Opportunities, Priorities & Challenges Facing Healthcare in 2017

By | Healthcare Reform, The Industry Pulse, Top 10, Uncategorized | No Comments

The HCEG Top 10 list of healthcare priorities, challenges and risks faced by healthcare industry executives is developed each year at HCEG’s annual forum. For the past seven years, the HCEG Top 10 list has served as the keystone for industry wide analysis, and subsequent research: The Industry Pulse, an annual survey initiative, conducted over the past seven years in partnership with Change Healthcare – a sponsor partner of the Healthcare Executive Group.

The Industry Pulse research survey is designed to gather additional insight on priorities and challenges facing healthcare industry constituents across the country and provide stakeholders across the healthcare spectrum real-world, actionable insight into near term obstacles and opportunities. Combined, the HCEG Top 10 list and The Industry Pulse encourage continuous and evolving dialog on the main issues and concerns facing member organizations.

The 7th Annual Industry Pulse Research Survey

On March 29th, a webinar provided an overview of highlights from The Industry Pulse was shared here to help industry leaders better understand the current healthcare environment, as well as to prepare for, and navigate, change. The webinar offered an initial interpretation of research survey results across the following topic areas:

  • The Current State of Clinical & Data Analytics (HCEG Top 10 Item #3)
  • Privacy & Security in a Data Driven Environment (HCEG Top 10 Item #4)
  • Customer Service: Cost vs Quality Transparency (HCEG Top 10 Item #5)

This post presents a recording of that webinar including the entire slide deck presentation and an infographic presenting some key findings from the 7th Annual Healthcare Industry research survey.

Webinar Recording

Presentation

Infographic

Healthcare industry insight recording healthcare industry pulse presentation deck healthcare industry pulse infographic

More Insight, Trends & Analysis

Over the following weeks and months, additional analysis and insight will be gleaned from The Industry Pulse and shared by HCEG and Change Healthcare. To stay abreast of the unique insight offered by the Healthcare Executive Group, the HCEG Top 10 list and The Industry Pulse research survey, be sure to subscribe to our newsletter and follow HCEG on Twitter, Facebook and LinkedIn.

Collections of Information on HCEG’s 2017 Top 10 List

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One of the overarching reasons why the Healthcare Executive Group exists is to promote the sharing of information and ideas between its members and the healthcare community at large. Towards that end, we’re pleased to announce the availability of Twitter “Collections” for HCEG’s 2017 Top 10 Priorities, Issues & Challenges.

A Twitter Collection for each of the Top 10 items has been created and each collection contains articles, studies, white papers, commentary and other information pertaining to a specific HCEG Top 10 item.  These collections will be maintained on a go-forward basis so when you are looking for specific information pertaining to one of the HCEG Top 10 items, be sure to check out one of the HCEG Top 10 Collections.

( Click on one of the follow HCEG Top 10 items to access its collection of information)

Value-based Payments: targeting specific medical conditions to manage cost and quality of care Total Consumer Health: improving member’s overall well-being – medical, social, financial, and environmental
Clinical and Data Analytics: leveraging big data with clinical evidence to segment populations, manage health and drive decisions Cybersecurity: protecting the privacy and security of consumer information
Cost Transparency: growing legislation and consumer demand Harnessing Mobile Health Technology: improving disease management, member engagement, and data collection/distribution
Addressing Pharmacy Costs: implementing strategies to address growth of pharma costs versus benefits to quality of care and total medical costs Care Redesign: leveraging team-based care models, focusing on behavioral health and social needs
Accessible Points of Care: telehealth, retail clinics and micro-hospitals vs. large, integrated systems Next Generation ACOs: additional programs in bundled payment, episodes of care-shared savings, and growing participant base

For more information on the priorities, issues and challenges facing healthcare executives in 2017 and beyond, consider checking out HCEG’s social medial channels:

On Twitter – @HCExecGroup

On LinkedIn – healthcare-executive-group

On Facebook – HealthCareExecutiveGroup

“ACA: The Road Ahead in Transitioning from “Accessible” Care Act to the true “Affordable Care Act”

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Last week one of HCEG’s sponsor partners, HealthEdge, co-hosted a webinar “Payment Reform: Exploring Technology Implications for Health Insurers” with Medica. The hour long webinar, available here on YouTube, was presented by Andrew Davis – VP & GM of Medica’s Medicare segment  and Harry Merkin, VP of Product Marketing at HealthEdge.  The webinar addressed the move from fee-for-service to value-based reimbursement models; specifically the underlying technology systems health insurers are using or will soon need to use to avoid left behind. The impact of new MACRA legislation was another topic discussed throughout the webinar and during the Q & A period at the end of the webinar.

Value-Based Reimbursement is Big – And Getting Bigger

The move to value-based reimbursement (VBR) and other business models based on quality and value is dramatically reshaping the U.S. healthcare system and is happening faster than anyone could have anticipated even just a couple years ago. Currently, CMS is on track to have 30% of its reimbursements under value-based arrangements this year in 2016. And CMS is targeting 50% of all its reimbursements to be value-based by 2018 and 75% by 2023.

Agility – Efficiency – Transparency

A survey by McKesson – Journey to Value: The State of Value-Based Reimbursement in 2016 – reveals that 61% of payers and 41% of hospitals expect VBR reimbursement to positively impact their organizations.  In order for payers and hospitals to realize positive benefits from VBR, or at least avoid being unduly impacted by new value-based systems in a negative way, these healthcare organizations need to focus on three technology imperatives

Agility – health plans must be able to adapt to new payment models and rollout new benefit designs and lines of business quickly. And they must be willing and able to rapidly share relevant, actionable information with their provider networks.

Efficiency – the increase in administrative and reporting processes demanded by value-based reimbursement dictate that health plans automate key processes to enhance their competitive position.

Transparency health plans must be able to provide a patient-centered, 360 degree view of their members to the entire care team. Member experience and engagement should no longer be nice to haves.

Additional Insight from the Webinar

 The webinar provided a lot of statistics, information and actionable ideas for webinar attendees. The reader is urged to watch the webinar on YouTube where they will be presented with information and ideas like the following:

“MACRA raises a concern about ensuring adoption across all provider types. MACRA is ‘Meaningful Use on steroids’”

“There is widespread concern about conflict and misalignment between quality measures under Medicare FFS and the quality measures proposed MACRA”

“There will be a significant administrative burden managing multiple measure sets needed to comply with existing quality measure reporting programs and MACRA’s new Merit-Based Incentive Payment System (MIPS)  – at least as far as these programs are defined today.”

“Larger provider organizations working w/ ACO’s have a significant advantage under MACRA”

“Medicare Advantage is gold standard for effective risk-based contracting in today’s healthcare marketplace”

healthcare“Providers must treat all Medicare beneficiaries the same regardless as to whether they’re reimbursed via FFS, Medicare Advantage risk or new MACRA reimbursement”

“MACRA brings a bigger set of carrots and sticks that payers can with providers.”

“MACRA will enable Medicare and Medicaid programs to keep providing healthcare for generations to come”

Other Webinars by the HealthCare Executive Group

The HealthCare Executive Group (HCEG) is a national network of select executives from across the entire healthcare spectrum; coming together to continually learn, grow, share and reshape the healthcare industry. HCEG periodically sponsors webinars such as the one described in this post. For more information on becoming a HCEG member, see Why Join HCEG? on the HCEG website.

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

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