[Editor’s Note: this
blog was originally written by Ken Perez, vice president of healthcare policy,
With the U.S. presidential election campaign season in full
swing and a number of polarizing candidates apparently gaining traction among
sizable portions of the electorate, the longstanding issue of media bias has
arisen once again. One need only watch the two leading cable news networks to
wonder if they are covering developments on two different planets!
Media bias certainly exists in the political realm, but is
it also at play in the coverage of the financial and clinical performance of
the U.S. healthcare system?
In the March 4, 2013 issue of Time, Steven Brill, founder of
Court TV and the American Lawyer, delivered a withering critique of America’s
healthcare system in an article entitled, “Bitter Pill: How outrageous pricing
and egregious profits are destroying our healthcare.” It was the cover article
of the issue, and with more than 42,000 words, it was the longest in the
history of the magazine. Brill reported, “In the U.S. people spend almost 20%
of the gross domestic product on healthcare, compared with about half that in
most developed countries. Yet in every measurable way, the results our healthcare
system produces are no better and often worse than the outcomes in those
countries.” In a subsequent article in the Jan. 19, 2015 issue of Time, Brill
went on to describe the U.S. as having “a broken-down jalopy of a healthcare
Brill’s “Bitter Pill” article garnered generous, positive
coverage by CBS, the Commonwealth Club, the Huffington Post, the Los Angeles
Times, National Public Radio, the New Yorker, the New York Times, and even Jon
Stewart’s “The Daily Show.”
But how do the mainstream media cover good news about the
U.S. healthcare system?
There is a recent case that answers that question. The July
28, 2015 issue of the Journal of the American Medical Association (JAMA)
included an article, “Mortality, Hospitalizations, and Expenditures for the
Medicare Population Aged 65 Years or Older, 1999-2013,” that shared the
findings of a study of over 68 million Medicare fee-for-service and Medicare
Advantage beneficiaries by a team of well-respected medical researchers from
Yale and Harvard.
This lengthy, detailed, heavily footnoted and carefully
written article reported the following encouraging findings:
All-cause mortality for all Medicare beneficiaries
decreased from 5.30% in 1999 to 4.45% in 2013
The total number of hospitalizations per 100,000
person-years declined from 35,274 to 26,930 (for fee-for-service beneficiaries)
Mean inflation-adjusted inpatient expenditures
dropped from $3,290 to $2,801
In other words, for the vast majority of American seniors,
from 1999 to 2013, the healthcare system saved more lives and did so with fewer
hospitalizations and at lower cost — not too shabby for a broken-down jalopy.
The researchers wisely offered a wide variety of possible
reasons for these impressive gains, including healthier behaviors (e.g.,
increases in rates of exercise and decreases in rates of smoking), shifting
lifetime exposures (e.g., younger seniors have benefited more from improvements
in public health), technological advances (e.g., improved therapies) and other
factors. The authors mentioned at the outset national efforts to improve the
care of all patients across the study period, citing federal initiatives to
improve the quality of healthcare dating from the early 1990s. Like an ocean
liner, because of its size and staggering complexity, the U.S. healthcare
system requires considerable time for it to change course.
The study’s results do lend support to the belief that the
U.S. healthcare system can indeed “bend the cost curve,” even under the
frequently criticized fee-for-service model. Interestingly, it should be noted
that the biggest drop in the rate of hospitalizations (9%) during the period
studied occurred in 2013, the first year of the Hospital Readmissions Reduction
Program, which penalizes hospitals for excessive readmissions within 30 days
Of course, these gains achieved under the fee-for-service
system do not mean that the quality improvement and cost reduction initiatives
in Medicare Advantage and Medicare’s accountable care organization programs,
respectively, are unneeded — we can and must do better clinically and
So what kind of media coverage has this study with
encouraging news received? The last time I checked, while a number of the more
serious healthcare industry publications had covered the JAMA article, not a
single one of the mainstream media that covered Brill’s article had done so.
So what are we to conclude? Evidently, in the eyes of many
mainstream media editors, the improved performance of the nation’s healthcare
system doesn’t constitute much of a story and thus doesn’t merit coverage. Such
unfair and unbalanced treatment is the bitter pill that good news about the
U.S. healthcare system must swallow.
[Editor’s note: this
blog was originally written by Alan Portela, CEO, AirStrip]
I was very pleased to see that U.S. Senator Lamar Alexander
is recommending the delay for Stage 31 of Meaningful Use,
since it would drive the entire system to its knees. We all agree that the
industry needed to change. This has been a bi-partisan initiative that started
with President Bush and his appointment of David Brailer as the National Health
Information Technology Coordinator back in 2004. For the past decade, this
effort has been continued by the Meaningful Use program under the ONC.
I am not criticizing the initial goals of Meaningful Use
(Stage 1 – Data Aggregation & Data Access; Stage 2 – Healthcare Information
Exchange and Care Coordination; and Stage 3 – Outcomes Improvement). Rather, my
extreme disappointment is directed to the fact that we did not pay attention to
the first pillar – Data Aggregation and Data Access – to achieve outcomes
improvement, which cannot be accomplished without clear and aggressive
guidelines on interoperability requirements. Instead, the effort was directed
to the implementation of EHRs for data entry, which created silos around few
vendors. Of course, the consolidation and collaboration of healthcare providers
that resulted from the Affordable Care Act (ACA) exposed the failures of Stages
1 and 2 around interoperability.
If the right level of interoperability is not established
early in the program, then the healthcare system cannot easily migrate to Stage
2 – Healthcare Information Exchange and Care Coordination. Why? Because the
only data available is now centered around very limited interoperability
standards of C-CDA & HL-7 and to the Fast Healthcare Interoperability
Resources (FHIR) – which, due to its many shortcomings, should really be called
SHIR for Slow Healthcare Interoperability Resources.
Rather than immediately addressing the issue of limited
access to clinically relevant data, the ONC came up with a 10-year road
map2 that brings the industry to where it needs to be toward
the end. To top it off, the push to Stage 3 – Outcomes Improvement – would
force a value-based reimbursement model without giving caregivers access to
clinically relevant data to make informed decisions – again exposing the
limited success of Stage 1.
It seems as if developments are now moving at “Washington
Speed” – driven by political elections and not by the original mission and
vision of the Meaningful Use program. It is time for the government to start
listening to the providers and patients, not the vendors. This could be a
win/win situation – providers and patients know what is good for the industry,
and can help get the politicians the votes they need.
[Editor's note: the following blog post was written by Rita Bowen, MA, RHIA, CHPS, SSGB, senior vice president of HIM and privacy officer.]
AHIMA's Information Governance Principles for Healthcare (IGPHC) provides a comprehensive framework for managing and governing trusted information. The eight principles form the foundation for a maturity model to help organizations determine how to proceed with an effective IG program.
This article is the first in a series that will discuss key steps to achieve each principle-starting with accountability.
Viewing Accountability as a Valued Strategic Asset
Accountability in IG means responsibility for establishing stewardship of trusted information. According to AHIMA's principles, an accountable senior leader should be formally designated as responsible for overall IG program development and implementation. The senior leader is accountable for ensuring the IG program is aligned with organizational goals and strategies, and for securing appropriate resources to support the program.
Healthcare executives must understand their responsibility as stewards of information that enables organizational strategies and priorities-quality of care, cost reduction, compliance, improved patient outcomes, risk mitigation, accurate reimbursement. Accountability is central to the business value of IG as a strategic asset-how it helps the organization achieve its goals and strategies.
To realize the full benefits of information governance, AHIMA recommends:
- An accountability framework and decision rights to ensure the effective use of information, enterprise-wide
- The essential standards, rules and guidelines for functioning in an increasingly electronic environment
- The defined processes, skills and tools to manage information throughout its entire lifecycle, as a critical business asset
Achieving Accountability through Collaboration
AHIMA advocates a collaborative, interdisciplinary approach with input from all stakeholders, business process owners and domain experts. Senior leaders can benefit from collaboration with health information management (HIM) directors to assess current policies and procedures, identify gaps and deficiencies, and set priorities.
Through collaborative leadership, achieving accountability encompasses the following IG directives:
- Establish an IG structure for program development and implementation.
- Document and approve policies and procedures to guide its implementation.
- Remediate identified issues.
- Enable auditing as a means of demonstrating the organization is meeting its obligations to both internal and external parties.
Accountability depends on clearly defined roles and responsibilities for developing policies, implementing technology, and improving practices that build trust in information. Here are eight steps to help achieve enterprise-wide accountability:
1. Align strategic planning with IG requirements. Create a multidisciplinary team to guide strategic planning-setting priorities and goals. Make sure all players are represented and know the ultimate goal. Without a strategic plan, achieving goals aligned with IG principles will be difficult.
2. Identify regulatory and legal requirements and get buy-in. Many stewards must come together to achieve organizational goals. The healthcare environment typically has pockets of stewardship in various departments that manage source systems. Consistent governance is critical.
3. Establish relevant standards across systems. Transferring information from one system to another requires standards that support accurate communication across systems. Make sure source documentation definitions are consistent.
4. Create and implement organizational policies and procedures. Once standards are set, develop and document enterprise-wide policies and procedures to support your decisions. Best practices include consistency around data and collection, use, retention and destruction processes-throughout the information cycle.
5. Provide multidisciplinary training and education. Secure buy-in regarding all standards, polices and procedures. Changing the way things have always been done can be a challenge. Show benefits for various departments and for the organization as a whole.
6. Define stewardship roles to achieve common goals. Stewards involved with various source systems should assume a stewardship role for the entire enterprise. Define roles and determine who is responsible for achieving goals for all systems-and ensure consistency in the process.
7. Perform compliance monitoring, auditing and reporting. Promote program awareness of best practices. Provide ongoing education to ensure information is properly protected, accessed, stored, retained, released and dispositioned. Report audits to appropriate governing bodies.
8. Invest in IT resources that meet enterprise-wide goals. IT must support established standards, policies and procedures aimed at achieving the organization's accountability goals. A collaborative, centralized approach to IT decisions will serve the needs of all departments.
AHIMA's principles also emphasize the importance of helping the workforce understand how to implement IG practices. Program policies and procedures must be clearly documented, approved and communicated through ongoing training that reinforces compliance with standardized practices.
Assuring Trust in Information
Trust in information is the essence of IG. Accountability builds the trustworthiness required to ensure records are properly governed for auditing and program improvement to support enterprise-wide goals. The future of every healthcare organization depends on it.
Additional IG resources including AHIMA's benchmarking whitepaper, principles document, first IG infographic and more are available at http://www.ahima.org/infogov.
Rita Bowen is senior vice president of HIM and privacy officer at HealthPort. She can be reached at firstname.lastname@example.org.
[Editor's note: the following post was written by Dan Malloy PhD, executive vice president, Quantia, Inc.]
ACOs have long understood that patient engagement is a critical element to keeping individuals healthy and the chronically ill stable. Now ACOs are beginning to appreciate the importance of physician engagement and alignment around the cost and quality measures that have emerged as the performance threshold for their organizational health. After all, the criteria driving these metrics often lie in the hands of the physicians associated with the organizations.
However, many ACOs struggle to know for sure that their physicians are aligned in ways that will achieve such metrics. When they're not, it's crucial to understand why. By offering physicians access to web-based, expert-led content on topics that drive these metrics, ACOs and other health systems are helping avoid potential financial penalties associated with these measures, not to mention improve patients' quality of life.
ACOs that fail to reach the quality metric in the area of depression screening may face reduced reimbursement. Yet a recent poll of over 3,500 physicians who participated in an expert-led QuantiaMD content segment on depression screening performance measures found that the majority (61%) only screen patients who present with symptoms. Just 25% say they screen every patient, and 7% say they don't screen any patients at all.
That healthy percentage of physicians who are only screening patients with symptoms may be putting their patients - and their quality metrics - at risk. As one physician remarked, "Since I've started screening every new patient, I've been astounded at the number of ‘good actors' there are in this world with very high numbers on their PHQ but who I would never have dreamed are depressed by their affect. It's been a very gratifying activity."
As part of this segment, these physicians offered their own reasons for the inconsistency, and opportunities for systems to address these barriers.
Reasons cited for inconsistent depression screening include:
- Lack of time (63%)
- Lack of access to mental health services (14%)
- Uncertainty on how to screen (10%)
Opportunities physicians cited to help increase depression screening include:
- More time with patients (57%)
- Better access to mental health services and better screening tools (40%)
- Staff-assisted onsite care support (27%)
- More education on depression (20%)
While physicians may always feel strapped for time, their call for increased education and exposure to available screening tools is something that can be addressed through web-based content, including expert advice on how to best manage these screenings. Concise, interactive presentations that are convenient for physicians-along with the ability to ask questions directly of these experts-enable providers to address the reported obstacles and help them to better leverage the resources that are available to help achieve these metrics.
Colorectal cancer screening
Another key ACO quality metric for which physicians have significant potential impact is colorectal cancer screening rates. Thousands of physicians engaged in an expert-led interactive presentation on the topic on QuantiaMD to brush up on best practices for increasing compliance rates.
Based on a follow-up survey of nearly 300 physicians who interacted with this segment, they appear to have gained a deeper understanding of their influence on increasing screening rates in their practices, and feel greater confidence in their ability to improve screening rates after interacting with the expert led content. For example:
- 75% of physician respondents say the content influenced how they manage colorectal cancer screening in their practice
- 68% feel they can increase colorectal cancer screening compliance rates in their practice after interacting with this presentation
- The number of physicians who say they've initiated a patient activation system since interacting with this content increased by 65%, and the number of those who have since designed a delivery system within their practice to enhance screenings increased by 36%
While many physicians acknowledge that a lack of patient activation is one of the toughest obstacles to overcome, some physicians suggest that we all have a role in helping reverse the major image problem that the preparation for this test has.
As one physician remarked, "The procedure is not always the hesitancy...word is out there that the prep is vile. That said, there are MUCH better preps now (bisacodyl + miralax as one example), which makes it way more tolerable. One awful prep, folks tell 10 people, and then 10 do not go. Easy prep, IV sedation, easy procedure...we need to get the word out there."
The good news is that based on this survey population, at least, the majority of physicians are leading by example-less than 10% of those doctors who are eligible for colorectal cancer screenings themselves admit non-compliance. The reasons they cite for avoiding the test are the same ones their patients have - fear, laziness, other medical problems taking a higher priority, and even the self-described "lousy excuse" of not wanting to give up two days in the office to get the procedure. Recognizing these universal barriers to optimal preventive health can help physicians approach their patient conversations with greater empathy.
The consequences of inconsistent screenings-in terms of undiagnosed medical conditions and reduced reimbursement-are obvious. Gaining a window into physician's attitudes and behaviors around these metrics helps identify and address these issues.
Do you have the insights and physician buy-in needed to address these and other quality and patient care outcomes? The nation is watching.
[The following blog post was written by Rita Bowen, MA, RHIA, CHPS, SSGB, Sr. VP of HIM and Privacy Officer, HealthPort]
Healthcare must move beyond compliance to a greater model of IG.
For the past three years, the Privacy Point column has focused primarily on privacy and security- issues, challenges, priorities along with strategies to promote compliance and mitigate risk. During that time, the HIPAA Omnibus Rule was piloted and refined in 2013 and 2014, with September 23, 2014 as the final date for all business associate agreements to comply with the current regulations. With procedures in place for that phase of compliance, the focus is now shifting to the value of information governance (IG) in healthcare.
Going Beyond Compliance
Despite decades of privacy and security regulations, many organizations lack proper governance and management practices to address ever-increasing risks and threats. According to the Identity Theft Resource Center, approximately 42 percent of major data breaches reported during 2014 were attributed to healthcare organizations. That's a stunning statistic. And security risks may be on the rise for 2015, especially if the HHS Office for Civil Rights (OCR) follows through with its random audit program to assess compliance with HIPAA privacy, security and breach notification rules.
Traditional privacy and security solutions are not sufficient to address rapidly emerging risks and threats. Data and security breaches and compliance penalties point to inadequate control of information. Establishing proper controls requires effective IG that ensures protection of trusted information. Compliance alone is not enough.
AHIMA's IG principles recommend a proactive, collaborative, interdisciplinary approach. Privacy and security must be viewed from a new perspective-as foundational components of an enterprise-wide information governance model.
Former AHIMA CEO, Linda Kloss, MA, RHIA, FAHIMA and author of Implementing Health Information Governance: Lessons from the Field, states: "Leading organizations understand that governance and management of privacy and security must be in full compliance, but must also build trust and transparency through ethical stewardship practices that may go beyond compliance. . . They also understand that a compliance mindset does not fully serve the interests of the patients they serve. . . Their sound governance of privacy and security considers ethical compliance and fiduciary responsibilities."
As the demand for trusted information increases, leading healthcare organizations are moving from a compliance approach to a broader IG perspective aimed at improved quality of care and organizational performance. Fortunately, AHIMA has taken the lead toward a smarter, strategic maturity model. And HIM professionals are best qualified to educate all stakeholders on the value and responsibility of stewardship-privacy and security, risk management, and overall data integrity-critical components of trust in information.
Advancing IG through Collaborative Leadership
While some organizations have taken steps to initiate an IG program, most are still in the infancy stage of implementing consistent and collaborative IG practices. Whether your organization is just beginning or in the process of refining its program, here are four strategies for advancing IG:
- Assess existing policies, procedures and systems for capturing, processing, delivering and storing data. Set priorities to build a program aligned with your organization's goals.
- Engage an executive sponsor by showing the business value of IG-quality of care, cost reduction, compliance, improved patient outcomes, risk mitigation, accurate reimbursement.
- Create an interdisciplinary team including HIM, IT, compliance, C-suite, revenue cycle, legal and risk management.
- Develop a plan for implementing the AHIMA principles.
HIM professionals already know the value of IG. Their knowledge, skills and experience will advance enterprise-wide information governance through strong collaborative leadership.
Focusing on the Essentials
Once an IG framework is established, organizations should focus more closely on the essential elements of an effective program-privacy and security, quality and integrity, data capture, records management, availability and use of information. While privacy and security concerns continue to occupy center stage, each component is an integral part of a greater IG model.
In the coming months, IG Matters will delve deeper into the various aspects of each component, including the following:
- Clean master patient index (MPI)-Ensuring a high level of MPI integrity must be a top priority for enterprise-wide IG programs. Preventing errors and inconsistencies is critical to patient safety.
- Data dictionary and data map-Both tools are key to understanding the source and meaning of data across systems.
- Best practices to promote data integrity-Quality and integrity management are the foundation for trust in information.
- Interdisciplinary education-Ongoing education regarding privacy and security, risk management, and quality of information builds a culture of IG.
In today's evolving regulatory environment, healthcare providers cannot afford the risks of ineffective management and governance of information. That is why 2015 must be the year of IG in healthcare. And HIM is ready to lead the way.
Welcome to the IG Journey
With many thanks to all the dedicated followers of Privacy Point, I now invite you to join the IG journey. Throughout 2015, IG Matters will focus on strategies for building and sustaining a successful program, the essential elements of IG, lessons learned from case study organizations, and more. Your ideas for future topics are most welcome.
Rita Bowen is senior vice president of HIM and privacy officer at HealthPort. She can be reached at email@example.com.
[Editor's note: the following blog post was written by Jeff Margolis, chair and CEO, Welltok]
Data, data, everywhere...the practical dilemma is that even as the increasing threat of data security challenges is hitting the front page, healthcare industry leaders and pundits are in nearly universal agreement that far more - not less - consumer interaction and engagement with meaningful healthcare data is necessary to drive significant improvements in healthcare value. It's perhaps analogous to the notion of a person needing water to drink, but the water around them is either saltwater or it potentially contains harmful bacteria or parasites. Frustrating to say the least!
While all of the facts around the Anthem breach aren't known yet, other health plans and providers are - as any rational person might expect - expressing heightened concern and examining their own vigilance. It's difficult to feel "safe" when you contemplate the awe-inspiring scope and alleged consumer-harming intent of the breach. Although healthcare industry organizations endeavor to follow best practices, even the most prepared organizations can be subject to the challenge of a data breach. And beyond the challenges of Anthem and its members, digital innovations across the industry that can generally benefit consumers will almost certainly face potential delays.
Allow me to put the healthcare industry data security dilemma into practical terms. First, understand that the HIPAA and HITECH Acts establish minimum requirements for compliance with the Security and Privacy Rules, with the intent of these regulations being to define a common baseline across the healthcare industry. Second, understand that these regulations do not set forth best operational practices for assuring the protection of consumer data, nor do they impart a step-by-step security and privacy framework that establishes best practices for the dizzying array of computers and devices that consumers use today to interact with their health plans, doctors, hospitals and pharmacies.
To be sure, there are excellent and capable people, consultants and security-centric companies to drive and share best practices. However, I feel legacy technologies and existing platforms in healthcare will struggle to apply new security advancements at a sufficient rate to mitigate efforts by the "bad people" who plague multiple industries today.
Today's healthcare consumer-interactive platforms need to be built on the fundamental principle of anonymity with security and privacy engineered into the core design, unlike those based solely on HIPAA. This includes applying the HITRUST CSF security framework and data segregation of PHI/PII from consumer facing capabilities. We began the development of our CaféWell Health Optimization PlatformTM from the perspective that there needs to be a better way to deliver both an engaging, personalized user experience and a safe, secure environment that also mitigates risk.
As my intent is not to be overly technical, I'll conclude with this thought. Figuring out how to help consumers benefit from more data about themselves without increasing the risk of exposing their identity is not easy...but it is possible!
[Editor's note: the following blog post was written by Dr. van Terheyden, CMIO at Nuance Communications.]
Regardless of which side of the exam table you sit, we're all healthcare consumers. Technology holds the potential to create clinical synergy between patients and caregivers, providing better intelligence about personal health data and outlining proactive measures to take to become better partners in health care.
There is no known medical condition that enables an individual to predict the future. While such an ability would be extremely useful for myriad reasons, we have, instead, learned to hone and leverage our analytic skills to deduce what might occur, relying on the data we cull and parse to help forecast the future. So, when it comes to predicting the year ahead, we should consider the one we just had.
Regardless of which side of the exam table you sit, we're all healthcare consumers
Consumer technology is often a good indicator of what type of capabilities and functionalities might be in store for health IT. This past year, we saw major players in the tech space announce their forays into healthcare. While this will not be without its challenges, it does not diminish the underlying fact that there is a need and want for better technology in healthcare- regardless of whether you are a patient looking to effectively manage your weight or a physician struggling to juggle patient care and administrative duties.
In the last year, we saw a wave of next-generation wearable devices flood the market, and as a result, we, as patient consumers, now have streamlined access to information such as our daily step count and average heart-rate on our watches. We know that ease-of-use, understandability, and some level of gameification ("Congratulations! You've reached your target heart rate today!") are vital to maintaining engagement.
I believe this is the beginning of something much larger, a groundswell movement that will result in patients wanting more information about their health data, and, more importantly, craving a better understanding of what all these numbers actually mean and how to positively impact them. Achieving this level of engagement demands a simpler intelligent interface that doesn't require a learning curve, but is one that consumers can just use. Clever user interface designs can only go so far, particularly given the small visual real estate available on wearable devices, and the addition of capabilities such as intelligent voice assistants will be an integral part of this explosion of personal health management.
Having a heart-to-heart about your heart
Technology holds the potential to create clinical synergy, bringing patient consumers (who have become professional health IT consumers, or health prosumers) better intelligence about their personal health data and outlining the proactive measures they can take to become better partners in their own health. The average patient consumer may not have a reaction to the phrase "Your Protime this week is 3.3," but for someone with a heart condition, this number is very important and indicates how fast her blood is clotting. The data, while extremely useful to a clinician, is only helpful to the patient if she understands what it means and how she can take the right actions as a result.
The future is about patients managing their own care and working alongside clinicians to drive better outcomes. To the woman who has a Protime of 3.3, access to these results supplemented with clinical guidelines would mean that she wouldn't need to wait for her physician to call with diet recommendations, she would know her blood is clotting too slowly and that she might have an inadequate protein consumption or might need to increase her vitamin K intake. If the number required that her Coumadin dosage be adjusted, this would be the point where her physician would reach out to her to discuss.
Although a basic example, it is one that has endless permutations when it comes to building a more engaged patient population. There is no one more invested in your health than you, and the person who cares the next most about keeping you well, is your physician. I believe that clinical synergy will be driven by both patients, who want to actively manage their chronic conditions and take meaningful preventative care measures, and physicians who want to empower their patients to better understand how the choices they make have significant health implications. Technology is the connective fiber that can enable the transmission of this important data, and help translate it into wisdom. And that truly is the crux-the data flowing between patient and physician must be relevant and meaningful. That ability for technology to determine the relevancy of health data information is just around the corner and soon our wearables will be able to notify our health information data that deviates from our personal "normal" results.
Approximately 75 percent of U.S. healthcare expenditure is related to chronic care management, imagine the impact this level of clinical synergy will have on driving a healthier population while reducing cost. I'm ready, are you?
[Editor's note: the following blog post was written by Bonnie Cassidy, senior director of health information management (HIM) innovation for Nuance.]
Much has been said about the politics and jockeying of groups behind the scenes, lobbying either for or against ICD-10. That's not going to change. Healthcare providers must be proactive and plan for ICD-10 compliance, while also being agile enough in their planning to realize that another course correction may lie ahead.
In its latest news, CMS announced that Oct. 1, 2015 is the ‘new' final ICD-10 compliance date. "ICD-10 codes will provide better support for patient care, and improve disease management, quality measurement and analytics," argues CMS in its July 31 announcement. I could not agree more!
My advice is stay positive, nimble and be wise by reading between the lines. Much has been said about the politics and jockeying of groups behind the scenes, lobbying either for or against ICD-10. That's not going to change. Our current administration in Washington, DC has been riddled with constant criticism and commentary scandals and may view the transition to ICD-10 as risky. All healthcare providers must be proactive and plan for ICD-10 compliance, while also being agile enough in their planning to realize that another course correction may lie ahead.
What steps do you do now to ramp up readiness efforts?
- Stay the course! You have an ICD-10 transition plan at hand; move forward with it. Update your ICD-10 project plans with dates and deliverables, built for an October 1, 2015 compliance date.
- Be nimble. Don't ever find yourself thinking ‘black and white.' We must expect the unexpected. If the government changes the deadline again, you adjust and do a course correction, but you don't stop and never blow up your plan.
- Focus on improving clinical documentation integrity throughout the patient stay. Be the champion for clinical documentation improvement (CDI) and focus on getting the right information into the right medical record at the right time because this will have a positive impact on quality, reimbursement, and coding regardless of shifting dates.
- Leverage technology to enhance your clinical documentation and coding workflow. Many providers use many manual processes, for instance,, Spreadsheets and sticky notes, for clarifications and queries in medical records and emails to physicians. Take this opportunity to assess your workflow and plan for technology-enabled solutions for assisting your medical staff and clinical documentation specialists with your CDI program and coding/compliance.
- Now you have 14 months to develop a customized dual coding program plan for your organization.
- Know your own data! Identify your high impact surgical procedures in various clinical specialties and train your coders the nuances of coding in ICD-10-PCS.
Stay positive, plan for success and always be willing to course correct should there be a shift in the ICD-10 compliance date.
Bonnie Cassidy is the senior director of health information management (HIM) innovation for Nuance, where she oversees the development and implementation of HIM strategies. She currently serves on the Commission on Accreditation for Health Informatics and Information Management (CAHIIM) Board of Directors, is a Fellow of AHIMA, an AHIMA Academy ICD-10-CM/PCS Certificate Holder and ICD-10 Ambassador, and a Fellow of HIMSS. Prior to joining Nuance, Bonnie served as the vice president of HIM product management & innovation at QuadraMed, and served as an executive with the Certification Commission for Healthcare Information Technology (CCHIT), Ernst & Young and the Cleveland Clinic Foundation. She was the 2011 President/Chair of AHIMA.
[Editor's note: the following blog post was written by Toby Samo, M.D., chief medical officer, Allscripts. This is the first installment in our 5-part series focusing on Global Healthcare Megatrends]
There are more than 7 billion people on the planet today. Our growing global population has triggered some of the biggest healthcare challenges we'll ever face. Listening to clients in Australia, Canada, Singapore, United Kingdom and United States, I believe many of these issues are universal. This post is one of a five-part series that explores the clinical, population health, financial, regulatory and technical challenges we share as a global healthcare community.
Caring for more patients than ever before
Worldwide healthcare providers are seeing more patients than ever before. In part, because we're living longer. In developed nations, there has been a huge increase in life expectancy over the last 50 years, and experts believe the trend will continue.
For example, U.S. citizens had a life expectancy of 68.2 years in 1950, which jumped to 76.6 years in 2000, and is expected to reach 83.9 years by 2050. Not only does that mean caregivers have more patients overall, but these patients are aging and require more health care.
Other cultural and economic factors contribute to an increasing number of patients. As middle classes expand in some nations, they seek more health care, more often. Countries that adopt universal health care models will also increase the patient population.
This growing number of patients heightens another global challenge: a shortage of primary care providers.
Providing the right caregiver at the right time
With more patients, the healthcare industry needs more caregivers. Several countries are employing "physician extender" positions to handle and coordinate routine care. These staff additions free the physician to provide expert care. Physicians can then practice at the top of their licensure, which is a better use of resources.
It also helps with clinician satisfaction as they are focusing their time on the patients that need their help the most. However, in some cultures this approach is more of a challenge, as patients may insist on seeing only the physician.
There is also an increasing types of sites of care. No longer will a patient only be seen in the physician's office. They may also receive care in pharmacies, schools, offices and grocery stores.
We must remember that quality clinical care is not just that patients can see any caregiver. It's that people receive the right level of care, no matter where they are.
Driving towards a single patient record
Most countries we work in are all large enough that choosing a single electronic medical record (EMR)* to facilitate data sharing is simply not an option. So everyone in the world is looking for ways to connect a virtual single patient record.
Even as EMRs gain traction in developed countries, we still struggle to communicate between organizations. Patient data does not easily flow among caregivers. New technologies are now appearing in the realm of Healthcare Information Technology to standardize and connect various systems. This technology will be at the hub of future healthcare delivery facilitating the movement of information between the many stakeholders of healthcare at the point of care.
Many cultural factors affect healthcare communications worldwide, including language. There are more than 6,900 languages spoken on this planet. Roughly 5% of the world's population speaks English as a first language, which takes third place to Mandarin and Spanish. This variety affects the single patient record on a most basic level: How do we manage patient data in different languages?
Measuring to ensure best practices
Many countries have identified important clinical measures. For example, it might be simple rates of immunization among children and influenza vaccine among adults. Or it could be more complicated measures of chronic diseases, such as regular Hba1c evaluations for diabetic patients.
Some countries are ahead in this process. Most developed countries have reporting requirements aims at improving quality of care. These is a movement towards setting up parameters that result in rewards, similar to Meaningful Use in the United States. Because it's not just about "checking the box" by ordering a certain test - it's about improving outcomes.
As we look at all of these clinical requirements, it's clear that proper use of EMRs can make a difference. There is still a lot of work to be done, and specific challenges to address in each region. But I'm encouraged by the progress I see globally.
Do these clinical challenges resonate in your part of the world? What other aspects would you add?
* Electronic Patient Record (EPR) is another term for Electronic Medical Record (EMR) or Electronic Health Record (EHR).
Please check back on Executive Insight for the rest of our Global Healthcare Megatrends series. We will highlight Population Health, Regulatory requirements, Technical landscape, and Financial models.
[Editor's note: the following blog post was written by Neil Pithadia, founder and CEO, I Will Change Healthcare]
Moe, the Two-Star Motel Repairman
I arrive at my motel on a road aptly named Motel Circle. As I approach my accommodation in my rental car, a man in a blue shirt that looks of Middle-eastern descent greets me. As he approaches me, I see his name, "Moe" sewn into his shirt I figure likely shortened for Mohamed. His sleeves are rolled up, he is carrying a paint bucket in his left hand and his pants are well worn with paint stains. I quickly deduce that Moe is the motel's repairman. He asks my name and we make small talk. We depart as I park my car and walk to the front office to check in.
"Good afternoon, Mr. Pithadia. I hope your journey from Texas was well." Perplexed, I ask the front desk person how he knew my name and furthermore how did he know I was coming from Texas. "Well, Mr. Pithadia I would like to say I have special powers, but you see Moe let me know that you had arrived and as per Texas, when booking with our agent, she made a note in our system that you were coming from Texas. So would you like to see my next trick?" Astonished, I nodded like a child. "Very good, you see this contraption to my right, I will now press this button and it will produce a document. This document is very important, so please focus." He pulled the document from the laser printer and flipped it so that I could read it, "you see that line [I nodded again], I need you to sign it should you incur any incremental charges." I chuckled as I signed and left the front office.
I booked the motel online two months ago getting a 15% discount. I thoroughly read the reviews online which were positive so I already knew I was getting good value in pricing. I was looking for an adequate no-frills budget motel to sleep for the night. However, the experience with Moe and the front desk was the type of welcoming you expect at a four or five-star hotel, but not the $58-a-night two-star Vagabond motel. Yup, that's right, Vagabond motel. The check-in experience was not expected and I wanted to know why Moe did what he did. I caught up with Moe working on some fencing and asked him if he did this for all customers. He chuckled with a genuine smile. He mentioned that even though this was a budget motel chain, the manager of the motel was a really good guy. "My family went through a rough patch with illness and the manager and owner helped me financially and allowed me to keep my job after being away for an extended time. It is the least I can do for them." In the scheme of things, any capable and competent handy person could do Moe's job. He, however, approached his job from a different angle. Moe was generating value for this motel all because Moe had a sense of purpose. His loyalty to the motel and manager was genuine. In his book, Drive, Daniel Pink points out that employees like Moe outperform once they are given two things: financial security and a sense of purpose.
All afternoon, I thought about Moe's situation. I was not asked nor given a survey to fill out, but instead I had a genuine desire to find a way to rave about what had just happened. I ended up spending two hours writing reviews on various websites. Whether the motel realized it or not, they had just generated "thick value." In his book, The New Capitalist Manifesto, author Umair Haque defines "thick value" as value, which is authentic, not created at someone else's expense, and is meaningful on human terms. According to Haque, organizations in the 21st century need to generate "thick value" to remain viable and that the era of "thin value" where organizations are shifting societal benefits to shareholder benefits is not viable.
Treat the Employee Right in Order to Treat the Patient Right.
If we treat our employees with the same level of care, we get those outcomes we so badly desire. A great example of a large organization that has embedded this mantra is the Ritz-Carlton. This motel group is synonymous with the best customer experience and they are upfront about it; their motto (Fig. 1): "We are ladies and gentleman serving ladies and gentlemen." Every employee carries around a pocket-sized card that describes the motel group's motto.
Be warned, having a flashy motto and forming a policy that all employees carry a card displaying it on their ID badge does not automatically translate into each and every employee indoctrinating the motto. This is where many of us in healthcare fail. We want to be sexy in healthcare: "Patient-first," "Top-tier," "World class," yet this falls short when it comes to translation. Why is that?
Ritz-Carlton knows that in order to translate its motto to a meaningful purpose, they must first empower their employees to do so. Each employee has the ability to spend upwards of a mind-staggering, $2000 a day per guest (1). This level of trust allows this organization to translate and deliver on their motto. What is Ritz-Carlton in essence? It is an experience, where luxury and desire intersect. They have developed a structure capable of providing this and have equipped their employees to deliver this experience. Accountability of delivering this experience lies solely on the employee.
What is healthcare in essence? You may mutter something along the lines of "delivery of quality patient care". Yet, these days we see zoom-creep in Doctors' offices, where we focus too much on an add-on service rather than the essence, itself. Things such as elaborate buildings, "diamond" or "medallion" services and free valet parking do not replace the fundamentals of quality patient care.
Lack of empowerment. How many frontline employees in Providers' offices do you know that are as empowered to take ownership of the patient experience? Most have become robotic "I apologize" machines. "I apologize Mr. Pithadia, the doctor is running late/behind" or one of my favorites, "I apologize Mr. Pithadia for waiting for an hour, but the doctor had to go to the hospital, he's going to have to reschedule your appointment." I have been short-changed many times when it comes to my time vs. their time to which I hear, "I apologize...." Never once has a front-desk employee said, "Mr. Pithadia, the doctor is running 20 minutes late, I'm going to tell him that you are waiting and he will be here in 5 minutes." These individuals are not empowered to make decisions that are best for the patient experience. The sexy motto of "Patient-first," can never translate into fruition because we have neutered our front-line employees.
The Powerless Healthcare Customer.
I knew exactly what type of service I would receive during my stay at the Vagabond motel. I was going to get a two-star motel for $58 a night. I had power as a consumer. By deciding to buy or not buy, consumers have created and decimated businesses-from motels, banking, travel to cellphones, pressure from consumers drive innovation and ultimately shift competition, prices, quality, and value. Yet, here is where healthcare remains unique. Healthcare has little price sensitivity and things such as market forces and consumer pressure do not affect price elasticity, quality or value.
Therefore, healthcare in America represents "thin" value. There are numerous articles getting lots of publicity regarding this. Steven Brill's Time's article, "The Bitter Pill: Why Medical Bills are Killing Us" (2) comes to mind which has stirred much attention. Brill mentions that large healthcare systems are thriving in this market, especially non-profits, terming them "non-profit profitmakers." Yet, it is these profits that are divorced from people being better off. So I ask you, healthcare leaders, what type of value are you creating for your patients?
We can open the discussion of how we got in this mess and how the larger issue is that millions of Americans are insulated from the true cost of healthcare. The point remains, that we are at a critical juncture where the purchasing power of the healthcare customer is becoming more relevant with advances in technology, pressure from government, and increasing transparency into our operations. Just in late April 2014, CMS called for the new P4P (Pay for Performance) measures in its Inpatient Prospective Payment System including requiring hospitals to disclose a standard list price for all medical services they provide. Whether or not this comes to fruition is yet to be determined, nevertheless, the customers are asking, "Where is the value?"
If we stick to the fundamentals of delivering quality patient care while instilling a sense of purpose and empowering our employees to make the best decisions for the patient experience and bring transparency to the consumer, we start to increase perceived benefits of the customer and this generates "thick value." We need a paradigm shift where we change the public's perspective of us. Not as "profit makers," but instead contributors to society, after all this is our distinct advantage.
1. Reiss, Robert. "How Ritz-Carlton stays at the top." http://www.forbes.com/2009/10/30/simon-cooper-ritz-leadership-ceonetwork-hotels.html
2. Brill, Steven. "The Bitter Pill: Why Healthcare Bills are Killing Us." http://www.time.com/time/magazine/article/0,9171,2136864,00.html
Neil Pithadia manages a multidisciplinary surgery group in Dallas, Texas. He is also Founder and CEO of I Will Change Healthcare (www.iwillchangehealthcare.com)
[Editor's note: the following blog post was written by Bonnie Cassidy, senior director of health information management (HIM) innovation, Nuance]
With the ICD-10 transition date now at least 16 months away, we must think about the impact this has on the workforce that was hired or educated with the original date in mind
The American Health Information Management Association (AHIMA) represents 74,000 members who have been preparing for ICD-10 for years. With the transition date now at least 16 months away, we must think about the impact this has on the workforce that was hired or educated with the original date in mind. Across the U.S, ICD-10 transformation teams have been assessing, training and implementing technical changes that were to be in place on October 1, 2014.
"This frustrates me. For the last 4 years of my career I have prepared for this transition, passed the AAPC ICD-10 Proficiency Assessment, and our government once again decides THEY aren't ready. How am I supposed to convince my surgeons that they have to work on this when it keeps getting delayed?" certified coder/auditor
Hospitals and provider offices in the U.S. hired skilled HIM coding professionals to prepare for the transition to ICD-10. Some were consultants, coders, and project managers while others supported revenue cycle and HIT initiatives. What are these organizations going to do now with these highly-skilled members of the workforce? There are concerns that smaller hospitals and health systems may be forced to have layoffs, while others may redirect these resources to Meaningful Use initiatives or stay the course while being champions for ‘No ICD-10 Delay'!
As a past president of AHIMA, I have been meeting daily with HIM colleagues across the country as they rethink their strategies for ICD-10 implementation. The ripple effect of this latest delay has been devastating for some, particularly new graduates. There are still so many refinements that must be addressed for ICD-9 and ICD-10 coding workflow redesign, that HIM resources are critical for the much needed fine tuning of clinical documentation to ensure the highest level of accuracy for both financial and clinical success - not to mention optimizing the use of new technologies tied to the current and future state of the healthcare coding system.
"We are going to find ways to use these employees we hired to do I-10 coding. There seems like there is so much need for documentation, classification and informatics in healthcare we will make sure to find use for these folks in the interim," reports Todd Strumwasser, CEO of Swedish Seattle.
The Impact of the Delay on Resources
- New grads and new hires - They expected their coding skills would be in high demand and now find that some of the anticipated vacant positions have vanished. This delay casts a cloud on the employment prospects of more than 25,000 students who have learned to code exclusively in ICD-10 in HIM associate and baccalaureate educational programs. We must ‘stay the course' and hire these precious resources.
- Physicians and practices - Some fell behind on their ICD-10 implementation and rejoiced at the delay news, but professional practices should use the time to prepare their clinical documentation for improved ICD-9 coding while they implement CDI programs.
- Coding educators - Coding education programs and educators had switched to teaching only ICD-10 codes to students, but now are reevaluating their educational plans and transition timelines, and are putting ICD-9 back into the curriculum and certification exams because new graduates need both ICD-9 and ICD-10 to work. This is a costly effort, as it requires re-training as well as redesigning coursework to appropriately prepare students.
- Tax payers - CMS estimated that another one-year delay of ICD-10 would cost the industry an additional $1 - $6.6 billion on top of the costs already incurred. This does not include the lost opportunity costs of failing to move to a more modern and specific code set, which better supports population health and data analytics to identify optimum clinical treatments on different types of patients. Don't kid yourself. We are all paying for the delay in some way.
The ICD-10 delay has been devastating to some and costly to all. My advice to healthcare executives and clinicians is do not stop your ICD-10 transition planning. Stay the course and use the time for testing and auditing so you will be prepared for success.
[Editor's note: this blog post was written by Michael Murphy, MD, founder of ScribeAmerica]
Medical scribes and medical scribe vendors are riding a new wave of change in the American healthcare system where doctors and hospitals are being consistently called upon to do more with less. But if there's one thing to remember in medicine it's that there's not always a one size fits all solution for every problem.
Medical scribes work hard to master the complexities of various EHR systems to help doctor's focus on medical decision making rather than being highly paid data entry specialists. As scribes continue to become the standard practice in emergency departments from coast to coast some groups are critically evaluating their provider to patient staffing ratios and whom they use to work those provider hours.
But when is it the right time to add medical scribes? No doubt the simplistic mind looks at scribes as a line item, but are they really an added cost or if implemented correctly a net revenue item? Would it be a better investment to hire a nurse practitioner (NP), or physician assistant (PA) who potentially can do more within the organization than just document on EHRs?
That answer historically depends on the needs and size of your organization, but I would argue it depends more on the provider to patient staffing ratios, which really should drive decisions about additional coverage. Most large emergency departments with more than 20,000 annual visits likely have the resources and needs to bring on both scribes and PAs/NPs. What if your hospital is smaller than that? Does it make more sense for you to bring on a PA/NP rather than a medical scribe or vice versa?
Looking at the numbers
For many hospitals PAs and NPs have proven to be an effective means of dealing with the demand for more doctors without having to pay the full salary of a doctor. Nationally, the average salary for a Emergency Medicine doctor is about $250,000 per year, versus $87,000 for nurse practitioners, and $79,634 for physician assistants.
However, for an average of $20-$23 per hour you are able to hire a medical scribe with the ability to customize their hours to fit the needs of your organization. So taking an 18k volume ED where you see on average 2 patients per hour but experiences boluses of up to 5 patients per hour. The department may want a PA/NP for about 6 hours per day to cover those busy hours, however cannot hire someone for 6 hours and are forced to pay for a 10 or 12 hour shift and thus significantly affecting the revenue flow. Replacing the PA/NP with a medical scribe will put a spring back in your provider coil and allow you to see those large volumes of patients that you once could not, without one. At the end of the day, you have a net revenue positive of $200,000 annually while not compromising patient care. In today's Healthcare environment, this is a significant impact on the bottom line.
Medical scribes enable a physician to see and treat more patients. Whereas a PA or NP can help divert patients with smaller problems away from a doctor to allow them to focus on the most serious cases. A study by medical system reviewer Software Advice found that NPs and PAs on average can perform about 80 percent of the same tasks that a doctor can.
When is a right time to add PA/NP? Well let's look at a 60k volume ED with an average provider to patient ratio of 2.08. This site has 56 physician hours and 24 PA/NP coverage daily. Due to decreased reimbursement and a new lower payer mix, the emergency department now requires a subsidy from the hospital to keep its doors open. Instead of taking this subsidy why not consider changes to the staffing model to increase your PA/NP utilization and reduce your physician hours? If you were to go to 36 physician hours and increase your PA/NP coverage to 48 hours you could even add 60 hours of medical scribe coverage and be budget positive roughly $320,000.
The above approach reduces the provider to patient ratios to 1.98 and emphasizes the physician as the quarterback, assisting the PA/NP with most cases.
Consult the budget
With those numbers in mind the next step in your decision-making is to consult the budget. Can you really afford to hire, a PA/NP or a medical scribe, considering that reimbursements cuts are a common theme in government discussions.
If the answer is no, you might consider looking at it in another way. Will your organization in its current form be able to effectively weather the big changes taking place in the American healthcare system over the next year? Between the ICD-10 implementation, the Two-Midnight Rule, and the major provisions of the Affordable Care Act taking effect it's likely you need to be preparing either through hiring additional staff, training existing staff, but more likely, both.
Assess EHR comfort levels
The next step is to assess your physicians' comfort level with EHR's. Many physicians find them challenging and get in the way of patient care. National data on EMR implementation has shown, that physician productivity decreases and persists 6 months after implementation. A medical scribe solution could be the best answer and most cost effective.
Consult your Press Ganey and HCAPS scores
Next you can consult your Press Ganey and HCAPS scores to see where there is room for improvement, regardless of whether your scores are high or low overall. For example if patients are complaining about long wait times to see a doctor, more than their quality of interaction with the doctor then either a scribe or mid-level provider solution will reduce the door to provider times.
Making your decision
The prevalence of both medical scribes and PAs/NPs are the result of the changing landscape of healthcare in America. Your critical analysis should consider the cost benefit of a scribe or PA/NP, take into account how your physicians are incentivized, and the overall provider and patient satisfaction. It's important to be prepared for the big changes ahead, but it's also important to consider other options when increased coverage is demanded.
[Editor's note: this blog post was written by Jackie Griffin, associate vice president of client services at TriZetto Provider Solutions]
It's less than 10 months until the ICD-10 deadline, but many providers are finding it difficult to get started with their ICD-10 planning. Others have started their efforts, but a transition of this magnitude can be overwhelming, and many don't know what the next step should be.
Whether you're stuck in the middle of planning or still trying to get started, here are five steps to help make your ICD-10 plan more manageable:
Identify all the places where your practice uses ICD-9 in current workflow. Some examples of areas where ICD-10 will impact are clinical documentation, EHRs, superbills, paper claims, electronic claims and reporting for government agencies. Wherever ICD-9 is used, there will be an ICD-10 impact, so identifying these areas now will help you plan how to transition them.
Conduct a gap analysis to understand where you need to be by October 1, 2014. The results of the analysis will help identify any gaps within your workflows, documents and technology systems that will make it difficult to transition to ICD-10. You'll need to focus your preparations here to avoid any negative impacts to your practice, such as delays in reimbursement or inefficient use of staff time.
Identify solutions that can help your practice transition in these areas, such as new coding books, new superbills and new paper claim forms. For nearly every practice, these solutions should include updating your existing software to accommodate ICD-10 codes. Your practice management software vendor and your clearinghouse may have already notified you about how they are updating their systems for ICD-10. If you haven't done so, contact your vendors to learn whether you need to install new upgrades for ICD-10.
In addition, you need to think about how you will train your clinical and front office staff for ICD-10. Some industry associations, such as AAPC, offer training boot camps to get your staff up to speed. Other organizations, including CMS
, offer ICD-10 resources on their websites for you to use to help prepare staff.
Outline your ICD-10 plan. Start by listing the solutions you plan to pursue, steps needed to implement them, expected cost for each step and timeline for completion. This will help you budget your time and resources appropriately.
Industry research estimates that transitioning to ICD-10 will cost the average 10 physician practice more than $200,000. In addition to the costs associated with preparation, many practices will experience delayed reimbursements and decreased productivity once ICD-10 takes place. It's recommended that you secure a line of credit at least six months prior to the ICD-10 deadline so you can keep your practice afloat.
Implement your ICD-10 plan. This will include training your staff, learning how to use new versions of your EHRs, installing software upgrades, adjusting internal processes, testing your claims with your clearinghouse or payers, and establishing a line of credit.
In addition to these steps, this ICD-10 Planning Worksheet is a helpful tool to guide your practice through each part of your ICD-10 transition.
Planning for ICD-10 is overwhelming, but attempting the transition without a well-organized plan could be catastrophic for your practice. I encourage you to take the time now to organize your efforts, one step at a time, to ensure you are ready for the deadline.
Editor's note: This blog post is written by Alex Tolbert, founder of Bernard Health.
Our healthcare system is broken partly because consumers don't
know what anything costs. As patients become more proactive in making informed
healthcare decisions, we all agree this should be fixed. But why is it so hard?
Achieving price transparency in healthcare is difficult because healthcare
business models rely heavily on a lack of transparency.
Insurers, hospitals and providers want a better healthcare
system as much as anyone, but can't afford to inflict damage on their businesses
by making prices transparent overnight.
To better understand how transparency affects healthcare, let's
take a look at the business models for insurers and hospitals.
Insurer Business Model
If prices were completely transparent, then insurance companies
who had negotiated the lowest prices would begin to lose their primary
advantage. This is because that pricing information would give medical
providers and other insurance companies more power when negotiating and
competing with them.
An insurer's business model can be boiled down to this:
- Negotiate discounted prices with providers.
- Insure people, collect premiums.
- Pay claims to providers at discounted prices.
- Keep the difference.
Since that is the business, here is how you win financially:
- Negotiate the lowest prices with
- Offer the lowest premiums so you can attract
the most insured people.
- Enjoy the virtuous cycle that ensues.
What virtuous cycle?
The more people you insure, the lower the prices you can get
from providers. If you can get the lowest prices, you can offer the lowest
premiums. Offering the lowest premiums will win you the most insured people,
and so you can continue to negotiate the lowest prices from providers. And so
Hospital System Business
If prices were completely transparent, then it would be
difficult for the hospitals to justify the high prices they charge for things
available elsewhere for a fraction of the price. In other words, if everyone
knew that "Procedure ABC" costs $3,800 at the hospital and $600 for the same
quality at a standalone facility next door, the hospital would lose a lot of
The typical hospital system business model can be boiled down to
- Negotiate prices with insurers to be
- Get paid at those prices on patient claims
submitted to insurers.
- Pay your doctors, "midlevel" providers, nurses
and facility/equipment costs.
- Keep the difference.
Since this is the business, here is how you win financially:
- Negotiate the highest prices with insurers.
- See as many patients as possible.
- Submit as many claims as possible for each
It's a lot easier to do more tests/procedures per patient than
to attract more patients. As such, your contracted prices for tests and
procedures are really important.
Fortunately, as a hospital system, your size gives you leverage
when negotiating with insurers. The insurers need you in their network more
than they need a given imaging center. As a result, you're able to negotiate prices that are a lot higher and still be in-network.
Fueling the Movement Toward
Creating a better healthcare system starts with price
transparency. The growth of health savings accounts and transparency start-ups,
like Healthcare Blue Book and Change:Healthcare have fueled the movement toward
In addition, insurers and hospitals are working hard to provide
transparency. To offset the damage transparency will inflict on their business
models, they're working to develop other competitive advantages.
As consumers continue to share the burden of ever-increasing
healthcare costs, it's only fair that they be armed with the information needed
to make informed decisions about their healthcare. This transparency will lead
to a better-functioning and lower-cost system with happier providers and
Editor's note: This article was posted with permission from its author, Christine Gondos, Igloo Software. She can be reached at firstname.lastname@example.org.
The fastpaced healthcare industry is continuously evolving --
whether it be newly released studies, new best practices or new techniques, the
healthcare community thrives off of innovation.
annual conferences provide the opportunity for healthcare professionals to
connect, the majority of professionals rely on email to exchange new findings.
Healthcare professionals have recently placed an importance on social media
networks (such as Twitter) as an additional outlet to exchange ideas. While
social media provides an opportunity for medical professionals to connect and
discuss best practices, this ultimately becomes problematic due to the
confidential nature of the discussions.
how can healthcare professionals network, engage in conversations about practice and
share knowledge while maintaining confidentiality and ethical standards?
Software's Senior Vice President of Marketing & Operations, Andrew
recently presented at the CIO Healthcare Summit where he discussed "How
Healthcare Organizations are Moving from Social Media Marketing to
Business Strategy." Instead of connecting on public social networks,
more healthcare organizations are creating a social business strategy so
can collaborate on their own private network.
Secure enterprise social platform
organizations like Igloo
unite healthcare professionals, practitioners and
patients so they can collaborate on ideas and keep information in one
area. After a patient leaves the office, you no longer need to feel that
sense of ambiguity questioning if you remembered everything he or she
longer does a conversation need to live in the room you had it; nor your
inbox, nor your notebook.
Enterprise social software erases ambiguity and allows information to be
accessible yet secure. Here are four use cases of how enterprise
social software enables healthcare professionals to stay connected outside the office.
- Kimberly-Clark Clinical Solutions
is a health division of a large consumer goods company that has a very large
health product portfolio including medical devices & infection prevention.
To facilitate research, they launched a social extranet solution to act as a
product evaluation center for open innovation & customer engagement.
- Ontario Health Quality Council,
an independent provincial body for patient care, coordinates a myriad of
stakeholders in a member portal to report on the health system's effectiveness
and opportunities for process improvement.
Are your patients curious about learning more
information about what you said in a recent appointment? While you may question the
validity of checking Wikipedia or the intimidating results Google reports back,
patients often feel alone when they leave their provider's appointment.
Healthcare organizations realize this and have bridged the gap by offering
patients a portal where they can connect.
National Medical Center provides patients with a secure, private virtual
place where they can ask questions, find answers and share experiences around a
specific health condition. Their Emergency Medical Services for Children
Program (EMSC) National Resource Center also provides a secure portal for
grantees to interact and share information with each other in support of EMSC's
national child advocacy programs.
Want to bring together key stakeholders within a healthcare
association to work together and improve healthcare delivery? A
conference may be a great way to get everyone together, but how will you
Enterprise social software platforms provide practitioners a
specific work area where they can collaborate on documents and share best
Drug Information Association uses a social
extranet to connect their 18,000 members in the biopharmaceutical industry for
online learning, collaboration and managing their communities of practice.
Since adopting this new form of technology, their collaboration tools are now
streamlined and this area facilitates knowledge exchange and relationship
building in a private member portal for their 32 special interest groups.
American Academy of Family Physicians (AAFP),
representing more than 100,000 family
physicians and medical students nationwide, improved their collaboration since
launching an online community for peer networking, information sharing and
practice transformation. Members have access to online seminars, practice
tools and the "Ask An Expert" area. Known as Delta Exchange, the award-winning online
network connects physicians, clinical staff, office staff and primary
care-focused residency programs committed to the Patient Centered Medical Home.
wholly-owned subsidiary of the American Academy of Family Physicians (AAFP)
also capitalized on the benefits of social collaboration. In an effort to
improve patient care and assist primary care physicians with medical practice
redesign, over 500 practices and more than 5,000 medical professionals across
the country connect and collaborate using Igloo Software.
External facing communities (extranets) have gained
tremendous momentum for healthcare organizations. Effective collaboration,
improved knowledge sharing, and accessibility anywhere - it is no wonder that
more and more healthcare organizations like The College of Family Physicians of Canada,
are adopting social intranets to collaborate inside their organization.
Bye bye filing cabinets and shared folders.
The organizations mentioned
above stay organized with hierarchical storage of documents with unlimited folders, inline preview
and full version control. Organizations and associations in the
healthcare industry now have the power to stay connected to other healthcare
professionals, practitioners and patients in a secure environment where
confidential information is safe.
For more information, visit http://www.igloosoftware.com/blogs/inside-igloo/continuingtheconversationoutsidethedoctorsoffice4waystostayconnected