A Snapshot of the HealthCare Executive Group

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Ferris Taylor has been around healthcare for a long time – for almost 30 years now. Over these 30 years, Ferris has seen the ebb and flow of healthcare from multiple angles.  He’s been on the inside of healthcare working for health plans and providers and on the outside working for vendors and consulting firms that serve health plans and providers.

For most of his 30 years in healthcare, Ferris has been involved with the Health Care Executive Group; a 26 year old organization of health care executives having a desire to share information, ideas and challenges that impact the regional, state-wide and area-wide HP’s and provider groups of which its executives are associated.

Ferris was recently interviewed by IntrepidNow where he shared his perspective on healthcare over the last three decades, the sea change that began in healthcare about five years ago, and three specific benefits the Health Care Executive Group provides to its members. Introducing the Healthcare Executive Group Podcast

Benefits of the Health Care Executive Group

  1. Exposure and access to a broad spectrum on industry participants: payers, providers, pharmacy, medical device and other companies that serve the healthcare industry.
  1. A select, non-competitive network of executives that HCEG members can interact with on a day-to-day basis to help address immediate issues and and look to the future to explore what the healthcare industry could be facing the following year and years beyond.
  1. A vetted group of vendor sponsors that take off their sales hat and participate with the HCEG members as thought leaders who share their perspective rather than pitching their solutions.

2016 HCEG Annual Forum

Ferris also shared some information about HCEG’s upcoming 2016 Annual Forum including details on its three areas of focus, what attendees can expect from their participation at the forum and what sets the HCEG Annual Forum apart from other healthcare conferences.

Listen to this podcast to hear what Ferris has to say and check out this page for more information on the 2016 HCEG Annual Forum held September 12-14 at the Renaissance New York Midtown Hotel in New York City. You can learn more about the Health Care Executive group on the Web and follow them on Twitter, Facebook and LinkedIn!

Payment Reform and MACRA: The World is Speeding Up

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Payment reform is much talked about, often written about and now becoming real in today’s world. The move to value-based reimbursements and other new business models is an inevitable reality that is dramatically reshaping the US healthcare system. In the Fee for Service model, providers were typically compensated for the volume: the number of patients seen and tests conducted; in the new world of value-based reimbursements they will increasingly be paid for successful outcomes, promoting healthy behaviors and the prevention of expensive episodes of care. As Richard Migliori, MD, Chief Medical Officer of United HealthGroup recently stated at an industry conference, In a Fee for Service world, the typical physician used to worry about who was in the waiting room. Now in the value-based world they have to worry about who is NOT in the waiting room. He went on to share that of United’s $100 billion in reimbursements, 43% have some tie to value today.

Now CMS is taking a leading role in the transformation, with the recently released MACRA (Medicare Access and CHIP Reauthorization Act of 2015) rule, designed to push quality measures tied to reimbursement incentives for Medicare providers. With the fastest growing segment of health insurance members belonging to government sponsored programs, including Medicare, Medicaid and Duals, CMS has publicly stated it is targeting 30% of all of its reimbursements to be value-based by 2019, with 50% by 2021 and 75% by 2023. The initial MACRA quality measures will start on January 1, 2017, with payments beginning in 2019. And the MACRA rule is written with specific intent of moving the model beyond Medicare into Medicaid, and ultimately into the commercial market over time.

Health plans are compelled to prepare for the change to value-based contracting and quality-based outcomes that MACRA will bring with it. Payors, particularly those with Medicare Lines of Business, must be ready to capture data related to the new quality and performance measures, beginning on January 1, 2017. Payors must have the ability to adjust the way services delivered are reimbursed under Medicare, and embrace the value-based models that MACRA is introducing and reinforcing. And to do so, payors need to leverage a technology infrastructure with the agility to move quickly in order to adjust their benefit and payment models.

Industry experts have been weighing in on MACRA through the recent comments period and in other public forums. A few examples are:

Deloitte: MACRA is poised to drive payment and delivery reform across the payer mix for the foreseeable future.

American Medical Association President Steven Stack: “Our initial review suggests that CMS has been listening to physicians’ concerns,” adding, “In particular, it appears that CMS has made significant improvements by recasting the EHR Meaningful Use program and by reducing quality reporting burdens.”

PwC: In many ways, MACRA genuinely reflects Medicare and Medicaid’s drive towards payments that are based on the quality of care physicians deliver rather than the quantity of procedures they perform.

Senator Debbie Stabenow, Democrat from Michigan: MACRA is a truly historic piece of legislation.

 

In June, a select group of health plan executives and other healthcare leaders gathered for an industry roundtable, sponsored by HealthEdge and Deloitte, for a discussion and to share their perspectives on MACRA.

Executives attending the roundtable considered many aspects of the anticipated changes, including:

  • How quickly the government’s push for pay for performance could truly extend beyond Medicare, into Medicaid and commercial plans and the resulting changes to payer-provider networks and contracts
  • The need for process changes and improved efficiency in how a population is identified and treated, particularly those in at-risk categories.
  • The urgency for health plan IT organizations to have a detailed understanding of the agility and flexibility required to handle changes to provider payments based on performance. Participants stressed that this is a key ingredient for system success that will translate to the financial health of the plan.
  • The ability for a health plan to consider members strategically and with a long-term view, particularly by establishing quality results for younger members and those with lower risk, to create a membership base with high loyalty for the future.
  • The potential impact the law will have on smaller and rural practices. Virtual groups of providers will be facilitated by CMS, along with $20 million of funding, all designed to aid providers of all sizes to participate in the Advanced Payment Model program
  • How the inclination for health plans to narrow provider networks to work with highly rated physicians must be balanced with proper access to healthcare services.
  • The consensus that much of healthcare is local and community based, and MACRA could encourage opportunities to strengthen those relationships in places where the linkage is already strong.
  • The realization that those providers and provider entities that are in denial (I.e. some IDNs) are in for a shock.

With the January 1, 2017 start of the first quality measurement period fast approaching, MACRA promises to be a significant force in how payment reform is accelerated, beginning with Medicare and expanding to all forms of health insurance in the future.

 

About the Author

3bf5dd8Harry Merkin, Vice President, Product Marketing, HealthEdge

Harry Merkin has worked with both payers and providers through many dynamic changes in healthcare for a number of years. He is currently responsible for Product Marketing at HealthEdge and previously had similar responsibilities at Evariant and NaviNet. Merkin has collaborated with many transformative entities across the healthcare landscape. He has helped introduce and promote enterprise software solutions that enable payers to improve their competitive effectiveness, as well as perform valuable communications between payers and providers, and allow providers to effectively collaborate with patients and consumers as well as with each other. Merkin is the parent of two Millennials and is a long-time New England Patriots season ticket holder.

The HCEG 2016 Annual Forum

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Healthcare Executive Group 2016 Annual Forum, Sep 12-14 in New York City

TheHealthCare Executive Group(HCEG) is a 26-year old national network comprised of select executives from across the entire healthcare spectrum health plans, health systems, providers and a handful of vendors that join together to learn, share and reshape the healthcare industry. HCEG was founded by healthcare organizations as a grassroots organization to serve healthcare executives by providing a forum for open discussions regarding the dynamic healthcare eco-system.

Thought Leadership, Education & Information

HCEG members benefit from a rich thought leadership, educational resources and information sharing opportunities throughout the year. In additional to enjoying access to an exclusive group of leading healthcare executives, HCEG members have continuous access to webinars, virtual panels, white papers and other content specific to their roles as high-ranking healthcare executives.

2016 Annual Forum – Sep 12 – 14 in New York City

HCEG’s Annual Forumbrings together 80-100 executives from across the healthcare spectrum for two days of transformative and compelling dialogue; focused on the continuous innovation in healthcare, as the marketplace becomes every day more and more dynamic with technology both leading and lagging what the patient consumer, the payers and the providers all demand. These topics and issues, which originate from the HCEG Top 10 (more below) will be extensively discussed throughout the Annual Forum, and are illustrated in the HCEG Integrated Strategy

This year’s theme HealthCare Innovation: The New Norm is not only timely and relevant, but promises to not only encourage, but deliver thought provoking group discussions.The close-knit networking environment the Annual Forum is widely known and appreciated for, provides HCEG members an ideal relationship building environment, with industry thought leaders presenting captivating sessions that effortlessly align on HCEG’s Top Ten Issues in Healthcare as voted by HCEG members during each Forum.

These Top 10 issues are:

unnamed1. The Consumer Experience: Omni-channel business, mHealth, HIX, social media and telehealth.

2. Payment reform: ACOs, P4P, value-based care and value-based reimbursement.

3. Population health: managing total health, including social and environmental determinants.

4. Provider/Plan integration: combining functions of care delivery and financing in a single organization.

5. Transparency: triple aim price, quality and service measures to support customer decisions.

6. Retail health care: established consumer companies disrupt traditional care providers (Tied).

7. Pharmacy: cost, compliance, convenience & specialty health (Tied).

8. Big data and advanced analytics: identifying patterns, opportunities in vastly detailed data sets.

9. Cybersecurity: protecting the privacy and security of customer information.

10. Genomics: customizing prevention and treatment to individual DNA.

HCEG is currently registering attendees for its Annual Forum in New York City on September 12-14th. HCEG leadership extends an invitation to join its organization and attend its Annual Forum in New York. See here for more information on the HCEG Annual Forum. To register, click here. Please contact Juliana Ruiz atjr@hceg.orgor 954.361.5236 for membership and/or information on the 2016 HCEG Annual Forum.

 

 

 

 

Is Your Organization Exposed to a Data Breach?

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Too often the theft of personal health information (PHI) or personally identifiable information (PII) can go undetected before law enforcement or FBI intervention. Last year alone, the healthcare industry experienced its largest healthcare data breach in U.S. history, compromising the data of nearly 80M health insurance members.

While insurers continue to be the target of sophisticated cyber-attacks, there are several ways to combat this threat. To start, the industry must learn to better understand both current and future threats and vulnerabilities. They must place a greater emphasis on cyber security to protect the information and data they are entrusted to mange by their customers, members, and patients.

In the individual health insurance market, payment facilitation relationships among health plans and other software companies are common, and assist with the facilitation of premium payment transactions paid by health plan members or the buyers. Serving as the merchant,the health plan may offer its benefit products both on and off public health insurance exchanges. To facilitate the large quantities of payments received, these relationships offer unique advantages to the health plan, shifting many functions and risks to the payment facilitator.

What is a Payment Facilitator

Payment Facilitators possess not only the power to accept payments, but also to disburse payments to third party entities. Offering services to a wide array of clientele, payment facilitators open up new doors for their stakeholders whom would otherwise not be able to perform critical business functions that affect their payment and transactional processes.

At the core of many businesses, including PayPal and Square, the payment facilitator model is typically employed by independent sales organizations, transactional processors, payment gateways, third party marketing firms, and/or web hosting companies. This model offers not only the power to accept payments but also to disburse them to third party entities.

Facilitating the credit and debit payments within payment ecosystems, payment facilitators or payment service providers (PSP) aggregate real-time transactions on behalf of merchants. And, without their services, small businesses, individuals, organizations, and charities would be incapable of fulfilling their transactional needs at the same level of ease. In turn, partnerships among individuals and/or organizations and payment facilitators have grown in both frequency and popularity.

In the individual health insurance market, payment facilitation relationships among health plans and other software companies are common, and assist with the facilitation of premium payment transactions paid by health plan members or the buyers. In this scenario, the health plan serves as the merchant, offering its benefit products both on and off public health insurance exchanges. To facilitate the large quantities of payments received, these relationships offer unique advantages to the health plan, shifting many functions and risks to the payment facilitator.

But how does this affect cyber security?

Becoming a payment facilitator is no easy feat. The process is undoubtedly complex and requires confirmation of the organization’s financial status and viability, proof of insurance, as well as other documentation obligatory for entering into a binding agreement with an acquirer. The payment facilitator must also contemplate the kind of customer relationship management (CRM) platform it will secure and utilize to manage its merchants, undergo stringent background and credit verifications, as well as acquire the necessary tools for regulatory compliance and data credibility much as fraud prevention instruments to reduce the payment facilitator’s liability and risk.

But perhaps the most important step surrounds the payment facilitator’s requirement to validate its PCI DSS compliance, which is set by the PCI Security Standards Council. The PCI Security Standards Council, a global open body that is composed of representatives from the five founding global payment brands and strategic members, creates and enforces stringent payment security measures that merchants, financial institutions, and point of sale vendors must adhere to.

What is PCI DSS?

The Payment Card Industry Data Security Standard (PCI DSS) is a proprietary information security standard for organizations that handle branded credit cards (Visa, MasterCard, American Express, Discover, etc.). Formerly referred to as the Payment Application Best Practices (PABP), PCI DSS was established to provide a definitive data set for software vendors to deploy payment applications.

PCI DSS offers a benchmark of technical and operational requirements to protect and secure cardholder data, utilizing twelve core requirements:

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Figure 1 PCI Data Security Standard: 12 PCI DSS Requirements

With PCI DSS, the risk of data hacks and breaches are significantly reduced. From customers to merchants and financial institutions, the security of cardholder data affects everybody and can lead to devastating outcomes. Likewise, the concept of payment facilitation has also become critical to numerous small business, charities, and other organizations in meeting the demands of their customer base and their desired payment acceptance methods. Embracing new payment approaches and data exchanges, the payment facilitation model delivers a unique value proposition to its stakeholders fulfilling business functions that the merchant would otherwise not be able to meet.

Read more on the steps required to become a payment facilitator and the significance of PCI DSS in Softheon’s whitepaper:Payment Facilitators & Aggregators: The Payment Facilitator Model Stakeholders & Considerations.

https://www.pcisecuritystandards.org/documents/pci_dss_v2.pdf

https://www.pcisecuritystandards.org/documents/pci_dss_v2.pdf

https://www.pcisecuritystandards.org/pci_security/

AHIP 2016 Highlights: Top Healthcare Industry Execs Discuss Data Integration Challenges & Discuss Priorities

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AHIP 2016 was held last week in Las Vegas, NV at the Wynn hotel & casino. It was an excellent turnout from an attendee audience perspective solid representation across payer and provider organizations as well as business and IT participation from departmental manager to CEO and vendor community support. Below are the insights and outcomes of an executive roundtable meeting that discussed data integration challenges and opportunities in healthcare hosted by MarkLogic, a leading operational and transactional Enterprise NoSQL database provider powering numerous healthcare digital transformation projects and data silo integration / aggregation strategic initiatives for payers, providers and health IT vendor platforms.

The following research and information is summarized and de-identified to respect the confidentiality of the executive roundtable audience and their respective organizations. The organizations represented included market leading payers, providers, health IT vendors and consultants. Audience titles ranged vertically from director to CEO and horizontally from clinical, administrative, financial, product, operations and IT functions. The prevailing executive roundtable observation and summary insight, after more than 90 minutes of discussion and debate on individual healthcare industry themes and use cases was that, breaking down data silos and developing an enterprise data layer or hub is fundamental to achieving any one of these strategic initiatives and use cases that are essential to our ability to innovate, modernize and survive.

The executive roundtable topics were sourced in part from the Healthcare Executive Group (www.hceg.org) 2016 Top Ten List (http://hceg.org/wp/hceg-top-ten/) and direct industry field interactions. The HCEG 2016 annual forum is scheduled for September 12-14th in New York City.

While there are many levers to flip and knobs to turn to lead healthcare into the modern era of the new digital health economy, this executive roundtable discussion was primarily focused on the underlying data integration challenges holding back innovation created by decades of departmental purchasing of proprietary, standalone point solutions and developing or implementing applications using rigid relational technologies requiring expensive and resource intensive extract, transform and load (ETL) processes.

The stimulus for the executive roundtable audience provided a categorization of broad healthcare market initiatives shared across geographies and lines of business focused on the strategic themes listed below:

  • Client Management
  • Consumer Engagement & Retention
  • Data Enablement & Infrastructure
  • Network Management
  • Payment & Reimbursement
  • Population Health & Medical Management
  • Quality, Accreditation & Compliance

The executive roundtable audience was asked to score and prioritize the degree of impact and importance data integration has on the strategic themes and initiatives listed above. The response scoring methodology, principles and process leveraged techniques from an acclaimed book on leading innovation called, Nail It then Scale It: The Entrepreneur’s Guide to Creating and Managing Breakthrough Innovation, by Nathan R. Furr and Paul Ahlstrom.

Some typical or common use cases aligned to the strategic themes / initiatives listed above were provided the simulation stimulus into give the executive audience context in their scoring consideration for data integration impact and importance. Use cases included, but were not limed to:

  • Client Management Use Cases
    • Client (group) contract management / search
    • Client (group) onboarding
    • Client (group) premium payments
    • Product & policy administration
  • Consumer Engagement & Retention Use Cases
    • Consumer360 / Vision 2020
    • Member communications
    • Provider search
    • Online enrollment / exchanges
  • Data Enablement & Infrastructure Use Cases
    • Enterprise data layer / digital transformation hub
    • M&A integration
    • Provider interoperability / health system integration
    • Mainframe migration
    • Re-platforming home grown apps (3rd party app conversions)
  • Network Management Use Cases
    • Provider contract management / search (FFS and VBR)
    • Provider network management (enrollment, credentialing, etc)
  • Payment & Reimbursement Use Cases
    • Billing, payments and collections (premiums)
    • Reimbursement (FFS, ACO, VBR, MACRA, etc.)
  • Population Health & Medical Management Use Cases
    • Care management, Disease Management, Utilization Management
    • Risk management / stratification
    • Data analytics / reporting
  • Quality, Accreditation & Compliance Use Cases
    • NCQA accreditation, audit & compliance
    • URAC accreditation, audit & compliance
    • STARS accreditation, audit & compliance
    • HEDIS audit & compliance
    • Fraud, Waste & Abuse and Special Investigations Unit (SIU)

The results of the executive roundtable audience scoring and prioritization the themes and use cases are below. The criteria for a minimum investment for an individual theme or initiative were $20 and the total budget available per audience member was $100. Investment per theme or initiative could be any amount between $20 – $100.

  • #1 Data Enablement
    • Average index score of $42.15 investment contribution
    • High = $50
    • Low = $25
    • Insight: 70% of the audience put some form of investment in this category. This was a high frequency and high average monetary contribution area of priority for data integration.
  • #2 Network Management
    • Average index score of $35.00 investment contribution
    • High = $60
    • Low = $20 (minimum investment)
    • Insight: 25% of the audience put some form of investment in this category. This was a low frequency but high average monetary contribution area of priority for data integration.
  • #3 Consumer Engagement & Retention
    • Average index score of $32.50 investment contribution
    • High = $50
    • Low = $20 (minimum investment)
    • Insight: 90% of the audience put some form of investment in this category. This was a high frequency but average to below average monetary contribution area of priority for data integration.
  • #4 Population Health & Medical Management
    • Average index score of $30.63 investment contribution
    • High = $40
    • Low = $20
    • Insight: 70% of the audience put some form of investment in this category. This was a high frequency but average to below average monetary contribution area of priority for data integration.
  • #5 Payment & Reimbursement
    • Average index score of $30.00 investment contribution
    • High = $40
    • Low = $20
    • Insight: 80% of the audience put some form of investment in this category. This was a high frequency and below average monetary contribution area of priority for data integration.
  • #6 Client Management
    • Average index score of $26.25 investment contribution
    • High = $40
    • Low = $20
    • Insight: 25% of the audience put some form of investment in this category. This was a low frequency and below average monetary contribution area of priority for data integration.
  • #7 Quality, Accreditation & Compliance
    • Average index score of $20.00 investment contribution
    • High = $20
    • Low = $20
    • Insight: 15% of the audience put some form of investment in this category. This was a low frequency and below average monetary contribution area of priority for data integration.

In summary, there was strong agreement among executive roundtable participants that data infrastructure investments and enhancements were needed before additional application, investments and enhancements. To be specific, most executive roundtable participates agreed that their organizations needed an enterprise data foundation that is transactional, not just another static data warehouse, to integrate data across disparate sources and formats to run our business on before organizations could truly improve application performance, utilization and ultimately customer experience and satisfaction.

About MarkLogic

For over a decade, organizations around the world have come to rely on MarkLogic to power their innovative information applications. As the world’s experts at integrating data from silos, Mark Logics operational and transactional Enterprise NoSQL database platform empowers our customers to build next generation applications on a unified, 360-degree view of their data. Headquartered in Silicon Valley, MarkLogic has offices throughout the U.S., Europe, Asia, and Australia. For more information, please visit www.marklogic.com.

MarkLogic is a registered trademark of MarkLogic Corporation in the United States and/or other countries. All other trademarks mentioned are the property of their respective owners.

About HCEG

The HealthCare Executive Group is a national network of select healthcare executives and thought leaders, who navigate the tactical and strategic issues facing organizations today and provide a platform that promotes healthcare innovation and the development of life-long relationships. Originally the Managed Care Executive Group (MCEG), The HealthCare Executive Group (HCEG), was founded in 1988 by healthcare executives looking for a forum where the open exchange of ideas, opportunities for collaboration, and transformational dialogue could freely ensue. For more information, please visit www.hceg.org

Author: Bill Gaynor, Healthcare National Director at MarkLogic Corp.

The importance of transparency in the new healthcare marketplace

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Transparency in healthcare has been an important topic for many years. The usual focus of discussions in this area had been on providing the right information to leaders inside of the organization, to enable them to make good decisions about their businesses based upon the performance of various products, offerings and services teams. Being able to see these metrics in real-time, in a way that would enable these leaders to pivot or shift as market needs changed, was considered the key to any transparency initiatives. Over the past few years, the expectations related to organizational transparency have expanded significantly, particularly related to external transparency. This has been driven by a number of important factors, most significantly the shift away from traditional fee-for-service business models towards models that leverage new approaches including value-based benefits and value-based payments (also still sometimes call pay-for-performance). While internal transparency is still critical for business success, many health insurers are now realizing that external transparency is equally important. This is particularly true with regards to many of the new healthcare business models, and particularly those models that require the active participation of stakeholders like members and providers. The success of many of these new models will be gated by the health plans. ability to provide accurate, actionable, real-time information to everyone involved in the healthcare delivery cycle. Members must have the information required to enable them to quickly and accurately evaluate price, quality and service, and to comply with their recommended care plans. At the same time, providers must have the ability to get the real-time information that will be required for them to play their roles in the new healthcare ecosystem, particularly related to their care of at-risk groups who may be participating in new programs where the providers are rewarded for their ability to help drive a healthier and happier population. To be successful in this new marketplace, health plan executives must determine what will be required to fully participate in this evolving healthcare economy, and they must then build and then execute a plan to bring their organizations to the required levels of transparency in terms of their people, their business processes, and, most importantly, their technology.

 

By Ray Desrochers, Executive Vice President, HealthEdge

Payer Provider Integration and the Eight Questions You Should Be Asking Yourself

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CMS Leading the Way

As we continue to look for ways to drive improvements in quality of care while positively impacting the rising cost trend, collaboration between and the integration of payer and provider organizations has emerged as a leading strategy and a vision for the future. While we see evidence of a more integrated future across all healthcare sectors, today CMS drives changes through the Innovation Center founded under the purview ACA.

The most prominent example of innovative initiatives is the ACO Pioneer Program implemented by CMS. The overall intent is to create accountability for the care of a population (Population Health) and align incentives with the providers and payers responsible for these populations. Initial models focused on shared risk and upside for savings while protecting against downside risk and then moving towards full risk agreements in the future. CMS continues to demonstrate innovative thinking through the introduction of new reimbursement models, for example bundled payments for specific services. Again, aligning incentives between payer and provider and promoting care coordination will ensure that patients experiences the full benefits of the Triple Aim of healthcare: focusing on population health, improving the experience of care and impacting the per capita cost of care..

How these initiatives are implemented varies across regions, but all are focused on the same core elements: defining the needs of the population, designing interventions to address these needs, coordinating care across care modalities, aligning incentives across the ecosystem and measuring performance. As I stated, companies implementation approaches vary, for instance what role does the health plan care manager take Who provides or funds the required care coordinators

As CMS clearly understands, the key to driving improvements in quality is a new system for provider reimbursement. Specific programs are being develop and tested to move away from payment for service to payment for value. A recent key initiative driven by the CMS Innovation Center is their Bundled Payments for Care Improvements (BPCI). CMS has created four broad models of care which link payments for multiple services beneficiaries receive during an episode of care. These models test different reimbursement approaches graduating to a full risk based prospective payment for all services. In Model 4, participating organizations enter into agreements where they are accountable from a financial and performance perspective for an episode of care. The accountability keeps the focus on driving improvements in quality and a reduced cost for Medicare.

Another recent focus area being led by CMS is the Comprehensive Primary Care Initiative (CPC) launched in late 2012. The CPC is a five year plan focused on improving patient care by helping primary care practices improve their operations and work with patients to provide:

  • Access to care providers and Continuity
  • Planned Care for Chronic Conditions and Preventive Care
  • Risk-Stratified Care Management
  • Patients and Caregiver Engagement
  • Coordination of Care Across the Medical Neighborhood

In an April 2016 announcement, CMS released the largest-ever initiative to improve how primary care is delivered and paid for in the United States. The Comprehensive Primary Care + (CPC+) will have two tracks:

  • Track 1 practice get a monthly care management fee in addition to fee for service
  • Track 2 provides the practices a monthly care management fee, reduced fees for E & M services but a monthly up-front comprehensive primary care payment for these services.

Lastly the newly announced Medicare Access and CHIP Reauthorization Act of 2016 (MACRA) directly impacts provider reimbursements and specifically incentives compensation for quality of care. The program focuses on changing the existing Sustainable Growth Rate (SGR) payment formula. MACRA should create a new framework for rewarding providers for giving better, rather than just more care and combining existing quality reporting programs into a single program. It also moves away from rewarding providers for use of technology under the current Meaningful Use Program and into rewarding providers who use technology to demonstrate improved care and outcomes.

While CMS is seen as leading the way, we have seen examples of commercial payers implementing their own value-based payment programs. Horizon Blues Cross and Blue Shield of New Jersey successfully implemented bundied payment programs that focus on payments for episodes of care as evidenced by their recent press release on February 16th, 2016. Aetna, Anthem and United Health Group all have plans underway to shift the majority of their payments to value based contracts over the next few years. While these programs have been in existence for years, what is different is the processes and technologies that support these programs that allow them to be successful.

Technology Implications

Technology is critical to the success of payer-provider collaboration and integration initiatives. CMS understood this and through the ACA has invested millions of dollars into helping providers acquire systems to support the creation of environments that allow data to be available and interoperable across organizational boundaries. Data is key to the success of all of these new collaboration and integration opportunities. Organizations that are self-contained, such as Kaiser, have an easier path to creating an environment where data is defined singularly and available across the organization. Because many of the organization that are collaborating to manage the health of a population are separate and distinct companies, their information architecture may be different making it difficult or impossible to exchange data. While the healthcare industry, spurred on by HHS, has been focusing on establishing and implementing standards for patient data exchange, we as and industry, have not made the progress required to find lasting success. We still have work to do as do vendors that provide solutions to this market.

Organizations cannot rely on single vendor solutions but must invest in tools and resources to support data exchange and aggregation between multiple platforms. The long-term vision is for the exchange of data to be at a discrete date element layer as opposed to sending a pdf report that cannot be used to support any analytic needs. The efforts cut across company boundaries and demand the interoperability of data across the entire healthcare ecosystem to support improvements in care at the time of service, enable the use of data to improve our ability to analyze the health of the population and support the implementation of interventions designed to address specific healthcare conditions. These efforts are not for the faint of heart, nor will they be addressed in a short-time frame. We will need to have patience to address both organization and technical barriers while recognizing the need to push forward as an industry to make progress. Lastly, in addition to data exchange and data aggregation for analytics, some of our existing core systems will need to be enhanced. For example, a claims system will need to be able to support payment for episodes of care as opposed to an individual claim.

Given all of this uncertainty, how do we as organizations move forward with these business ventures What are the critical success factors that need to be addressed to help mitigate risks and improve the likelihood of success

  1. Does your organization have a clear business strategy and plan that identifies objectives, and the roles and accountabilities that organizations will provide within these new business ventures
  2. Are incentives and the allocation of funds aligned to support the objectives you have defined
  3. Have you defined a care coordination strategy based upon an assessment of the health of the population that you will serve
  4. Are business requirements defined to support the model that you have developed:
  5. Does the business model identify the underlying data/information needs for each role/organization involved in this venture including the source and use of the data
  6. Do you have knowledge of the technical capabilities of the organizations in your business model to understand to assess their ability to address the identified requirements
  7. Have you developed a resource plan to support both the implementation and ongoing operations of your business venture
  8. Have you developed Key Performance Indicators (KPI) that will allow you to measure your progress

While the above question seems overwhelming, those sitting on the sidelines may be a risk as those organizations who are choosing to play the game may creating separation and competitive advantage.

 

Change Healthcare

https://changehealthcare.com/consulting

The Growth of Provider led Health Plans in the Individual Market

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Offering a health plan can give health systems a variety of strategic and economic advantages. The decision is not without risk, however. To benefit from this move, health systems will need to understand their consumers. A recent analysis provided by McKinsey & Company explains the growth of this business model and examines the key factors tied to success.

Recent Developments

Between 2010 and 2014, the largest enrollment growth for PLHPs in percentage terms occurred in the individual market. One of the primary drivers of this growth is the fact that many providers introduced public exchange plans as a way to drive volume. During that time, enrollment increased from about 270,000 to 670,000 members. This represents annual growth of approximately 25%. The number of providers offering health plans in the individual market rose to 55 from 36 during that span of time. The CO-OP shutdowns and losses incurred by large insurers, combined with heightened penalties for being uninsured, indicate that further growth in this market is likely for PLHPs.

Despite the significant increase in overall enrollment, most PLHPs remain comparatively small. In 2014, only five providers had plans that cover more than 500,000 members. In the aggregate, however, these plans had a fairly large market share. A regression analysis recently provided by Deloitte indicated that market share drives profitability for the PLHP model.

Since 2014, PLHPs have become more price competitive on the public exchanges. In the first open enrollment period (OEP), they were the price leader (the carrier offering the lowest-priced silver plan) in 15% of the counties where one or more PLHPs were available. That percentage rose to 19% in the 2015 OEP and then to 26% in 2016. PLHPs were especially likely to become price leaders in areas where CO-OPs exited the 2016 exchanges.

Consumerism

The possibility exists, however, that competition on the basis of price is not the appropriate strategy for PLHPs. The rise of healthcare consumerism has substantially changed what many people want from providers and health insurers. These changes play into the hands of PLHPs in many ways. If providers want to use health plans to increase volume, however, they must understand consumers price sensitivity and benefit preferences.

While people who buy health insurance for themselves tend to prefer low-cost plans, they do not base their purchasing decision on price alone. People have demonstrated a willingness to pay more for features that provide added convenience, such as guaranteed appointments, after-hours appointments, telemedicine services, and weekend appointments. The data also indicate that consumers are willing to let their health information be shared between insurers and providers.

Opportunities

Another important element to consider is the administrative model that these systems choose to employ. Often, the administrative infrastructure used to set up a PLHP is similar to that of a stand-alone health plan (granular claims requirements, extensive prior authorization lists, utilization management and care management prerequisites, etc.). This represents a lost opportunity for PLHPs, who really should take advantage of the chance to rethink the traditional payer administrative infrastructure. Because most provider-led plans cover 150,000 lives or less, it is impossible for them to attain the benefits of scale using the traditional payer administrative model. Greater efficiencies and reduced costs can be discovered by aligning policies between the health system and the health plans business units to achieve a level of cohesion that traditional payers simply cannot.

Health systems with their own health plans have an important advantage: integrated claims and clinical data that can allow them to produce sophisticated analytics. As a result, they should be able to make the most of opportunities for better medical management by identifying at-risk patients, offering them appropriate preventive care, and, when necessary, intervening early.

There is an opportunity for PLHPs to consider pricing and product benefits in a new way. The product benefits should be tailored to the strengths of the care management offered by the underlying health system. As with any business, location is a critical component to the success of a PLHP. The most suitable place for a PLHP is a region where the health system has a large share of a consolidated provider market and the level of payer consolidation is low.

Common Sense Health Service Purchasing: Medical Shopping 2.0

By | Uncategorized

Introduction

In a world where consumers can quickly and easily compare costs and buy nearly any item they desire online from cars to plane tickets it is safe to say that consumer’s expectations around the purchasing experiences are higher than ever. However, it’s not just the retail sector that has figured out how to streamline these web-based and omni-channel encounters. Online banking, travel, hospitality and other service-oriented organizations have been quick to follow its lead. Yet the health care industry has lagged far behind in these efforts. There are many reasons for this delay, including the following factors:

  • Health care pricing is incredibly varied and involves a complex interplay between each provider’s negotiated rates with the payer and the consumer’s own benefit design and deductible balance.
  • Provider bills are reconciled and payments are received weeks or even months after service is rendered through the claims submission, adjudication and reimbursement process with the insurer.
  • Health care decisions were not always as consumer-driven as they are currently. In the days of HMOs and other restrictive plan designs, providers and payers served as gatekeepers often deciding where, when and what kind of treatment was best for a patient.
  • In the recent past, the insured’s cost share for utilizing health care services was significantly lower. Most of the insured’s cost resided in the premium payment. With little or no financial out-of-pocket responsibility at the point-of-service, consumers were decidedly less concerned about comparison shopping for care.

Shining a light on cost variation and avoidable utilization

There is no doubt that consumer concerns about their rising share of costs and experience dissatisfaction are well founded. Many experts in the industry will admit that there is widespread pricing failure and lack of a common sense experience across the traditional health care system. Cost variation within and among payers, providers and geographies is widespread. One Blue Cross and Blue Shield Association report shows that costs for knee and hip procedures can vary by as much as 313 percent. Another industry report shows that for MRIs, the most expensive hospital in the nation has prices twelve times as high as the least expensive hospital. However, cost variation also plagues the ambulatory care side of the industry. Certain out-of-network providers bill up to 100 times more than other providers for the same services. Research shows that 71 percent of emergency room visits could have been avoided through consumer selection of more appropriate, lower-cost care options.

Transparency tools fall short

Many health plans have certainly attempted to make health care service costs and decision-making better for consumers. Most payers have implemented some type of transparency tool for their members. However, there are problems inherent in using this approach as a standalone band aid approach that addresses a symptom (unknown price estimates pre-service) and not the root cause (pricing failure in health care, known and reliable prices pre-service). These tools are not electronically actionable or transactional, and are often inaccurate, resulting in surprise consumer EOBs that dismantle consumer trust and confidence instead of building it. That’s because pricing information in transparency tools is often based on batch, not real-time, data, regional allowed amount averages at worst, or at best, historical paid claims costs. However, even historical claims payment information can easily become outdated as provider contracts change and it is more limited in its usefulness in rural areas, where a health plan may only have a small sample size of data. Consumers inherently doubt and distrust the accuracy of price quotes or estimates that are not immediately transactional or binding.

Many consumers also find these first generation price transparency and cost estimating tools limited in relevance for everyday health care needs. That’s because many of these tools are geared towards high cost acute services. Most also lack instant gratification transaction processing capabilities and pricing assurance. Perhaps it’s not a surprise then that while industry surveys show that 98 percent of health plans say they offer cost calculator tools, only two percent of members actually use them.

Addressing the shortfalls of today’s fragmented system

Consider the convenience and value of the real-time e-commerce purchasing approach compared to the traditional health care shopping and transparency model. In the traditional model, consumers have to seek out information from different stakeholders and avenues. There is no consistency, convenience or sense of ongoing engagement. Consumers may turn to their health plan for information about network providers and benefits, search for provider reviews on third-party websites or by asking friends and family, and then utilize transparency tools to approximate their costs. Then they must contact providers directly to confirm network status and schedule office visits. Finally, payment itself can be a complex interplay between point-of-service payments such as copays and additional balance payments submitted via mail after benefit reconciliation is complete, and this process typically takes more than 30 days.

This fractured and disconnected traditional process can only be understood through research and heavy lifting from consumers actively seeking out information from all of these stakeholders in a variety of different ways. Expecting consumers to navigate through this maze of information seeking and experience is clearly one reason why health care has failed to effectively engage, activate and influence consumers enough to significantly move the needle on cost and quality. This legacy process is disjointed, frustrating and time-consuming. As a result, many consumers will simply give up trying to make an informed decision and will select providers based on factors such as geography and availability.

Using e-commerce strategies to enable health care purchasing modernization

In order to support consumers throughout their entire health seeking journey, health care organizations must borrow from retail and other sectors with proven consumer engagement strategies and successful histories of transforming into digital enterprises. The global e-commerce industry saw impressive growth in 2014 with goods and services worth $1.5 trillion bought by shoppers via desktops, tablets and smartphones. Experts also predict that e-commerce sales will reach $3.5 trillion within the next five years.

Given the successful reach and consumer familiarity with the model, health care organizations should consider implementing a similar e-commerce approach that has a foundation of real prices and precision payments. Gartner analysts have predicted, By 2018, precision payment will replace value-based contracting as the bleeding edge of payment reform. Within the optimal e-commerce model, health care consumers can actively consider, compare, purchase and share experiences with various care options across different settings (e.g. telehealth or physical setting hospital, ambulatory center, urgent care, primary care, retail clinic). One leading company has already developed a viable, accessible and simple approach to doing just that.

The SpendWell Health e-commerce platform is a benefits-integrated, transactional consumer solution that allows consumers to easily access a service catalog with known prices and choose the health care services they want and need. SpendWell forges a direct digital connection from consumers to providers, giving health plans a new avenue to demonstrate value and create more informed, value-conscious members. Using this web and mobile health purchasing resource, consumers can make care decisions and purchase services with trust, confidence and no post-service effort.

Gartner analyst research has also linked the need for a personalized experience in medical policies and practices to precision payments. Precision medicine and precision payment are tied to each other in order to achieve the systemic changes that will improve the overall health and economics of the medical system. The Gartner research continues to exam these transformational dependencies, Precision medicine will fundamentally alter the institutions, vendor community, processes and technologies used in the payer industry to establish medical policy, authorize services and complete medical necessity review the gradual change from retrospective reimbursement mechanisms, typified by fee-for-service reimbursement and concurrent payment systems in value-based care, will move to prospective payment specific to a member’s current and future medical needs. Precision medicine, if combined with a new payer competency in precision payment, offers a new way of provisioning care that is appropriate to the individual, of high quality and financially effective.

The buy now button for health care

It’s also important to note that the moment of purchase is a very powerful part of an e-commerce approach, converting consumer interest into action and initiating a transaction to move the process forward. Transparency tools alone do not address this phase. To understand why it’s so critical, we can examine the potential parallels with today’s most successful retail models. A consumer may read product reviews on Amazon to compare the cost and quality of a particular product, and then immediately (and easily) make a purchase. In this way, the buy now button serves to help close the decision-making loop. Similarly, an e-commerce approach to health care services like the one developed by SpendWell supports consumers from consideration to evaluation, purchasing and post-purchase perceptions. It converts initial interest into an actual transaction with recurring options, just like auto-refill at a pharmacy but for health services and products.

 

Author: Bill Gaynor

SpendWellHealth.com

Strategies to Improve Health Plan Margins on Public Insurance Exchanges

By | Uncategorized

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We’ve analyzed the poll results from our webinar on Strategies to Improve Health Plan Margins on Public Insurance Exchanges. Get a firsthand look at the results. On March 29, 2016, we held a webinar in conjunction with AIS Health which gathered leading healthcare executives from health plans, health systems, and consulting firms. This presentation offered a valuable look into how qualified health plans (QHPs), and insurance carriers participating on health insurance exchanges, may minimize financial losses and achieve greater success. Offering a in-depth look of our reporting and analytic techniques for health plans doing business on ACA exchanges, the webinar polled participants on key topics relating to the current healthcare landscape. Here’s a sneak peak into the results.

Poll #1: How is your organization handling its healthcare exchange analytics?

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Voiced by the vast majority of respondents in our data set, organizations are handling their healthcare exchange analytics in-house via a developed process or solution (52%), followed by utilizing an outside vendor (16%), does not apply to my organization (20%), and lastly, have not decided (12%).

Poll #2: Currently, what is your biggest financial concern relating to your exchange business?

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By a landslide, the majority of respondents have selected Medical Loss Raio as their biggest financial concern relating to their exchange business (57%), followed by does not apply to my organization (19%), User or Per Member Per Month (PMPM) fees (9%), high administrative costs (9%), and costs related to technology (4%).

Poll #3: Which of the following do you anticipate as the next priority or opportunity for health payers?

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Our poll indicates that among our participants, the next priority or opportunity for health payers will be automation & performance automation (44%), followed by regulatory & health reform mandate compliance (27%), membership retention (16%), and privacy & security (11%).

For more information on this webinar, contact us atwebinar@softheon.comor access thewebinar recording now.