Category: For Hospitals & Physician Groups

Cleveland, home to Quadax headquarters, is also home to some of the finest medical facilities in the world. (Many of them, we’re proud to say, are Quadax clients.) At the same time, out of 88 counties in Ohio, Cuyahoga County (the greater Cleveland area) ranks 62nd for health outcomes[i]. Overall life expectancy is 1.6 years below the national average. Infant mortality is well above the national rate, with significant racial disparity. In terms of health factors contributing to outcomes, Cuyahoga County ranks 86th in Ohio for Physical Environment, and 81st for Social & Economic Factors, which include children in poverty, income inequality, unemployment, and violent crime.

In response to this dichotomy, Dr. Akram Boutros, M.D., FACHE, President and CEO of The MetroHealth System said, “It’s time to stop applauding medical care that’s administered after the fact, no matter how good it is, and start providing health care before people get sick.”[ii]

The MetroHealth System is doing just that, as announced in their recently-issued 2018 Annual Report, with the new Institute for Health, Opportunity, Partnership and Empowerment (H.O.P.E.)—just one of the programs they’ve created to identify and act on social determinants of health.

The Centers for Disease Control defines Social Determinants of Health (SDoH) as the conditions in the places where people live, learn, work, and play affecting a wide range of health risks and outcomes.[iii]  “Right now in the United States of America in the year 2019, your zip code is more predictive of your health outcomes than your genetic code,” says Kate Walsh, President and CEO of the Boston Medical Center Health System. Commonly cited research reveals the contribution of clinical care to an individual’s health to be only about 10%, while socio-economic conditions, health behaviors, and physical environment combine to contribute 80% to a person’s health status.

Figure 1. Source: Minnesota Department of Health

Lists of SDoH vary in number of categories, based on the arrangement of contributing factors, depending on the source. The CDC identifies five key areas; this table (below) from the Kaiser Family Foundation arranges the factors into six categories:

Figure 2. Source: Kaiser Family Foundation

The relationship between social conditions and health has been recognized for many years.  Now, as our health care system shifts further toward value-based care, ever greater attention is being given to these socio-economic factors which will either support or undermine medical intervention.

AARP has found social isolation among older adults is associated with an additional $6.7 billion in Medicare spending annually. In people of all ages, factors such as social support, food security, economic stability, and physical safety will dictate their adherence to plans of care, making appointments, and avoiding hospital readmissions.

In a reimbursement environment focused on outcomes, providers will see greater success when patients’ health is established and maintained over the long term, enabling them to consume fewer acute care resources.

 

It’s a Community Thing

Dr. Boutros has stated, “Poor health doesn’t just affect the sick; it impacts entire communities.”He also observed, “The chronic stress of poverty has been demonstrated to hinder the development of executive function and to create dysregulation of emotion and attention. These lifelong effects are some of the underlying reasons why children living in poverty may not excel in school, choose risky behavior and have more suicide attempts.”

To that end, MetroHealth has developed programs to address Physical Environment, Health Behavior, and Socio-economic Factors in order to improve physical and mental health and reduce health care costs. The Institute for H.O.P.E will become a hub to provide access to resources and programs for education, employment, food, transportation, and housing. A grocery store, food pantry, classrooms, legal aid services, and financial literacy training are just some of the features planned. MetroHealth has also announced plans for new apartments, programs for employee assistance, and telemedicine service for college students in four states. These programs add to a long list of initiatives designed to transform the community, including the Open Table model.

A little less than two hours to the west of The MetroHealth System, ProMedica is likewise committed to caring for their community: the greater Toledo area, stretching into southeastern Michigan. In 2015, partnering with the AARP Foundation, ProMedica announced the formation of The Root Cause Coalition, a 501(c)(3) nonprofit organization to address hunger and other social determinants of health. In the same year, it opened its first food pharmacy, distributing food to patients with a physician referral. Since then, two additional Food Clinics have begun operation, and overall the Food Clinics have served more than 6,600 distinct households with “food as medicine.”

Recognizing many in ProMedica’s community live in food deserts, ProMedica has also invested in Market on the Green and a Mobile Market to bring fresh, local produce and fresh meat, dairy, and more at affordable prices to families and individuals who otherwise would never see fresh, healthful food in their neighborhoods.

According to Randy Oostra, President and CEO of ProMedica, “The healthcare industry must not only deliver clinical excellence and efficiency, we must hone in on how we can act as catalysts, innovators and leaders to improve the health of our entire communities.” Oostra has also observed that there is a business case for addressing social determinants of health in terms of lowering health care costs, reducing absenteeism, and increasing productivity.

Getting There from Here

In 2017, the Deloitte Center for Health Solutions conducted a survey of about 300 hospitals and health systems about health-related social needs investments. According to their findings, “80 percent of hospital respondents reported that leadership is committed to establishing and developing processes to systematically address social needs as part of clinical care.” However, current activity is often fragmented and ad hoc. There are gaps in screening, and finding sustainable funding is a challenge. Those hospitals making the greatest progress toward value-based care models, such as accountable care organizations (ACOs), are reporting the highest level of activity in the area of addressing social determinants of health.

Research into the association between social services coordination by health systems and a reduction in health care expenditures has to date been limited, but preliminary studies do show a positive correlation. A study conducted by WellCare Health Plans and the University of South Florida College of Public Health found a 10% reduction in health care costs for people who were successfully connected to social services for needs such as housing services and utility assistance.

Effective analysis of the return on investment for addressing social determinants of health requires hospitals employ data analytics to track meaningful measures—and to be patient as results are more likely to be seen over the long-term. Collecting data, selecting meaningful metrics, and understanding which components are providing the greatest ROI will depend on collaboration between clinical areas, social service partners, and revenue cycle representation.

While the data and analysis may take years to capture and understand, the data presently available on the connection between SDoH and health outcomes is clear and compelling.

As Dr. Boutros has pointed out, we have known for twenty years that increased Adverse Childhood Experiences lead to increased likelihood of diabetes, obesity, depression, sexually-transmitted disease, or suicide attempts. We also know, just as low-income Americans suffer higher rates of heart disease, diabetes, stroke, and other chronic conditions, poor health statuses also contribute to lower income, creating a cycle that’s hard to break.

Moving interventions upstream presents numerous challenges, but as characterized by Dr. Boutros, it’s a moral imperative.

Quadax applauds the efforts of The MetroHealth System and ProMedica in going beyond symptoms to tackle root causes and enhance the overall health of these Ohio communities.

In future articles, we’ll examine other SDoH initiatives as well as practical steps for moving forward with such efforts.

[i] https://www.countyhealthrankings.org/app/ohio/2019/rankings/cuyahoga/county/outcomes/overall/snapshot

[ii] Dr. Akram Boutros, “What Hospitals are Getting Wrong and How We Can Fix It,” delivered at The City Club of Cleveland, June 7, 2019. https://www.cityclub.org/forums/2019/06/07/what-hospitals-are-getting-wrong-and-how-we-can-fix-it Transcript here.

[iii] https://www.cdc.gov/socialdeterminants/index.htm

Primary Care Physicians often feel they’re running out of gas.  The value they provide is real: research shows significantly better healthcare access and experience for patients receiving primary care.  However, office visits to primary care physicians (PCPs) declined 18% from 2012 to 2016[i], suggesting that the value of PCP care is not widely acknowledged.  Meanwhile, physicians experience frustrations with administrative demands that encumber their ability to deliver needed care.

A JAMA Internal Medicine article reinforced the importance of primary care following a study of many thousands of US adults with and without primary care, concluding “policymakers and health system leaders seeking to improve value should consider increasing investment in primary care.”

Will the newly announced Primary Cares Initiative be the investment that makes a difference?

The American Academy of Family Physicians (AAFP) and America’s Physician Groups were among those applauding the CMS Primary Cares Initiative when it was announced on Monday, April 22.

AAFP Vice Speaker Russell Kohl, MD said, “To truly unleash the power of primary care, we must do two things: Unhinge it from the episodic-based incentives of fee-for-service, and eliminate the administrative complexity of practice that distracts family physicians from patient care. In short, it has become clear that we must create payment models that support our desired delivery models.”

Those distracting complexities cited by physicians in discussions of today’s greatest challenges include increased third-party administrative requirements, a rapidly changing reimbursement environment, and even measuring quality measure incentives and disincentives.

Time spent with EHR data entry is a significant frustration, as well.  “EHRs were supposed to make patient records easily shareable among physicians. In theory, that would lead to more coordinated care and fewer medical errors,” says Sally Pipes, president, CEO, and Thomas W. Smith Fellow in Health Care Policy at the Pacific Research Institute in Forbes.

“Instead, the mandate has been a bureaucratic nightmare. Doctors now spend half their time on EHRs and desk work — and barely a quarter of their time with patients. In 2000, doctors spent more than 60% of their day providing medical care. The increasing bureaucratization of health care has left two in three doctors feeling burned out, depressed, or both.”

Enter the CMS Innovation Center and the Primary Cares Initiative, called “a major commitment advancing primary care in this country.”  Health and Human Services Secretary Alex Azar introduced the new value-based care initiative in a speech at the Washington office of the American Medical Association.

The initiative comprises a set of five voluntary program models grouped into two paths: Primary Care First (PCF) and Direct Contracting (DC). PCF targets smaller practices, offering a general payment model and a second payment model for high-need populations. The three models in the DC path are Global, Professional, and Geographic; these target larger practices and are more ambitious.

The payment models incentivize participating providers to deliver advanced, patient-centered primary care services while keeping those patients healthy and out of the hospital.  They focus on value-driven, population-based metrics.

In the PCF general model, population-based payments and flat primary care visit fees are meant to assist in the transition from fee-for-service to a value-based model.  Performance-based adjustments can reward providers up to 50% of revenue, or risk a 10% downside adjustment. Quality measures include acute hospital utilization in all 5 years of the program; starting in year 2, quality measures will include Patient Experience of Care Survey, control of hemoglobin A1c and hypertension, care plan, and colorectal screening. The Quality Gateway for practices serving high-risk and seriously ill populations will be developed during the model.

Data sharing is a key component of the program.  The plan for PCF data sharing is for participants to submit claims (with reduced documentation requirements) to CMS, and for CMS to return performance data to providers, to be used in their own analytic tools, so that providers may assess their own and their peers’ performance in the program to encourage continuous improvement.

Administrator Verma, in remarks to the National Association of Accountable Care Organizations, said, “Technology, and the sharing of data, underpin the entire move to innovative payment mechanisms.  Without effective, open data sharing, providers cannot keep patients healthy.  Without data to track patient progress or understand quality, payers cannot tie payment to outcomes.”  To this end, CMS is moving to modernize their processes for data sharing, encouraging APIs wherever possible.  The intent is for providers to “track their beneficiaries’ healthcare utilization and spending at a granular level, and then modify a patient’s care plan in response.”

The vision for value-based care is to both hold clinicians accountable for cost and quality while also giving them the flexibility to innovate—to provide quality, coordinated, appropriate care free from the dictates of bureaucracy and regulation.  Azar referenced the 4 Ps that are the goals of value-based care according to CMS:

• Patients in control as consumers
• Providers acting as accountable guides through the healthcare system
• Payments based on outcomes
• Preventing disease before it occurs or progresses

It’s not clear whether value-based payment models will automatically result in a complete system of value-based care delivery, though such an outcome would be good for both patients and physicians.  Reimbursement has been recognized as an effective steering wheel for the vehicle of healthcare delivery, however, so there is optimism for the results of this and subsequent initiatives.  Further, by encouraging multi-payer alignment, CMS hopes to retain firm control of the steering wheel.

Administrator Verma has indicated additional value-based payment models will be forthcoming, including programs for rural care, oncology, and other specialty physicians and surgeons.  She has also said future models are likely to be mandatory rather than voluntary.

For the Primary Cares Initiative, participation is voluntary, and several conditions must be met in order to apply for the program.  The application process is expected to begin soon—“Spring 2019” according to the CMS timeline.  Qualifications for participation in PCF include geographic and demographic aspects, having experience with other value-based payment arrangements, using 2015 Edition Certified Electronic Health Record Technology (CEHRT), supporting data exchange with other providers and health systems via Application Programming Interface (API), and connecting to their regional health information exchange (HIE).  Practices must also comply with a set of “advanced primary care delivery capabilities,” such as providing 24/7 access for patients to practitioners.

What does this mean for the business office?

Under a payment model such as PCF, claim processing will be different, but still vital. Hopefully, rejections and denials will be minimal, but it is unlikely payment discrepancies will disappear. Nor will the revenue cycle functions of patient access management, coding, cash application, etc. be rendered either inconsequential or obsolete.

Data tracking and analysis will become more important than ever to practices as they evaluate performance, innovate based on outcomes, and predict and confirm performance-based adjustments.

Data preparedness is associated with disaster readiness and response; it’s the “ability of organizations to…effectively deploy and manage data collection and analysis tools, techniques, and strategies in a specific operational context.”[ii]  In the context of value-based payment, data preparedness and ease with analytics capabilities is important for providers prior to joining a model, in order to confidently assume risk.  Understand your patient population, have a clear picture of costs and budgeting, and be ready to work with payment and performance data following model implementation.

Many unknowns remain as we look to the future of healthcare reimbursement—of course, that’s nothing new.  What is known: the best way to succeed regardless of payment model (or variety of them) is to ensure all the parts of your revenue cycle are operating at peak efficiency.  When your staff enjoys greater productivity with cost-effective, connected tools for patient access, claims management, reimbursement management, and data analytics, you’ll be ready to hit the value-based road with confidence.

Quadax can help.  Contact us to hear how we’ve helped both primary and specialty physician groups optimize their workflow and their cash flow.

To learn more about each path under the Primary Cares Initiative, tune in to an upcoming CMS webinar: for Primary Care First or for Direct Contracting.

[i] Health Care Cost Institute, HCCI Brief: Trends in Primary Care Visits, October 2018 https://www.healthcostinstitute.org/research/publications/hcci-research/entry/trends-in-primary-care-visits

[ii] Nathaniel Raymond and Ziad Al Achkar, Data preparedness: connecting data, decision-making and humanitarian response, November 2016 https://hhi.harvard.edu/publications/data-preparedness-connecting-data-decision-making-and-humanitarian-response

The topic of balance billing is in the news again, closely associated with the newer term, “surprise billing.”  Patient experiences such as those of Drew Calver, who received an unexpected $109K bill following treatment for his heart attack, have focused new attention on this long-standing issue.

Balance billing is the practice of pursuing from the patient any balance remaining on account after the insurance payer has reimbursed its portion to the provider, beyond the expected co-pay, co-insurance, and deductible.  The terms of the contract between the provider and insurance plan will generally dictate what is or is not billable to the patient – the aforementioned co-pay, co-insurance, deductibles, for example – and these contract provisions (and state law, typically) will control whether or not a patient may have further financial responsibility.

When there is no contract, of course, all bets are off, since an out-of-network provider has no negotiated payment rate.  As high-deductible health plans have become more widespread, many patients are keenly aware of the benefits of staying in-network to keep those expected costs as affordable as possible. But what about when services must be rendered by an out-of-network provider?

In a number of cases highlighted by the media recently, a patient was not aware that out-of-network providers were engaged in the treatment.  This commonly happens when an emergency department physician working through a staffing agency, or an anesthesiologist or radiologist is involved in care but is not in-network. Hence, the surprise of “surprise billing” – the receipt of an out-of-network bill when the patient thought they were at an in-network facility.

New Jersey’s Assembly Bill No. 2039 has likewise garnered quite a bit of attention since its enactment and particularly since its effective date August 30, 2018. Governor Phil Murphy, who signed the legislation earlier this year, said “We’re closing the loophole and reining in excessive out-of-network costs to prevent residents from receiving that ‘big surprise’ in their mailbox. At the same time, we’re making healthcare more affordable by ensuring these costs are not transferred to consumers through increased health premiums.”

New Jersey is among 21 states that have partial or comprehensive protections against balance billing by out-of-network providers in emergency departments or in-network hospitals. Stipulations of the protections vary by state.  Variables include applicability by setting, type of managed care plan, the type of protection, and the payment outcome, whether a payment standard or a dispute resolution process. And since ERISA currently exempts self-funded employer sponsored plans from state regulation, 61% of privately insured individuals are not covered by their state’s protections, adding to the complexity.

There is speculation that changes could be made to ERISA (the Employee Retirement Income Security Act of 1974) to overcome this loophole to state protections.  Senator Bill Cassidy, M.D. (R-LA) announced on September 17 a discussion draft of a bill that would modify ERISA to defer to state limits for patient costs for emergency care; or, in absence of state limits, define restrictions within the proposed legislation itself to cap patient responsibility.  This is one issue among several concerning healthcare price transparency that is being discussed by a working group, and not the only discussion on the topic of potential laws governing balance billing.

So what’s a healthcare provider to do?

• Be aware of the regulations applicable in your state, and be prepared to comply. As media focus continues on this topic, more legislators are taking up the issue.  Stay tuned to your state’s law-making process to eliminate surprises for your cash flow.
• Apply your organization’s payment policies consistently.
• Communicate clearly with patients, whenever possible, about the charges they should expect and their options for payment. In non-emergency settings, check patient eligibility, and provide a pre-service estimate based on their health plan coverage.

Complex billing issues are par for the course in today’s healthcare business office. That’s why Quadax delivers software and solutions that solve revenue cycle complexities, streamlining accounts receivable and reimbursement operations to improve cash flow and payment results.

If you’re ready to work with a partner that believes in transparency, communication, and earning our clients’ trust every day, get in touch with Quadax!