing that you bring up how to communicate it, so September is National Preparedness Month, so there will be a lot of messaging around this. And one of the best ways that you can ensure that staff are available is by making sure that they also have their own individual and family preparedness plans. There’s a ton of great information out there from FEMA, from the American Red Cross. And lots of information around building your own independent emergency plan, making sure you have the right supplies on hand, making sure that you have gas in your tank, that you’ve got cash on hand in case all the electricity is down and you don’t have ATMs. All sorts of things like that that each individual should consider on their own and make a plan that’s appropriate for them and their family.
Knieser: And if I can piggyback, just a couple of things. Ali covered super well, but two things she didn’t mention when you’re thinking about protecting your employees and their family that are really important is child care, and so a lot of times after disasters, schools and daycares are closed. And so your staff may be capable of coming to work, but there’s nobody to watch their kids. And so thinking about that in advance. And then also medical countermeasures and personal protective equipment. And I think we saw this at the very beginning of the COVID-19 pandemic where people just didn’t feel safe being exposed to a public health emergency, and they also were terrified of bringing something home to their family. And so the more that, you know, organizations can plan to make sure that their employees have vaccines and other medical countermeasures as well as the appropriate personal protective equipment to feel safe and feel like they’re not bringing something home, the better off it will be.
Grotto: Let’s talk about patients for a moment. How should healthcare organizations be communicating with their patients in anticipation of events like this and during without overwhelming them?
Knieser: It’s hard to answer in a concise way, because there are entire disciplines just around risk communication, and so it’s a really good idea for healthcare leaders to just become familiar with some of the basic principles of risk communication, things like communicate early and often, be consistent with your messaging but also be honest and transparent, and I think that’s a balance that can be really difficult to strike because as we know, public health emergencies and disasters, they evolve really quickly and sometimes what you know today could be different that what you know tomorrow. And so it’s hard to be consistent when information is changing. But that being said, it’s OK to say that you don’t know yet when your facility is going to open back up or when the power is going to come back on. And I think it’s equally important to just keep reassuring people that you’re working as hard as you can to bring your services back and make sure that your patients and your staff are safe and that you’re going to keep giving regular updates. The critical thing then is make sure you actually show up and give those updates like you say that you’re going to. I think another thing during a disaster that you really want to consider is how do your patients and your staff prefer to receive information? You might need to consider different ways of getting in touch with people. Some might prefer phone calls and voice mails, and others might only look at email. We know social media is a really important tool these days, as is TV and radio. But in some places, you might need to distribute flyers at grocery stores and community centers, and it’s important to remember that not everybody is going to look for information in the same place. Likewise, not everyone will receive your information unless they think it’s coming from a trusted source, and so you also want to think about who is actually the one standing out there giving updates and giving notices. For me, several years ago, I worked for Columbia University doing disaster research, and we did a project, a really interesting project, in New York City, where we attempted to find out where certain segments of the population actually went for trusted news during disasters and public health emergencies. And it was fascinating how different the responses we got were. You know, teenagers in Harlem, for example, only trusted their friends and their family, but they did look at social media. And if it was something that their friends or their family posted on social media, they were likely to trust it. Completely differently, a Spanish-speaking neighborhood in Brooklyn looked to a local TV network that they got for a lot of their day-to-day messaging. Still others said I would look to federal and state entities and authorities like the CDC and the Department of Health and Mental Hygiene. And the diversity of responses just went on and on. So for healthcare leaders who are looking to communicate with their patients during a disaster, they might need to consider both different forms of communication and enlist the help of trusted messengers within a community.
Grotto: I hope that people listening who maybe have not paid as much attention to their disaster plans as they should have or maybe haven’t updated it in awhile or maybe just haven’t even looked at it in awhile will take care to do that soon. Lauren and Ali, thank you both for joining me today.
Hochreiter: Thank you.
Knieser: Thanks so much, Erika, for having us.
Grotto: Voices in Healthcare Finance is a production of the Healthcare Financial Management Association and written and hosted by me, Erika Grotto. Sound editing is by Linda Chandler. Brad Dennison is the director of content strategy. Our president and CEO is Joe Fifer, who will be on the podcast next week—that’s right, we have an episode coming out in one week—talking about palliative care. If you like what you’re hearing, please subscribe to our podcast and leave us a rating or review in your favorite podcast app. And if you want to talk with us, you can email our team at [email protected].
As National Preparedness Month approaches, healthcare organizations, their leaders and staff should turn their attention to updating their professional and personal preparedness plans, according to two recent guests on the “Voices in Healthcare Finance” podcast.
Patients outside hospital walls
Although it’s crucial to plan for what happens inside a hospital during times of disaster, caring for patients who are not in the building is just as important, according to Lauren Knieser, a senior director at Audacious Inquiry, a PointClickCare company.
“The greatest need for medical care is continuity of chronic care,” she said. A good first step is planning where to place patients with chronic conditions in lower acuity settings, so the hospital isn’t overwhelmed when patients with disaster-related injuries or illness arrive.
Outreach before a disaster can be helpful as well, she said. If a hurricane is approaching, for example, reminding patients to refill their medications can be helpful.
“It’s a really simple thing but can make a very big impact after disasters,” she said. “Over the last couple of years, we’ve seen lots of the larger pharmacy chains doing proactive outreach to their patients, which is amazing.”
Ali Hochreiter, an engagement manager with Audacious Inquiry, a PointClickCare company, said it also can be helpful to connect with local and state response authorities.
“Hospitals aren’t always the first place people go to seek help, so there could be community centers or schools, community hubs that are natural gathering places,” she said. “The more you can be connected into these local organizations and the infrastructure that exists already, the faster recovery can happen.”
Looking out for staff
Healthcare organizations also should consider ahead of time how to take care of staff during emergencies, Hochreiter said. The first step is assessing what types of disasters are most likely to occur based on whether they are events that have notice — like hurricanes — or no notice — like tornadoes. It might be necessary to provide housing on site if roads aren’t passable or safety of staff or their families is a concern, as it was in the early days of the pandemic, she said. But it is important to understand that staff will prioritize their families.
“Setting the expectation for staff members to go above and beyond in an emergency is always a bit of a challenge,” she said. “People should account for a certain amount of attrition in those cases because you can’t expect someone to give up caring for their family and showing up to work if their home is also being washed away, or they have also lost electricity, and they have someone who’s ill at home or needs extra care at home.”
Communicating with patients
Effective communication around disasters can make a big difference, Knieser said.
“Be consistent with your messaging, but also be honest and transparent,” she said. “I think that’s a balance that can be really difficult to strike because as we know, public health emergencies and disasters evolve really quickly. What you know today could be different than what you know tomorrow.”
It’s fine to say when you don’t know something, but it’s equally important to provide updates as more information becomes available, she said.
It’s also important to ensure that patients are receiving messages from trusted sources, she said. That could mean reaching out via text versus phone calls or email, but it also means considering who the spokesperson is during a disaster and whether information is distributed on social media, television or other sources. It could be necessary to take different approaches for different communities, she said.
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