Tuesday, October 4, 2022

How your practice can thrive in a patient-centric health care landscape

There is no escaping the talk of consumerism in health care. This new approach to health care began several years ago and appears to be here to stay. In fact, a 2020 health care consumer experience study noted that finding, accessing, and paying for health care in the U.S. is so inconvenient that half of the consumers surveyed said they have avoided seeking care altogether.

For many clinicians, consumerism is a concept that is not very tangible. As a result, practitioners may not know how to fight something that they cannot see, feel, or touch. Ultimately, practices will feel the outcomes – a decrease in revenue and a decline in patient retention.

So, what does this mean and how does it affect your practice’s operations? What changes need to be implemented to satisfy patients? We’ve outlined tangible actions that you can take to persevere and, eventually, thrive in a health care landscape that is moving towards patient centricity.

What is Patient Consumerism?


Patient consumerism, also known as health care consumerism, is the practice of patients actively shopping for and vetting their care options prior to selecting a provider. This practice acknowledges the role that patients play as both managers and financers. As patients are now responsible for a larger portion of their own health care costs, a circumstance created by high-deductible health plans and substantial premiums, they want to ensure their health care experience will fit their needs.

How does this affect providers and practices?


To best serve patients, you must create a positive patient experience. A strategy should start with knowing your patient population and what they value, and then working to meet those needs to the greatest extent possible. Patients are, in general, looking for affordability, convenience, and access to care that aligns with their schedule.

5 Shifts to Make in Your Practice to Increase Patient Satisfaction


It can feel intimidating to make changes in your practice in response to patient consumerism, but it is a necessary task to maintain your patient population. Fortunately, it can be broken down into smaller implementations that will all work together to increase patient satisfaction.

1. Utilize a cost estimator


Remember, patients are responsible for a greater share of their health care costs than ever before. Similar to how a consumer will shop around for the best value before purchasing any other good or service, today’s patients need to make wise, value-based decisions regarding their health care. According to NRC Health, 75% of consumers see health care decisions as some of the most expensive and important they make. Therefore, it is important to make your practice pricing available ahead of time. Not only is it better service to your patients to enable them to make financially responsible choices, but it is better for your practice, so that you do not find yourself with outstanding collections that are unlikely to get paid.

2. Offer online scheduling


Convenience is a huge deciding factor for today’s patients, probably second only to cost. Calling a doctor’s office and sitting on hold to make an appointment is a time-consuming task, not just for the patient but also for your practice’s front desk staff. Giving patient’s the opportunity to schedule appointments that fit in with their schedule, while viewing what is available to make the best possible choice, is something that will improve patient satisfaction and free up valuable staff time for more pressing concerns. For example, Henry Schein Medical, through its SolutionsHub, offers Yosi Health, a patient engagement platform that provides self-scheduling and automatic appointment reminders for patients, digital check-in and patient intake, and patient queue management.

3. Adopt digital patient intake


Another traditional doctor’s office experience that today’s patients are looking to eliminate is the long time spent in the waiting room filling out a clipboard full of forms. Traditional patient intake has always been incredibly time-consuming between patients answering detailed medical questions on the spot and front desk staff having to enter that information into an electronic health record (EHR). With digital intake, patients can fill out their intake forms online before they arrive at the office, doing so when it is most convenient for them, and eliminating the long time spent in the waiting room. As a bonus, this saves your staff the data entry work as the information is directly transmitted into the EHR. Your practice should take a holistic approach to improving every digital touchpoint along the patient journey, and deploy solutions such as PatientPop, a platform that helps practitioners promote their practice online, attract patients, and retain them.

4. Include telehealth as a service


Remember, convenience is of prime importance to patients. If there is a way for them to see the doctor without disrupting their day, they want it. Telehealth provides a more convenient option. Offering telehealth in your practice is another great way to provide patients with the experience they are seeking. Utilizing a telemedicine solution such as MedPod, which is available in a cloud-based format as well as cart deployments, can help your practice improve relationships with patients looking for convenient access to health care.

5. Implement convenient payment options


Patients want to be able to handle their health care similarly to how they take care of any other business in their lives. Meet patients where they are by instituting online payments or, even better, mobile payment options so that patients can quickly and easily pay their balances. There are many barriers to patients paying their medical bills and financial difficulty is only one of them. By implementing convenient payment options, you can eliminate the other barriers and ensure that you receive more of the payments you are owed. CueSquared MobilePay™ is a platform that augments the collection efforts of patient self-pay balances, allowing patients to access and pay their bills anywhere. A solution like this can help increase patient revenue, accelerate payments, and reduce costs to collect.

The concept of consumerism is somewhat abstract to clinicians who may have a difficult time understanding the tangible repercussions for not meeting a patient’s expectations. Simply put, patients are selecting physicians based on three main factors: cost, convenience, and reputation. This is what defines their consumeristic or shopping behavior.

Practices must commit to changing the look, feel, and operation of their practice. These changes cannot be window dressing, but rather ingrained in the way the practice operates.

If this change is not embraced, consumerism will have real implications as new emerging competitors will disintermediate patients from their traditional care delivery methods. This means that independent clinicians may struggle to attract new patients, and those who do not focus on patient experience will be fighting to keep patients from competitors who operate with more patient-centric models.

There is no doubt that patient consumerism is changing the face of the health care industry, and this is a fantastic opportunity to improve health outcomes by helping patients to become more engaged, while also strengthening your practices’ revenue cycles. All it takes is to determine what it is that patients are looking for and do your best to implement those changes.


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Monday, October 3, 2022

Value-based care catching up to fee-for-service

Is value-based care having a moment?


Health care policy experts and institutions have long agreed that fee-for-service (FFS) medicine is wasteful, outmoded and at least partially responsible for the U.S. spending far more than peer nations on health care, but with outcomes that are no better and often worse.

Now, after years of experimenting, cajoling, and incentives, value-based payment models — those tied to patient outcomes and spending targets — seem to be gaining traction. According to the Health Care Payment Learning & Action Network’s (LAN) annual measurement of participation in alternative payment models, slightly more than 60% of health care payments in 2020 included some form of quality and value component. That is up from 53% in 2017 and 11% in 2012.

Similarly, 49% of practices responding to the American Academy of Family Physicians (AAFP) 2022 value-based care survey said they are participating in some form of value-based payment, and 18% are developing the capabilities to do so.

That is welcome news to AAFP President Sterling N. Ransone, Jr., M.D., FAAFP. “Our system is set up to prioritize and reimburse based on volume of patient visits versus outcomes,” Ransone says. “Value-based care prioritizes outcomes. And however we can get our population healthier is where the health care expenditure should go instead of the transactional fee-for-service environment we’ve been in for so long.”

Pandemic spurs interest
in value-based care
Much of the energy behind the search for alternatives to FFS comes from the federal government through the Medicare Shared Savings Program and the Centers for Medicare & Medicaid Innovation Center (CMMI). The latter — established in 2010 as part of the Affordable Care Act, former President Barack Obama’s health care law — is tasked with developing and testing payment models aimed at improving care quality for Medicare and Medicaid beneficiaries while slowing cost growth in both programs.

The COVID-19 pandemic has also changed some practices’ thinking about the importance of participating in value-based payment programs, says Corinne Lewis, M.S.W., program officer for delivery system reform at The Commonwealth Fund.

“Fee-for-service is a volume-driven payment system, so when patient volumes dropped (in the early phase of the pandemic), especially for elective and primary care, payments decreased substantially.” Lewis says. “So, providers are recognizing the need tomove toward more value-based approaches for more flexibility and protection against future volume shocks.”

In recent years the search for workable alternatives to FFS has been fueled by growing recognition of the role that factors such as access to adequate housing and nutritious food — social determinants of health — play in determining patient outcomes.

“How can we address patients’ behavioral and social needs in order to meaningfully bend the health care cost curve?” Lewis asks. “There’s growing recognition that value-based care will be essential to all those things and that’s where a lot of the interest is coming from at the Medicare/Medicaid level as well as commercial payers and providers themselves.”

Obstacles to value-based programs remain


Do these developments mean value-based payment models are the wave of the future, and FFS medicine will disappear? Probably not, experts say. There are still numerous obstacles to increasing provider participation in value-based models, and powerful forces working to preserve FFS.

Among the obstacles is the term “value-based care,” says Suzanne Delbanco, Ph.D., Catalyst for Payment Reform’s executive director. “It implies that whatever care is provided is of good value, which isn’t always the case,” Delbanco notes. Instead, she says, we should think in terms of payment reform and care delivery reform, with the latter being defined as “approaching care more broadly than just one visit at a time.”

“Both are needed for either to succeed,” Delbanco argues. “Payment reform for its own sake isn’t exciting, but if it can lead to higher quality, more affordable care it becomes interesting. And new care delivery models aren’t likely to be sustainable unless there’s a way of paying for them that makes them attractive to providers and leads to better results.”

Judged by those standards, movement away from FFS is less impressive than it first appears. Although LAN’s data show 60% of 2020 health care spending was in some form of alternative payment models, most of that was in programs built on FFS but including opportunities for additional revenue such as care coordination fees or through shared-savings programs. Only 6% of total spending was population based, such as per-member per-month or global budgets, and not linked to FFS.

‘Incentives haven’t really changed’


“Fee-for-service is still at the base of most alternative payment models,” says Delbanco. “The doctor or hospital is still billing and getting paid that way. So, for the front-line physician the day-to-day incentives haven’t really changed.”

Little of this comes as a surprise to Robert Berenson, M.D., a fellow at the Urban Institute’s Health Policy Center and former vice chair of the Medicare Payment Advisory Commission. “In my view, the people who come up with value-based plans don’t really understand the strengths and weaknesses of the various models, so they just focus on what they think are elegant new incentives without realizing some of them can’t be implemented.”

He cites the example of Medicare’s implementation of a payment code for “check-in” telephone calls with patients before an office visit, under the premise that such calls might head off unnecessary visits and save the program money.

The problem, Berenson says, is that the code’s payment amount—$14.53—was less than what it cost practices to bill for the service when administrative costs were factored in. “Docs aren’t completely stupid. They aren’t going to work below costs,” he said. “It’s an example of what sounds like a good idea in theory but operationally it makes no sense.”

Another hurdle many practices—especially small ones—face with value-based payment contracts is the upfront cost of the technology and personnel they need to compile, analyze and report data showing they have met a payer’s quality metrics. Such is the case for Melissa Lucarelli, M.D., FAAFP, owner of a family practice in rural Randolph, Wisconsin, and member of the Medical Economics® editorial advisory board.



“Our margins are so thin right now that it’s hard for me to pay upfront to jump on board a payer’s (value-based) initiative that will increase my administrative burden and may or may not increase my revenues,” Lucarelli says.

Nearly all Lucarelli’s Medicare patients are in some form of FFS-based quality program that includes bonuses for meeting certain Healthcare Effectiveness Data and Information Set quality guidelines, she says. Whenever possible, she bills for services such as chronic care and transition care management, advance care planning and cognitive impairment assessments.

The numbers challenge


“These piecemeal things are how we’re staying afloat right now,” she says. “But the administrative burden even from these on my little independent practice is phenomenal. It’s like being in a game where they change the rules every year.”

Making the challenge even greater is the sheer number of value-based arrangements. In addition to those available through Medicare and Medicaid, virtually every commercial payer has them, each with its own reporting requirements and quality metrics. For practices in contracts with multiple payers, keeping track of it all can seem like an insurmountable hurdle.

“A lot of our members, especially in small and solo practices, say they don’t have the resources to make sure they’re following the participation requirements (for alternative payment models), or even find out what they all are,” says AAFP’s Ransone. “So, they just throw up their hands and say, ‘Forget it, I’m not even going to bother.’ ”

Ransone adds that the academy has a project underway to address the problem. Dubbed “Vision 2025,” its goal is to reduce variability in payment structure and participation requirements for value-based models so small practices can receive the enhanced payments they often provide.

CMMI, in its 2021 “Innovation Center Strategy Refresh” white paper, acknowledged these and other problems with the value-based care models it has developed and experimented with for Medicare and Medicaid. Among the challenges it cites are complexity and overlap among many of the models; difficulty for providers to join or stay in value-based plans due to administrative burden and upfront investments; and developing better coordination among stakeholders.

“Alignment with private payers, purchasers and states is needed to increase the number of providers participating in value-based payment models and to make their participation sustainable across payers,” the paper says. To accomplish this, CMMI promises more public outreach in the form of listening sessions with payers, providers and health care purchasers, as well as learning from nonparticipants about barriers they face to participating in value-based models.

The paper notes that although CMMI has launched more than 50 models during the past 10 years, only four have met its requirements for being continued and expanded. “I think a lesson from the last decade that CMMI has taken to heart is the need to focus on a smaller number of strategic models that can really move the system,” says Mark McClellan, M.D., Ph.D., professor of medicine and business at the Margolis Center for Health Policy at Duke University and a former CMSadministrator.

Support for the status quo


Another obstacle to widespread use of value-based care and payment models, experts say, is the number — and power — of individuals and institutions who are satisfied with the current system. “There are many stakeholders who are fat and happy with the status quo,” says Catalyst for Payment Reform’s Delbanco. “Too many providers, and even payers, have found ways to be profitable with payment systems and delivery models that aren’t linked to quality.”

Berenson notes that more widespread use of payment models such as capitation or bundled payments would benefit primary care physicians more than specialists, because many services the former perform are underpaid or not billable. “Many of them (specialists) earn more than twice as much as primary care doctors, and they have enough power to prevent CMS from changing that on its own or from Congress authorizing CMS to do it,” he says.

Where FFS remains useful


What lies ahead for value-based care and the payment models that support it? Experts believe participation will continue to grow, but that FFS is not going away — in part because it remains well suited to some forms of care. “I don’t think fee-for-service will ever be eliminated entirely, because in some cases it can be an appropriate mechanism for incentivizing care that we want to see more of,” says Lewis.

Berenson agrees, citing vaccinations as an example. Practices need to be reimbursed for purchasing the vaccines, which is next to impossible under a capitation model given their year-to-year price variation. Beyond that, Berenson says, “if you pay fee-for-service for immunizations it’s much more likely they will be performed. And when you’re using fee-for-service to make sure an important service is provided, it means you’re improving value.”

FFS is also appropriate in primary care for discrete services such as hospital visits or minor surgeries, Berenson says. But in general, he adds, primary care clinicians would fare better under some form of value-based model such as capitation.

He cites research showing that up to 30% of activities primary care doctors perform, such as calls to pharmacies or patient callbacks, are not coded and so are not billable under FFS. “The beauty of capitation is, you don’t have to code for all those services. Instead, the payer says, ‘We’re going to pay youfor taking care of this population of patients and you allocate your time and resources to accomplish that,’” Berenson says.

Paying for social determinants of health


Duke’s McClellan says the increase in telehealth visits resulting from the COVID-19 pandemic is another reason why primary care clinicians and their payers should favor alternatives to FFS. Under FFS, he says, there is little incentive to use telehealth for the patients who would benefit the most — such as those in rural areas — and to coordinate telehealth with other community-based services those patients often need to address their health issues.

“You rarely see significant programs to address the social (determinants) of poor health in an FFS model because there just isn’t any way to do that,” he says. “How are you going to pay for air conditioners or transportation or whatever else the patient needs? Community-based health services are easier to provide widely in value-based arrangements because they’re built on the foundation of accountability for total costs and outcomes for patients.”

Ultimately, experts say, what’s needed are payment models that combine elements of FFS and value-based arrangements. For Lucarelli, such a hybrid approach would include “some form of per-patient reimbursement, or income floor, that covers stuff like doing their prior (authorizations) and coordinating with specialists.” Such an arrangement, she explains, “would allow us to provide these services regardless of the ebb and flow of patient volume during the year.”

Specific procedures, such as minor surgeries or IUD implants, should remain under FFS, she adds. “That way I’m fully reimbursed and can practice to my full scope of training. If I’m just getting a capitated amount, then doing most procedures becomes money out of my pocket and I might as well send the patient to a specialist.”


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Saturday, October 1, 2022

Using natural language processing to improve prepayment reviews

Payers have traditionally relied on post-payment claims reviews to detect, prevent and correct fraud, waste and abuse, accurately facilitate claim payments and reimbursement, and ensure medical necessity of services delivered.

However, the post-payment review process can be lengthy, cumbersome, administratively inefficient, and result in provider abrasion. To overcome the drawbacks associated with post-payment reviews, payers have recently started implementing prepayment claim review programs that allow for prospective claim reviews, in which payers evaluate claims prior to rendering payment to providers.

While prepayment reviews are likely to provide greater savings, faster turnaround times and reduce provider abrasion, performing these audits accurately, consistently, and efficiently requires the utilization of technology that surfaces key information from patient records, enabling payers to determine the medical necessity of services that a patient received.

To this end, clinical natural language processing (NLP) technology has proven particularly valuable in enabling payers to read, extract, and produce clean information from unstructured data buried in the narrative sections of patient records. NLP organizes disparate, unstructured data into a comprehensive, longitudinal, and semantically interoperable patient record that captures all key health information, such as diagnoses, treatments, and care plans.

In addition, accurate claims routing and workflow plays an important role in increasing efficiency of claim reviews in a pre-pay environment. This includes document management, ensuring all pertinent information is present for a determination to be made, and a rules-driven dispatch to ensure claims are routed to an appropriately skilled auditor to optimize productivity.

Say goodbye to “pay-and-chase”
For some payers, the “pay-and-chase” post-payment review process has become deeply ingrained over many years. The process involves reviewing claims after payment, verifying whether the services described in those claims are medically justified for a given patient’s diagnosis, and then attempting to recover funds when overpayment has been identified.

This retrospective form of analysis requires a significant investment in resources for post-payment reviews and overpayment recovery efforts. In addition to the resources required to retrieve documentation from often disparate sources in a timely manner, the “pay-and-chase” process increases provider abrasion by retracting portions of prior payments which results in additional administrative overhead, detracting resources that are otherwise focused on patient care.



While post-payment reviews can negatively impact payer-provider relationships, the industry has found that “pre-submission notification,” a process in which payers alert providers of potential errors before the claim is submitted for payment, can result in goodwill from providers. By enabling providers to file more accurate claims, pre-submission notification helps reduce administrative burdens and lower costs, greatly reducing the negative experiences of providers.

Separately, Medicare administrators have experienced success in moving away from a “pay-and-chase” approach to one that involves more upfront education and technology to predict improper payments. The U.S. Centers for Medicare and Medicaid Services (CMS) in 2021 reported its lowest-ever improper payment rate of 6.26%, a substantial improvement from 2014 when the figure stood at 14%.

How NLP helps
In the past, payers have depended on costly and time-consuming chart reviews to find and extract key unstructured data from patient records and claims. In recent years, however, NLP has played an increasingly important part in confirming payment integrity prior to payment.

By giving computers the ability to read, understand, and interpret clinical language, NLP extracts and organizes data from patients’ episodic health records, enabling payers to modernize chart review processes and eliminate antiquated and bloated workflows associated with manually reading a medical record. Leveraging NLP technology in audit workflow tools unlocks the key pieces of data buried in unstructured documents to empower more accurate automation of claims management. Organizing and presenting claim-specific data elements to auditors provides a rapid and efficient path to determination.

A significant advantage of NLP is that chart reviews can be performed just one time to extract all key patient data, as opposed to multiple reviews by multiple clinicians, researchers, or auditors who are all looking for different pieces of information. Further, NLP technology is a key component of interoperability between healthcare information systems, structuring and standardizing health information from a wide variety of sources including claims and patient charts.

In cases when payment integrity is in question, there is often a pattern of repeatability in the data, such as a large number of patients meeting the same prior authorization requirements. NLP helps payers detect these patterns that lack the natural variability found in legitimate patient records before claims are paid.

In the same respect, NLP can help payers spot unusual data that may be representative of fraud, such as expensive tests for which there is no medical necessity. With its ability to accurately analyze unstructured data to identify anomalies within records, NLP can quickly verify the presence, or lack of, substantiating data.

Post-payment claims reviews are a backward-looking process that should largely be confined to the healthcare industry’s past. In contrast, with prepayment reviews that leverage NLP to surface new insights from unstructured patient data, payers can improve the speed and accuracy of claims adjudication while cutting administrative costs. This ultimately improves a payer’s cash flow by saving millions of dollars from leaving the organization in the first place.


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