Nov 16, 2023 | Uncategorized
The practice of value-based care has gained significant momentum, driven in part by the COVID-19 pandemic, which highlighted the limitations of fee-for-service reimbursement. Healthcare providers now face increasing pressure to stay up-to-date with emerging trends in the field. In this article, we’ll explore five key trends in value-based care.
1) Embracing Value-Based Care:
A heavy reliance on fee-for-service reimbursement can leave healthcare providers vulnerable to volatility and changes in demand. Those who had invested in value-based care were better equipped to weather the storm, as they had a consistent source of revenue even during periods of low utilization. The rapid changes in healthcare delivery driven by the pandemic underscore the importance of embracing value-based care. Providers have the opportunity to realize a rapid return on their investment in value-based care, thanks to stable revenue streams and new regulatory flexibilities. Innovative care delivery models further enhance this potential.
2) Continued Innovation and Disruption:
Value-based care has long been a hotbed for innovation, and we are seeing a surge in innovation and disruption in both payment and care delivery models. The Centers for Medicare and Medicaid Services (CMS) had prioritized value-based care during the Trump administration, and the Biden administration’s health care goals are likely to further emphasize cost savings, driving a greater push towards value-based care. Commercial payers are also seeking innovative payment and care models, especially in light of the disparities highlighted by the pandemic.
3) Leveraging COVID-19 Infrastructure:
The COVID-19 pandemic prompted transformative changes to the healthcare system. These changes created ongoing opportunities to manage patient care and provide high-quality services in lower-cost settings. Telemedicine and digital health modalities, initially introduced as temporary measures, have become permanent fixtures in healthcare. Providers who adopted digital health solutions during the pandemic can now capitalize on this investment to manage patient care efficiently and see returns on services that were traditionally unreimbursable under fee-for-service arrangements. Programs like the Hospital Without Walls and Acute Hospital Care at Home have also opened doors for lower-cost services that benefit providers.
4) New Opportunities for Provider Alignment:
Recent changes in federal law have aimed to lower barriers to value-based care. CMS and the Office of Inspector General (OIG) have introduced new flexibilities under the Stark law and Anti-kickback Statute for value-based arrangements, allowing providers to enter into arrangements that were previously restricted. These exceptions and safe harbors provide new opportunities for providers. Careful crafting is required to take advantage of these allowances. They enable providers to align and incentivize activities that promote value-based goals. Additionally, information blocking rules ensure patients and providers can access health information, further reducing structural barriers to value-based care.
5) Focus on Social Determinants of Health:
In the value-based care space, especially in Medicaid programs, there is a growing emphasis on addressing social determinants of health. Providers and payers recognize the significant role that non-medical factors play in patient health. Providers and payers can achieve notable improvements in patient health and outcomes by addressing issues such as transportation, food, housing, and language services. Simultaneously, they can maintain relatively low medical costs. The focus on social determinants of health is an emerging trend in value-based care. This trend is expected to grow as stakeholders seek creative ways to manage patient arrangements.
Healthcare providers and payers are emerging from the upheaval caused by the pandemic and the revolutionary changes in healthcare. A renewed interest in value-based care is expected! Opportunities abound to fully investing in patients.
Post adapted from original article published on natlawreview.com
Photo from NCI
Oct 25, 2023 | Uncategorized
The Healthcare Code Landscape Is About To Witness A Significant Transformation
The Centers for Medicare & Medicaid Services (CMS) have recently unveiled the ICD-10-CM 2024 codes. These updates, slated for use by all provider types, encompass both Inpatient and Outpatient settings. The release includes crucial components such as the 2024 Addendum, Code Descriptions in Tabular Order, and Code Tables, Tabular, and Index. Alongside these, the FY 2024 Conversion Table and Present on Admission (POA) Exempt Code List (to be posted soon) complete the comprehensive package of changes.
The 2024 ICD-10-CM changes take effect from October 1st, 2023, to September 30th, 2024. Providing the medical community with a significant overhaul of
395 New Codes, 25 Deletions, and 13 revisions across 17 of the 21 Chapters!
Notably, “Capturing the Context”. Great Job Docs! Your excellent documentation of Where and/or How injuries happened has given way to a major boom in Chapter 20: External causes of morbidity! A whopping 123 new codes out of the 395 overall additions to be exact! These additions range from “Foreign bodies entering through a natural orifice” like batteries, buttons and plastic toys to sharp glass, swords and daggers”!
Some Other Major Changes Include:
- Chapter 3, Neoplasms, a notable addition to includes 13 new codes for desmoid tumors, a rare type of tumor that presents unique challenges in terms of classification and treatment. Chapter 3 introduces 8 new codes related to Sickle-cell conditions with dactylitis. This is a condition marked by severe inflammation of fingers and toes, commonly observed in infants with sickle cell anemia.
- Chapter 6, the Nervous System, focusing on diseases of the nervous system, welcomes 24 new codes, including those for Lafora Body Disease and chronic migraine with aura. These additions reflect a growing understanding of neurological conditions and their complexities.
- Chapter 21, Factors Influencing Health Status and Contact with Health Services, 30 New Codes include a variety of conditions such as carrier status, history codes, and codes related to Social Determinants of Health (SDOH), like New Subcategory Z62 which addresses “Problems Related to Upbringing”; and New Subcategory Z91.A9 “Caregiver’s Noncompliance with Patient’s Medical Treatment and Regimen”.
The changes aren’t limited to specific areas; they permeate through various chapters, addressing an array of conditions and diseases.
Learn more about the author Delana Williams, CPC, CPCI, CEDC
ICD-10 Questions?
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Information collected and condensed by
Delana Williams, CPC, CPCI, CEDC
Coding and Compliance Manager at Welter Healthcare Partners.
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Photo by National Cancer Institute on Unsplash
Oct 17, 2023 | Uncategorized
Specialty Healthcare in the US
Many doctor visits involve seeing a specialist at some point in the process. The specialty healthcare system in the United States needs to be improved in order to help patients and doctors alike. Specialists are important in American healthcare.
Almost 9 out of 10 doctors specialize in different areas. They handle a big part of medical visits, cost a lot in Medicare and private insurance, and their role in outpatient visits and overall healthcare costs is increasing. To improve healthcare in the U.S., we need to make specialty care better. We can do this by breaking it down and making the various services offered by specialists work well together.
Core Activities of Specialists
Specialists are problem-focused experts responsible for the care of individuals with specific health conditions. They expand their expertise through a range of core activities, including:
- Consultations (providing advice to fellow clinicians)
- Co-management (sharing the long-term management of a particular issue)
- Principal care (assuming full responsibility for a specific problem)
- Primary care (offering a medical home)
- Procedures
The blend of these activities varies based on a specialist’s field and individual practice. For example:
- Cognitive-based specialists, like endocrinologists and nephrologists, tend to engage in consults, principal care, primary care, and co-management, often with minimal or no procedures.
- Procedural-based specialists, such as gastroenterologists and cardiologists, also partake in consults, principal care, and co-management, in addition to procedures but provide little to no primary care.
- Surgical specialists, including orthopedists and neurosurgeons, primarily engage in consults and procedures.
Challenges of Bundling
In various industries, bundling products and services with multiple components is commonplace to reduce production and distribution costs. However, including elements that some consumers never utilize can lead to increased costs and a potential mismatch with individual consumers’ specific needs. Specialists often employ uniform processes, resources, and business models to deliver widely differing services.
This bundling approach makes specialty care less accessible; for instance, individuals in need of prompt attention may face delays due to specialists’ schedules being occupied by those receiving ongoing care. It also inflates costs for simpler services due to unnecessary overhead, disrupts the patient experience with cumbersome processes, and diminishes effectiveness when resources are insufficient for complex requirements. Additionally, it places undue strain on specialists and their staff, who must frequently shift their focus between highly disparate tasks.
Unbundling as a Path to Improvement
The internet’s influence in reducing distribution costs has allowed many companies to unbundle products and services into stand-alone offerings that are more affordable and cater to specific consumer needs. Breaking down specialist activities into modular components and delivering each with tailored clinical, operational, and business models could potentially make specialty care more accessible, cost-effective, efficient, and patient-friendly. Below are strategies for unbundling the four core services of specialists:
- Consultations: Provide stand-alone consultation services, enabling patients to seek expert advice without committing to long-term care.
- Co-Management: Develop specialized co-management programs for patients with ongoing conditions, streamlining their care without compromising efficiency.
- Principal Care: Offer principal care as an independent service, providing individuals with comprehensive management of specific health issues.
- Procedures: Establish specialized procedure clinics, ensuring that patients receive necessary treatments promptly without delays caused by bundled care models.
In conclusion, revamping the U.S. specialty healthcare system involves breaking down the traditional bundled approach and reimagining specialist services as individualized, efficient, and accessible components. This shift towards unbundling holds the potential to address the existing challenges and enhance the overall quality of specialty healthcare in the United States.
Original article published on hbr.org
Read more on welterhp.com
Oct 6, 2023 | Uncategorized
Physician Compensation And Medicare:
When it comes to physician compensation within the Medicare system, it often feels like we’re applying quick fixes rather than addressing the underlying issues. Instead of constantly maneuvering to avoid these pay cuts, it’s important for the government to take steps towards creating a sustainable payment system. In this article, we’ll delve deeper into this ongoing challenge.
2% Reduction In Medicare Payments In 2023
The recent efforts by the American Medical Association (AMA) to mitigate an impending 8.5% Medicare pay cut in the 2023 omnibus spending bill managed to slow down the impending crisis but didn’t bring it to a complete halt. Physicians are still poised to experience a 2% reduction in Medicare payments this year, with a further 1.25% cut looming in 2024. Relying on stopgap measures and perpetually averting cuts year after year is an unsustainable practice, as emphasized by Todd Askew, the Senior Vice President of Advocacy at AMA.
In the initial stages of 2023, Medicare physicians were confronted with a daunting 8.5% reduction in their payment rates. This significant reduction stemmed from a combination of factors, including the expiration of a 3% bonus designed to account for evaluation and management (E/M) increases, the introduction of new E/M values necessitating a budget-neutral adjustment of 1.5%, and an additional 4% cut attributed to pay-as-you-go (PAYGO) measures aimed at curbing excessive spending. Todd Askew observed, “The timing couldn’t have been more unfavorable, particularly considering that many practices are still grappling with the financial aftermath of reduced revenue during the peak of the pandemic.”
PAYGO Cut Successfully Averted
Through collaborative efforts, the American Medical Association (AMA) joined forces with 150 other physician organizations and healthcare groups to diligently prevent these impending reductions. Todd Askew, in reflecting on these advocacy endeavors, noted some positive strides. He stated, “In the larger picture, we managed to delay the 4% PAYGO reduction, effectively eliminating it for this year.” Furthermore, Congress orchestrated a phased reduction of the physician bonus, which offsets the E/M increases, reducing it to 2.5% for the current year, with an additional reduction planned for 2024, bringing it down to 1.25%. Lawmakers opted not to address the counterbalancing of the heightened E/M values, which were responsible for other budget-neutral cuts. All in all, this translates to approximately a 2% reduction in Medicare reimbursement fees from 2022 to the present year, as succinctly explained by Askew.
Medicare Participation Under Scrutiny
While a 2% reduction may be preferable to the initially proposed 8.5%, the impending decrease will cause medical practices to confront challenging decisions. Some practices are already operating on razor-thin margins, with a 2% or even 0% margin. “This situation will undoubtedly prompt many practices to reevaluate the feasibility of their participation in the Medicare program,” he stressed.
For older adult patients, this predicament is likely to lead to widespread access issues across various specialties and healthcare services throughout the country. The ongoing erosion of Medicare payments when compared to inflation will undoubtedly carry long-term repercussions, as pointed out by Askew. Physicians have already witnessed a cumulative reduction of 22% in their payments over the past few decades. Askew underscored this by stating, “This reduction is primarily a result of the underlying payment system’s lack of a mechanism for regular increases to keep pace with the rising costs of inflation.”
A Call for Congressional Attention
Notably, Congress has not undertaken any substantial review of the existing payment system since its inception under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The 2% reduction serves as an alert to Congress, urging them about the ongoing cuts and the gradual devaluation of Medicare payments. This poses a substantial threat to healthcare access.
Askew strongly urged physicians to remain engaged through the AMA’s social media platforms and to remain vigilant for alerts from the Physicians Grassroots Network. “We cannot afford to wait for another crisis because it is highly likely that we will face further reductions in the coming year,” he cautioned. This article was originally published on ama-assn.org.
Welter Healthcare Partners Can Help
- REVENUE CYCLE MANAGEMENT (RCM) PROGRAMS: Increase your Revenue & Cash Flow to ensure financial stability, so you can focus on delivering exceptional patient care
- PROVIDER ENROLLMENT: Managed program eligibility, timely re-credentialing, and compliance that ensures revenue integrity.
- CREDENTIALING / CVO: Verified provider qualifications and training, equals quality patient care.
- CODING COMPLIANCE: Welter Healthcare Partners stays informed of changing coding standards helping you to maximize reimbursement and mitigate risk
Sep 26, 2023 | Uncategorized
In The Rapidly Evolving Landscape of Healthcare
Patients are no longer tethered to a singular provider network. They are now opting instead to distribute their care across a multitude of platforms. As the industry adapts to this shifting paradigm, healthcare providers must use the power of data and establish comprehensive metrics to truly understand patients as consumers. Integrating consumer-focused metrics into strategic planning presents certain complexities. However, it is an essential step for healthcare systems aiming to stay competitive in this dynamic environment. Continue reading to explore the challenges faced by health systems as they endeavor to integrate patient data effectively.
The Evidence Is Stark
American patients are no longer steadfastly loyal customers. Each year, they diversify their care across an average of four to five distinct provider networks. The healthcare landscape boasts an array of choices, spanning from innovative virtual and primary care providers to emerging retail players and urgent care facilities. It’s not surprising that patients seek diversity in their healthcare experiences. To remain competitive, traditional health systems and provider organizations must embark on a journey to comprehend patients in their roles as healthcare consumers. Understanding the intricate mechanics behind their decision-making processes, their underlying motivations, and the how, where, and why of their engagement within the broader healthcare ecosystem.
Additionally, they must decipher how the dynamics of supply and demand shape the markets in which they operate. Indeed, the battle for patient engagement is on the horizon. A staggering 44% of Americans are active Amazon Prime members, contributing to Amazon’s extensive reservoir of consumer data for its ongoing healthcare expansion and targeted strategies. The largest healthcare system in the nation, HCA Healthcare, engages with only 1% of Americans through its care delivery system. As healthcare providers, hospitals, and health systems navigate this new terrain, they must take a page from the playbook of tech giants like Amazon. They need to start adopting consumer-focused strategies to thrive in a shifting healthcare economy valued at $4.3 trillion. This journey begins with data utilization and metric establishment.
Two Pivotal Challenges
One of the foremost challenges encountered by health systems in their pursuit of consumer-focused metrics integration lies in the limited scope of data tracked in this domain. Another hurdle is the reliance on a handful of traditional consumer/patient satisfaction metrics, such as the Net Promoter Score (NPS) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, to project future patient behavior. For example, this will forecast a patient’s likelihood of returning to the same system for care based solely on their self-reported satisfaction with a prior hospital experience. However, patient satisfaction does not serve as a reliable metric of future actions. A patient’s consumer profile may deviate significantly from their intentions.
Healthcare leaders should refrain from banking on patient satisfaction measures to predict and account for future patient behaviors. Instead, they must scrutinize patients’ actual behaviors and weave this information into their strategic planning fabric. To fortify their competitive stance and vie for a dwindling pool of patients, health systems must establish clear-cut measures and metrics that better cater to consumer needs—whether at the individual, organizational, or market level. Among these, two critical categories of metrics warrant diligent attention:
Consumer-focused Preferences and Proclivities
Retail giants like Amazon and Walmart have adeptly employed data from consumer-focused metrics to study diverse customer segments, tailoring their services accordingly. Amazon’s recommendation engine communicates with shoppers through personalized product suggestions, based on past purchases and potential interests. Regrettably, healthcare systems and the broader health economy have lagged behind in adopting such data-driven practices, even though they are indispensable for long-term patient engagement. Health systems must probe deeper to decipher whether a patient’s absence results from a lack of available appointments or a preference for another provider organization.
While some questions may prove more challenging to answer, enhancing technological infrastructure allows health system leaders to deploy data engineering resources effectively, linking patient healthcare utilization patterns with behavioral profiles on a grand scale.
- Does the data unveil patterns of no-shows or cancellations during specific hours?
- Does the integration of consumer behavior data unveil fresh insights into the behavior of distinct patient demographics at different times of the day?
- Can psychographic profiles elucidate internal dynamics or identify reasons behind the loss of market share in specific specialties?
These are the real-time insights that become apparent when health systems collectively harness healthcare and patient behavior data, exploiting resources readily available within the healthcare ecosystem. By grasping the driving forces behind consumer behavior and decision-making, health systems can take tailored steps to engage and serve healthcare consumers, all while respecting their preferences and needs.
Share of Care
Organizations outside of healthcare that take consumer-focused metrics into consideration invest into understanding the economic underpinnings of their businesses. They diligently track their total addressable market, market share/value, and strategies to outperform competitors. Healthcare systems should adopt the same ethos. They must transcend mere revenue targets and delve into understanding their “share of care” within their respective markets.
Utilizing Internal and External Data
What proportion of a health system’s treated patients received care interactions outside the purview of that health system? Health system leaders can look at internal data, encompassing patient journeys across care settings and individual electronic medical records. External data, including local U.S. Census data, benchmarks, and indicators of leakage from health plans, also provide valuable context. Understanding the total addressable market and applying patient behavior metrics are essential for strategic investment decisions. Many health systems have invested in specific access points, such as telehealth and urgent care, with the expectation that these will serve as the “front door” to care, securing patient loyalty for future procedures and healthcare needs.
Utilizing Longitudinal Patient Data
However, longitudinal patient journey data reveal that this hypothesis does not always hold true. This realization can significantly impact service line and investment decisions. Unfortunately, data fragmentation and lagging interoperability initiatives impede access to such vital information. Electronic medical records data, while informative, often neglect patient interactions beyond the walls of a health system’s organization. In a landscape offering more healthcare options than ever before, knowledge is the most potent asset at the disposal of health systems. The healthcare delivery landscape grows increasingly competitive. So, health systems must become data-driven, and align with metrics specific to patients. Armed with consumer-centric insights, health systems can prepare themselves to compete for a share of care in an environment where the supply surpasses current demand for services. The original article was published on hbr.org.
How Welter Healthcare Partners Can Help With Consumer-focused Metrics
With decades of experience we take pride in helping Hospitals, Private Practices, and offices across the US. Using our services like Revenue Cycle Management, or Provider Enrollment, can ease the burden of “back office work”. This will open up your employees time to focus on the happiness of patients!
Sep 21, 2023 | Uncategorized
Patients & The Billing Process
Here at Welter Healthcare Partners, we acknowledge and applaud the dedication of revenue cycle leaders who tirelessly work to benefit patients, including financially. A critical aspect of ensuring a positive patient experience is providing education to guide them through the billing process.
At a recent HealthLeaders Patient Financial Experience Summit, Mary Neal, AVP of Revenue Cycle at Ochsner Health, and Savanah Arceneaux, Director of Pre-Service and Financial Clearance at Ochsner Health, joined a summit session to discuss strategies for creating and streamlining patient education resources. These strategies aim to improve patient satisfaction, particularly in the face of challenges like the No Surprises Act.
Patient Billing Challenges
Revenue cycle staff are faced with the complexities of billing statements and good faith estimates, placing a significant burden on their shoulders when assisting patients in navigating these intricate documents. In todays landscape a subpar financial experience can overshadow a five-star clinical encounter. Therefore, revenue cycle leaders are under increasing pressure to streamline processes for their patients. So, what’s the key to addressing this challenge? Neal and Arceneaux emphasize the importance of comprehensive patient education. Additionally, emphasis on payer and cost education throughout the revenue cycle is crucial.
Financial Responsibility
“In recent years, payers have shifted more financial responsibility onto patients, presenting a significant challenge. This shift has driven us to reevaluate our long-term strategic vision for creating a more consumer-friendly experience. We’ve opened a digital front door, offering patients various options to access resources and education about their plans,” noted Arceneaux. This approach has led Ochsner to embrace services and technology that facilitate closer patient engagement and connection even before their scheduled visit.
“While we aim to collect owed payments as a patient-centered organization, we also want to involve our patients every step of the way. We strive to ensure they are financially informed before their visits, contributing to their overall satisfaction,” Arceneaux added.
Help your practice or hospital get ahead of billing challenges by contacting Welter today!
