Category: Industry News

The initial issues of this blog will lay a foundation of understanding that will allow us to do a deeper dive into healthcare-related issues.. Continue reading “Taking a Trip Down Healthcare’s Memory Lane”

If you think managing the healthcare revenue cycle is challenging now, brace yourself because there are several forces that are likely to drive more complication and complexity into the revenue cycle. Recent analyses of hospital finances are painting a complex picture – Medicare spending cuts, declining service volumes, rising costs, a shrinking payer mix, underutilized technology and increasing financial waste are all threatening the profitability of our hospitals and providers.

We’re Getting Older

As more and more baby boomers reach the age of 65, the mix of profit-generating commercial business and break-even to unprofitable government payers will continue to shrink. In addition to the increasing Medicare population, reductions in federal payments to hospitals will total $252.6 billion from 2010 to 2019, according to a new report commissioned by the American Hospital Association and the Federation of American Hospitals.

To compound the issue of an aging population and cuts in federal reimbursement, a report from Fitch Ratings predicts the third straight year of declining profitability for the nonprofit hospital sector, but not as steep as the previous two years. Finally some good news!

No More Passing the Buck

As the nation transitions from fee-for-service reimbursement to value-based care, coordinated efforts amongst an array of providers are required to improve quality and efficiency of patient care – and reimbursement. Under this approach, providers are financially rewarded for positive patient outcomes and efficient care delivery. This is a major shift in behavior from the traditional fee-for-service model, where providers are compensated for each test, treatment, and medication, regardless of patient impact.

While the goal of value-based reimbursement is expected to improve our population’s health, the shift in approaches brings along a new set of challenges for the healthcare industry. While many organizations are hiring care management coordinators and behavioral health support staff members to build the necessary infrastructure for value-based care, many are still citing the following as barriers to adopting this standard of care:

• Lack of staff time to collaborate between providers
• Unpredictability of revenue
• Lack of ability to understand potential financial risk
• Lack of resources to report, validate and use data

Regardless of these challenges, with only 39.1% of healthcare payments made in 2018 under a fee-for-service structure and the increased industry demand for value-based care, profitable provider organizations need to partner with each other and insurers to deliver value rather than passing the buck back and forth.

 A Lot of Money is Wasted

Imagine throwing 25% of your paycheck right out the window. That is how much of healthcare spend in the United States is wasted. Administrative complexity is responsible for the most waste ($265.6 billion) – billing and coding errors and time spent reporting on quality measures. The authors of the report cited opportunities to reduce administrative waste through insurer-clinician collaboration and data interoperability.

The United States spends almost twice as much as other high-income countries on medical care despite similar utilization rates. Administrative costs were again identified as a major driver in the overall cost difference amongst the United States and other high-income countries.

The Data Struggle is Real

We are constantly surrounded by technology – from streaming TV, to an app that lets you see and speak to someone at your front door while you’re hundreds of miles away, to your Amazon packages being delivered by drones. There is no doubt that we are in the era of advanced technology, but adoption and investment in technology is still in its early growth stage in the healthcare industry. There could be several reasons why, including:

• A lack of general knowledge as to where to look for technology solutions
• A lack of understanding that there are solutions available to solve complex issues
• EHR implementations and maintenance is more challenging than anticipated
• All of the home-grown, legacy systems that require updating before being able to integrate with newer systems

Data interoperability is the key to these problems facing the healthcare industry. Being able to exchange, interpret, use and share data amongst other providers, payers and even the patients themselves would undoubtedly cut down on administrative waste and enhance the implementation of value-based care.

There is Hope!

These challenges are daunting, but the right partner can shed the necessary light and get your organization’s revenue cycle where it should be to maximize your revenue. Quadax is more than a revenue cycle management solution provider. We are in lockstep with our clients from the beginning and that service and commitment never ends. If you’re ready to learn how Quadax can help your organization support a growing Medicare population and a value-based care model while decreasing your administrative waste and making your data work for you, reach out any time!

 

Ken Magness is a focused healthcare professional with more than a decade of experience in helping clients understand the true value of automation in the revenue cycle management process. As the Strategic Initiatives Leader at Quadax, Ken and his team are passionate about connecting with healthcare providers to help them create and leverage the appropriate technology solutions to optimize the revenue cycle process and improve the experience of their patients and staff.

With Election Day behind us and the upcoming Presidential election in 2020, Medicare for All is one hot topic. Continue reading “Eliminating Medicare Denials is More Important than Ever!”

We recently attended the American Association of Healthcare Administrative Management (AAHAM) Annual Conference in Las Vegas and brought home a wealth of insight… Continue reading “Hot Topics in RCM: Automation, Patient Experience and Analytics”

What comes to mind when you hear “Artificial Intelligence” (AI)? From product pitches to the nightly news, the term AI is showing up everywhere. But just what are we talking about when we talk about AI? Driverless cars and robotically-assisted surgery?  Postal-sorting machines and facial recognition at Passport Control? Siri and Alexa? Smart forms in EHRs and product recommendations on Amazon? Since this field of research gained popularity in the 1950s, computers’ capabilities have advanced exponentially.  As our understanding of human intelligence has also improved, so too has our concept of what programs designed to replace human intelligence should be capable of doing.

Early initiatives to produce AI protocols consisted of distilling human knowledge into programming logic—lines of code to account for every variation of a particular scenario. Chess games could be won by a computer programmed with millions of potential moves, able to go through its library in mere seconds and calculate possible moves and outcomes based on known values. Algorithms were to be credited with success more so than what we today call machine learning. However, in the years between IBM Deep Blue’s defeat of chess master Kasparov in 1997 and Watson’s 2011 Jeopardy win, ground-breaking advances included natural language processing, improved information retrieval, automated reasoning and evolved machine learning capabilities.

Computers are not yet able to replicate human abstract thinking, high-level reasoning, or very complex problem-solving to fulfill the aspiration of “human-imitative AI.”  However, advances in machine learning are happening rapidly.  According to venture capital firm BGV, “Healthcare creates self-running growth by leveraging technologies that enable machines to sense, comprehend, act, and learn to perform administrative and clinical healthcare functions to augment human activity” and “The market is forecasted to be worth $6.6B by 2021, with a 40% compound annual growth rate.”[i]

Anticipated clinical applications of AI include reading and interpreting diagnostic imaging, producing medical diagnoses, predicting the most effective (and least risky) prescription drugs, and facilitating more productive patient engagement. The journal Nature suggests AI can already diagnose skin cancer more accurately than a board-certified dermatologist.

The non-clinical applications of AI in healthcare are equally promising.  AI is expected to transform the data-rich revenue cycle environment into a streamlined, proactive (rather than reactive), healthy financial enterprise characterized by speed and accuracy.  The power of sophisticated algorithms to convert data analysis to insights and then to action will eliminate human error, preempt obstacles to reimbursement, and feed strategic discussions.

At this point in time, though, many of the hopes for AI still outstrip its reality.

While work continues to develop capabilities and perfect responses, other issues persist.  The AMA Journal of Ethics warns “ethical challenges must be identified and mitigated since AI technology has tremendous capability to threaten patient preference, safety, and privacy.”[ii] Some have raised concerns pertaining to the values programmed into the decision-making algorithms—whether biases inherent to the humans developing the technology are lurking in the AI. How legal liability will be handled in cases of unintended consequences or errors in judgment. And more basically, whether or not an AI system can be trusted.

Undoubtedly, technology will advance to an integrative intelligence model combining different competencies (machine learning, natural language processing, vision, predictive modeling, and robotics) to produce human-imitative AI, and the accompanying ethical and legal dilemmas will be explored, debated, and resolved.

In the meantime, revenue cycle professionals will realize significant benefits from technologies upstream of human-imitative AI.  The starting place for the progression of artificial intelligence development, as we have seen, was a rules-based, if/then schema we may now think of as Intelligent Automation (IA).  IA is now offering cost savings and operational advances to healthcare organizations.

Intelligent automation features rules-based routines to enable an application to handle repetitive tasks, particularly those with high-volume. Any time there is a clear relationship between the circumstances necessitating intervention and the prescribed solution, it can be—and should be—automated. In the revenue cycle, such tasks are abundant. Prime candidates for automation include eligibility processing, assigning workflow statuses, correction of known errors, cross-walking new provider credentials, claim status checking, remittance splitting, payment posting, and other revenue cycle tasks which are not complicated, but typically require mind-numbingly repetitive manual intervention.

IA delivers on the promises often attributed to AI for streamlined work, greater productivity, and lower costs. For example:

• Streamline your claims management by relying on IA for data conversions, workflow management, auto-correction of known issues, and segregating those claims requiring extra attention prior to submission.
• In your denials management and your collections efforts, use IA to move toward an exception-based work environment for greater productivity and a reduction in the volume of work you must outsource.
• Automating certain revenue cycle tasks gives you extra bang for the buck – consider revenue leakage uncovered by the intelligent analytics of a contract management system. Using human capital, you can’t necessarily afford to pursue large quantities of low-dollar shortages. With automated efforts, you can. You win by not only repurposing staff and pursuing the high-dollar shortages staff already worked on, but also by recovering shortages previously written off.

Another tremendous advantage of the implementation of IA is the freedom to move human capital away from menial tasks into more meaningful work.  The workforce is thereby enhanced, improving both staff retention and expanding reach to improve operations.

When Adena Health System implemented RemitMax to convert paper-based payment documents to machine-postable ANSI 835s, jobs within the business office, particularly for cash posters, were radically revised.  Angela Lowery said, “It’s changed our mindset from ‘gotta key, gotta key, gotta key’ to an analytical approach of identifying payment problems and working toward solving them. You’re thinking, you’re reviewing, you’re analyzing, you’re contacting other teams and working with them. It’s truly been transformational.” (To learn more about the benefits Adena Health enjoys with RemitMax, read the case study.)

Begin the Journey

The science and technology of artificial intelligence will inexorably become more complex with greater precision, particularly for clinical applications. As AI continues to mature, don’t miss the opportunities afforded by IA.

Quadax solutions reduce complexity in the revenue cycle with intelligent automation in the areas of patient access, claims management, reimbursement management, denials and appeals management, and business intelligence.  Using Quadax tools, our clients enjoy more control, better data, and better cash flow. Let’s talk about the difference Quadax IA can make in your revenue cycle!

[i] https://benhamouglobalventures.com/2018/08/02/digital-transformation-of-healthcare-state-of-the-union/

[ii] AMA J Ethics. 2019;21(2):E121-124.

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