In the second of a two-part interview, Dennis Chornenky, Optum's senior vice president and chief AI officer, looks for inspiration from finance and institutional review boards to steer AI toward maturity.

Editor's note: This is the second of a two-part interview. The first part was posted on Wednesday, Sept. 28.

In early 2022, Dennis Chornenky, MPH, became chief AI officer and senior vice president at Optum Health, a subsidiary of the UnitedHealth Group health plan. In part 1 of his conversation with HealthLeaders, posted on Wednesday, he addressed the role of AI in creating data-driven insights to prevent disease and personalize care; how to apply governance frameworks to AI, and his prior role serving Presidents Trump and Biden in crafting national strategies on AI and telehealth.

HeathLeaders: Where are we on the maturity cycle of AI? Where are the limits of AI, particularly with the eye toward healthcare?

Chornenky: Maturity in the AI space is certainly an evolving concept. The further out something is, the less defined it becomes, and the more variability you're going to run into. My view is that we're early in the maturity stages, in terms of development potential. 

Dennis Chornenky, MPH, senior vice president and chief AI officer at Optum Health. Photo courtesy Optum Health.

Some of the work that I’m privileged to be advancing, that creates governance and a portfolio management model for our organization, is quite innovative and I would say ahead of the curve. I'm doing that by leveraging a combination of experiences and emerging frameworks.

With regard to managing a portfolio of AI investments, we can pull in some insights from the financial sector. We can look at institutional investment policy statements, for example, and approaches to outlining which risks you may be likely to encounter as a portfolio manager. What are you doing to mitigate those risks? What's the strategic goal of the portfolio? What level of risk are you willing to accept to achieve your target return? These kinds of established approaches can be helpful to keep in mind.

I also draw on my epidemiology experience with institutional review boards, which are designed to ensure ethics and safety in clinical trials. There is an emerging recognition in healthcare that we can do something very similar for the AI space, so we're seeing the emergence of “AI review boards,” loosely modeled on institutional review boards, that can screen AI projects, models, and applications for various types of risks in operational and clinical environments. We want to make sure that we have consistent and reliable processes that help ensure our models are safe, ethical, and as fair as they can be for any particular use case.

As for the limits of AI, we can frame this from the perspective of the trade-offs between performance when doing precise, clearly defined tasks against the ability to perform a broad range of tasks and solve a broad range of cognitive problems creatively. Machines excel at doing repetitive tasks with precision and humans excel at navigating dynamic environments and solving new problems. What business leaders should really be thinking about in this context is how to drive the kind of digital transformation in their enterprise that optimizes the collaboration of humans and machines in a way the amplifies the strengths of both and minimizes the limitations of both.

HL: The fact that you have this title of chief AI officer at Optum suggests that the day is not far off where AI becomes part of the standard of care. Is that something you ever hear discussed?

Chornenky: It's an interesting question. For me, this conversation started in telehealth, where the question was, could telehealth be the standard of care in the sense that there were concerns many years ago around the risks of doing telehealth? A health system that's providing care delivery through telehealth may be exposing itself to legal action if some harm comes from offering virtual care. The other side of that argument was that there may come a day where health systems that don't provide telehealth as a modality may be the ones exposing themselves to lawsuits, because they’re the ones providing less access to care, or restricting care, because they’re forcing people to only get care in person, potentially disadvantaging certain populations.

It's the same question with AI. Does using AI introduce legal risks, or will there come a day when it's expected and not using AI is what introduces legal risks? Because if you're not using more advanced technologies, you might be relying on imperfect and more variable human decision making in diagnosis and care delivery, without the use of more precise machine recommendations. We're pretty far away from something like that, maybe decades, because of the very limited maturity of the use of these technologies and the lack of scale. And in some ways, we may never entirely get there.

There's always going to be some sort of downstream human decision making. It's unlikely that we're going to get to a point where machines will completely control all aspects of the diagnostic or care delivery process. There's always a requirement, a natural need, to have humans make the broader decisions around whatever machine insights may be derived from data, and the kinds of actions we may want to take as a consequence. That said, over time we will certainly see a growing automation of tasks and more care decisions being informed by data-driven insights.

HL: Before the pandemic, Vinod Khosla was going on and on about how we don't need doctors. The pandemic changed that dialogue.

Chornenky: The pandemic forced a recognition of the importance of investing in technology. But I don't think It did much to support Khosla's case, which, if it can be described as doctors inevitably being replaced by computers one day, is a poor formulation. There are many tasks currently performed by physicians and medical technicians that will indeed be replaced with AI, i.e., computational methods and machines that simulate or surpass human cognitive capabilities. But the overall role of the physician is much too broad and requires the kind of big picture thinking, creativity, and bedside manner that machines are unlikely to achieve in the coming centuries, if ever.

CHIME and others say hospitals and other providers are not ready and need more help from HHS.

Despite assertions from the Office of the National Coordinator for Health IT (ONC) that it has gone the extra mile to help health systems abide by new information blocking rules that begin to take effect on October 6, several are lobbying for a significant extension of the deadline.

The College of Healthcare Information Management Executives (CHIME), along with nine other healthcare provider organizations, has sent a letter to US Department of Health and Human Services (HHS) Secretary Xavier Becerra requesting an additional year to comply.

In a statement, CHIME officials asserted the organization has been an ardent supporter of information sharing and continues to advocate for patients’ ability to access their healthcare information in a digital format. But members have been hampered by scarce resources in trying to meet the deadline, the organization said.

"CHIME members remain steadfast in their dedication to be a trusted partner for patients and safeguard their ability to access their healthcare records, but it’s clear that more time is needed to ensure that providers have a thorough understanding of these important policies," said Russ Branzell, CHIME's president and CEO. "There has not been enough guidance on best practices and potential enforcement."

Citing what it said was overwhelming feedback from CHIME members representing a broad range of providers from across the healthcare continuum, including electronic health record (EHR) vendors, CHIME leadership maintained that these stakeholders are not fully prepared for the deadline.

With clinician burnout rates increasing, CHIME officials said HHS' unclear and inconsistent information sharing about data requirements could further strain healthcare providers and their support staff and may inadvertently undermine HHS’ goals to reduce provider burden, improve interoperability, and empower patients with their information.

Branzell said the “need for clear guidance is so important, and we need to make sure that all healthcare providers fully understand the many nuances of these complex policies.”

Small and rural providers, who more heavily rely on their EHR vendors for regulatory compliance support, are particularly unready, CHIME officials said.

Postponing compliance was not CHIME's only request. The organization also requested that HHS use corrective action warning communication to providers-- especially before they impose any financial penalties or begin formal investigations.

CHIME urged the HHS to ensure that providers and clinicians have the guidance, education, and technology to support these new policies before full implementation and enforcement of information sharing regulations.

In a statement, CHIME officials said, "We believe strongly in information sharing and want to see these policies succeed. A successful implementation of information sharing necessitates that all stakeholders have the critical tools, knowledge, guidance, and systems required to comply. This is simply not the case for most of the providers represented by CHIME."

An ONC spokesperson noted that the agency has provided a wealth of information about information blocking, including fact sheets, FAQs, blogs, and webinar recordings.

The spokesperson said these resources have been continually updated since April 5, 2021, the date when the regulation became official, and pointed to a fact sheet posted at that time.

Starting October 6, "actors will be expected to avoid interfering with access, exchange, or use of the full scope of EHI, except when applicable law mandates the interference or an information blocking exception is met," the spokesman said.

The ONC also said it would post a related blog post ahead of October 6 on its Buzz Blog.

In 2016, the 21st Century Cures Act made sharing electronic health information the expected norm in healthcare by authorizing the HHS Secretary to identify "reasonable and necessary activities that do not constitute information blocking." The ONC's 2020 Cures Act Final Rule established information blocking exceptions to implement the law.

The CHIME letter was also signed by the American Hospital Association, American Medical Association, Federation of American Hospitals, and Medical Group Management Association.

In the first of a two-part interview, Dennis Chornenky, Optum's senior vice president and chief AI officer, describes how he is driving AI tech for 15 million members of the United Health subsidiary.

At the start of 2022, Dennis Chornenky, MPH, became chief artificial intelligence officer and senior vice president at UnitedHealth Group health plan subsidiary Optum Health, after having served as a senior advisor and presidential innovation fellow in the White House in both the Trump and Biden Administrations.

The chief AI officer is one of the newest titles in the C-suite. Only a handful exist, in places such as the US Department of Health and Human Services and at technology companies like IBM, Elevance Health, and eBay.

In this two-part HealthLeaders interview, Chornenky describes just what a chief AI officer does, how it dovetails with pressing needs in Optum and all of healthcare, and what AI means for the future of healthcare.

HealthLeaders: Optum has pushed for value-based healthcare. What role is AI playing in driving that?

Dennis Chornenky: At Optum and UnitedHealth Group we’re driving healthcare transformation toward comprehensive value-based care, and AI is playing a big role in that. It’s a key focus of our growth strategy, helping more patients and care providers transition from fee-for-service to value-based approaches. We’re applying advanced technologies to drive better and more consistent care outcomes at lower overall cost.

Dennis Chornenky, MPH, senior vice president and chief AI officer at Optum Health. Photo courtesy Optum Health.

We have around 15 million members participating in value-based arrangements with over 1,000 hospitals and over 100,000 providers. Through our OptumCare delivery organizations we’re leading the industry in terms of the proportion of the patients we serve participating in value-based arrangements. I think we're expanding that at the highest rate out of any other care delivery organization in the US as well. 

The way AI can help us accelerate this expansion into value-based care is by leveraging data to identify patients and members best fit for value-based care models and the clinical innovations and operational efficiencies that are most important in driving that transformation. There is a spectrum of data-driven insights that help us to better understand which patients may benefit most from which types of interventions and which types of care plans. That ends up getting broken down into a whole lot of different things, whether we're looking at disease prevention or surveillance, or integrating telehealth and virtual encounters into care modalities.

We are applying supervised machine learning techniques to improve our ability to predict disease progression and enable earlier interventions and unsupervised techniques like clustering to help us better understand the natural cohorts in our patient and member populations to advance more personalized care models. Overall, we are looking at anything that can help us improve patient outcomes, advance clinical innovation, and reduce costs.

HL: How can healthcare audit the AI it's starting to consume and use that to drive improvement?

Chornenky: You're right to make the connection that the way we approach the risks involved in deploying AI applications can be an important opportunity to drive improvement. AI governance is an emerging field that can leverage industry frameworks like Responsible AI to facilitate auditability and mitigate regulatory and reputational risks. A more technical framework referred to as ML Ops can help mitigate technical and model lifecycle risks. When done correctly, AI governance in healthcare helps to improve access to care and advance health equity. Without it, AI applications can run the risk of actually amplifying existing healthcare disparities.

I’m really encouraged that healthcare leaders are starting to understand that AI governance is an important area of investment and that it can help enterprises identify and mitigate the technical, regulatory, and financial risks posed by AI. 

It’s also fascinating how rapidly innovation has been evolving in this field, with more and more startups and AI enterprise companies launching new offerings for Responsible AI, ML Ops, and bias and fairness assessments. The more forward-thinking health systems are also making investments in internal processes. Mayo Clinic, for example, has recently stood up a governance model they refer to as the “AI Translation Assessment” process, led by a distinguished group of experts.

At the federal level, the FDA is developing regulatory guidelines for Artificial Intelligence and Machine Learning (AI/ML)-Enabled Medical Devices. NIST is developing a new AI Risk Management Framework.  There is a growing body of emerging legislation across the US and in the EU that will have a significant impact on how we develop and deploy AI. I participate in several industry groups focused on developing best practices and standards for AI governance in healthcare and strategies for regulatory engagement.

HL: What learnings did you take from your time at the White House?

Chornenky: Serving in a non-political role across Republican and Democrat administrations, especially during the pandemic, gave me a lot of perspective on how our federal government works and how to successfully formulate and advance national policy, particularly in the healthcare and technology sectors. 

As a senior advisor and a Presidential Innovation Fellow I was initially focused on advising our US chief technology officer on national AI strategy and our federal chief information officer on federal AI strategy. National AI strategy is how we think about cultivating growth and innovation in the private sector and the markets regarding AI/ML technologies, scaling up investment in R&D, academic partnerships, and also building trust in these technologies among the American people. This is also where we start getting into AI ethics and Responsible AI, or trustworthy AI.

Federal AI strategy is how do we think about standing up better data science capabilities across the federal government. This is everything from vanilla IT cloud migration, to upskilling the existing workforce with data literacy and analytics curricula, to thinking about data science as a career path, creating new job codes with OPM, and new processes and programs for engaging data science talent, recruiting, and retention. I had a portfolio of agencies I worked with to advance innovation, AI governance models, and AI capability maturity roadmaps.

As part of this work, we launched a new federal AI community of practice that was meant to bring together leaders and practitioners from across federal agencies to share best practices and do the type of collaborative work that they might not always be able to do within their usual, perhaps more constrained, agency environments. I also helped manage a government coordination committee that produced the executive order promoting the use of trustworthy AI in the federal government. This was a very important initiative that was bipartisan in nature, and the government is implementing the provisions of that executive order today.

When the pandemic hit, I was able to apply my training as an epidemiologist to help coordinate response efforts across federal agencies and our private sector partners, including technology companies, health systems, and payers. 

What turned out to be more consequential for me, however, was my background in telehealth. I previously had an AI-driven telehealth and smart-scheduling company out of Palo Alto. Through that work I got to know everybody in the industry, the CEOs of the larger telehealth companies, the different industry associations and who led them, and top law firms working on telehealth regulatory issues around the country. So I really ended up in a unique position to pull all of that together and very quickly formulate and advance a national strategy on telehealth and how we were going to work across federal agencies with our private sector partners to make telehealth accessible to as many Americans as quickly as possible. 

I think probably the biggest silver lining, if you will, of the pandemic, was that it accelerated telehealth adoption and access to virtual care for Americans across the board. It wasn't only for mitigating the risk of the spread of infectious disease, but also helped to ensure continuity of care for non-COVID related cases.

There was a tremendous amount of work done from an administrative and a policy perspective. Within just a few weeks, we put out over 50 waivers to enable telehealth, a couple dozen new billing codes, and a new modern website, telehealth.hhs.gov, to help patients and providers adopt telehealth in safe ways. We also convened a telehealth innovation summit, which was a great way to celebrate a lot of the work that had been done, particularly out of the deputy secretary's office at HHS, and with our private sector partners, but more importantly, to align on what the next steps should be to continue to advance adoption of telehealth and expanding access to care for all Americans.

Editor's note: Part 2 of this HealthLeaders interview with Optum SVP and chief AI officer Dennis Chornenky will be posted on Thursday, Sept. 29.

CIOs and other healthcare executives gathered in Boston this week for the HealthLeaders Innovation Exchange, where they talked about moving past the pandemic and into a new era of connected health.

As the healthcare industry seeks to regain its footing after the pandemic, those in charge of innovation strategy are looking to balance lessons learned from COVID-19 with the need to be on solid financial ground.

That's a challenging task, say health system CIOs and other executives attending the HealthLeaders Innovation Exchange this week in Boston. In many cases, health systems have adopted telehealth and digital health out of necessity, to deal with COVID-19, but they haven't really put the work into shaping a long-term strategy.

"For the better part of the last decade we've been paying lip service to digital transformation," said Saad Chaudhry, MSc, MPH, CHCIO, CDH-E, chief information officer at Annapolis, Maryland-based Luminis Health. The pandemic "was a splash of water in everyone's faces."

Chaudhry was one of about two-dozen healthcare executives attending this year's Innovation Exchange, an annual event designed to bring CIOs and others together to discuss innovation strategy. Today's event included a master class in human-centered design by Chris Waugh, vice president and chief innovation officer at San Francisco-based Sutter Health, along with round-table sessions aimed at defining innovation and discussing barriers and best practices.

In a poll conducted by HealthLeaders at the beginning of the event, about 70% said restoring their health system's operating margins was one of the top two priorities for the coming year, while advancing digital transformation followed right behind at about 64%.

Those results reflected a desire to move past the pandemic—in fact, only 18% listed as a priority coping with the fallout from COVID-19—and to apply lessons learned in the shift to virtual care to reimagine how healthcare is delivered. And they reinforced that digital transformation is at the top of the to-do list, as innovation was only listed among the top 2 priorities by 23% and strengthening cybersecurity—always a hot topic—didn't even get a vote.

"We should have done this a long time ago," Chaudhry pointed out.

When asked "who champions your causes most at the organization," 55% selected the CEO, indicating an emphasis on top-down support for innovation (10% selected the CMO or CNO, and 25% went with "someone else." But this question and the discussion around it highlighted the fact that innovation isn't necessarily channeled through one C-suite position or based in one department, and can and should be found in all areas and levels of the healthcare system.

James McElligott, MD, MSCR, executive medical director of telehealth and an associate professor at the Medical University of South Carolina's Children's Hospital in Charleston, echoed several comments in pointing out that innovation is best supported when many departments (and department heads) share in the process, and can be fostered as easily by one doctor with a unique idea or strategy as the head of a hospital.

That can also be a hindrance. When asked "who blocks your causes most at the organization," 25% selected the CFO, highlighting the challenge that innovation faces in securing financial backing, and 55% selected someone else, over the CEO (10%), the CMO (5%), and the CNO (5%).

This, and the discussion that followed, indicates innovative project face a wide array of challenges, including politics. A new technology or program might look great in a pilot, but it might run aground when several departments seek to take control and turn it into a political issue, or it might falter because no one wants to champion the project.

Bradley Crotty, MD, MPH, vice president and chief digital engagement officer at the Froedtert & Medical College of Wisconsin Health Network, as well as chief medical officer and chief product officer at Inception Health and an associate professor at the Medical College of Wisconsin, pointed out that the pandemic did give health systems a process that everyone followed to "get things done." That attention to one common goal worked, he noted, and showed healthcare organizations how to cut through the barriers to achieve a goal.

That should be a model for innovation, he and other said.

Finally, executives were asked where their organization stands in its digital journey. The results, as with the healthcare industry, were across the board. Some 44% were building out the technology and a process roadmap, while 33% were in the execution stage, 11% were conducting a needs assessment, almost 6% were either ensuring ongoing services and support or at the baseline.

The results speak to the various stages of digital health transformation, and point to the fact that each health system will travel its own path. But that doesn't mean they can't share advice on how to make that trip.

Todd Mallon, CFO of Advocare, says the organization has a near-perfect net collection ratio.

Improving net collection rates and overall revenue cycle management processes is top of mind for revenue cycle leaders and adding in new solutions and automation to streamline those operations has been a must for many organizations.

Todd Mallon, CFO of Advocare, one of Pennsylvania and New Jersey's largest independently physician-owned and physician–governed multi-specialty medical organizations, recently spoke with HealthLeaders about implementing new technology to streamline the health system's revenue cycle management operations.

With over 650 providers and 3,000 staff across over 150 independent care centers that facilitate roughly two million patient visits annually, Mallon said it was essential to simplify its revenue cycle.

Since implementing new technology from eClinicalWorks to help with its revenue cycle management operations, Advocare now has a 99% net collection ratio. As the industry standard ratio for net collections is 95%, Advocare is now operating well above average and experiencing the positive effects of that change across all of its care centers.

"I spend much less time discussing processes and denials with our accounts receivable teams. We now have the space and flexibility to focus on expanding our operations and meeting the needs of more patients in our community," Mallon says.

HealthLeaders: What sort of problems were you seeing in your revenue cycle that made you realize you needed to implement a change? What was your main driver?

Todd Mallon: Our net collection ratio was the strongest indicator that we needed to change our revenue cycle management solution. The net collection ratio measures how effectively our practice collects reimbursement for services from patients and payers. This metric has always been a top identifier of financial success in healthcare organizations.

However, our net collection ratio was continuously dropping with our previous practice management system. I felt like I spent most of my time at every financial review meeting discussing accounts receivable, denials, and current processes to get to the core of this issue. This meant our teams were spending most of their time fixing the day-to-day operations, which limited our ability to grow and provide high-quality care to more patients. So, our main driver for changing our revenue cycle management was to equip our finance and accounts receivable teams with the support and resources they needed to improve our net collection ratio.

HealthLeaders: What was the process of implementing new technology, and who was involved with the decision-making at your organization?

Mallon: Everyone on our leadership team supported the decision-making process. Between our CEO—who provides a medical perspective, the admin team and myself—who provide the financial and operational perspective, and our task force—comprised of multiple physician leaders across all of our specialties, we wanted all stakeholders represented in the decision-making process.

Leading up to the implementation, we had several meetings with our vendor to define specific goals, metrics, and deliverables to improve our net collection ratio. Once we aligned on the basic workflow and back-end operations, the next step was training. The system was new for everyone—from our CEO to the providers to the management staff—so we needed a lot of support to train our people. Without proper training, we were unlikely to see our net collection ratio improve.

Before the launch, a select group of our staff went to Boston for a complete overview and training of the new system. Three months before the launch, our vendor's team trained our providers so they would feel confident with the system. We also provided pre-launch training courses to the rest of our staff. However, even after the training, the team was available for a quick phone call or chat to answer questions or troubleshoot a potential issue with the system or workflow.

HealthLeaders: How long did it take for your organization to fully implement the technology, and how did implementation work since your practice spans so many clinics?

Mallon: Launching the system was challenging, and we could not have implemented the technology smoothly without the vendor's support. We rolled out the new solution across all 150 health centers in one day. We went all in from the beginning, and we needed to start strong.

We had eClinicalWorks trainers at every care center for about a week to two weeks after the launch to help with the transition process and to train additional Advocare staff. During the implementation, we trained internal staff as point people for the solution so they could carry on with further implementation and staff training.

HealthLeaders: Since implementation, what positive outcomes have you noticed?

Mallon: The most noticeable positive outcome is our increased net collection ratio. Several things contributed to this increase.

First, we now have a dedicated eClinicalWorks team that handles our day-to-day collections and follow-ups to ensure we receive claims on time. To create an efficient workflow, the team helped us set up ready-to-bill rules to ensure care centers complete reports accurately. We can create alerts for missing information or incomplete claims. In addition to these in-workflow rules, the team notifies us of any issues, which gives us plenty of time to gather additional information from providers or communicate the next steps with payers.

Second, our vendor's team also handles denial appeals for our care centers. So, if a denial comes back for a claim from a specific center that needs to be addressed or changed, they will help that center submit an appeal and track the claim progress within our system. Once we receive payments, they handle the cash collections and posts them internally so we can keep track of our revenue in real time.

HealthLeaders: What are some keys to success you could share with another organization looking to do the same for their facility?

Mallon: The first key to success I'd share with other organizations looking to improve their revenue cycle is to know where you currently stand. Know your net collection ratio and how many days your accounts receivable is outstanding. Once you have a baseline, you can set goals and implement strategies to improve workflows and increase collections. And once you have these measurements, keep track of them and update them regularly. We have regular meetings with our team to discuss our current metrics, compare them to our revenue and collections goals, and adjust our workflow and operations as needed. Everything needs to be measurable to be successful, especially in revenue cycle.

Second, train your team on the new technology. Especially for multi-site healthcare operations, it is imperative to have people at each care center who can monitor the solution’s success and train new staff as needed. Now each care center runs at its best. It is also easier to open new care centers because we have a unified system.

Finally, choose a health IT vendor that listens to and learns from your organization. Open communication between a health IT vendor and a practice customer can benefit both parties. For example, based on our experience with their technology and conversations between our staff and the eClinicalWorks team, they came up with a mass lock button that would lock multiple charts at once to minimize clicks and improve billing efficiency. The most valuable part of our partnerships is open communication. We are willing to learn from them, and they are willing to learn from us. Because of this open communication, our providers and staff leverage more efficient workflows and our net collections increased. Through them, we are also exposed to new opportunities to improve health IT solutions.

In the end, patients get a better experience, and everyone wins.

Several federal agencies issued a set of final rules based on the No Surprises Act aimed at making it easier for providers to contest payer decisions.

A new No Surprises Act final rule and additional guidance to further implement the independent dispute resolution (IDR) process and require payers to provide additional information to providers about qualifying payment amounts (QPA) was recently released by CMS and other federal agencies.

During the IDR process, an arbiter is directed to consider all information submitted by the physician and insurer, including the median in-network rate, complexity of the case, previously contracted rates, and market power of the physician and insurance company, among other items.

The law states that the QPA could be one of many equally weighted factors considered in payment disputes.

However, until a recent court ruling, the rule made the QPA the primary factor in the IDR process. Organizations have said that since the QPA is "an unverified rate set by insurers," and using it to settle disputes "sets an artificially low benchmark payment, for all care—whether in network or not, which may not support wider access to care—particularly in underserved areas."

In the new rules, CMS references the court decision, saying it will "remove the provisions that the District Court vacated." Now IDR entities may weigh QPA and other factors equally in making their decisions.

This is not a full reversal for the QPA's role, though, according to Part B News.

David McLean, a partner with Hall Booth Smith PC in Atlanta told Part B News that "although the final rules do not require the certified IDR entity to select the offer closest to the QPA, the Departments remain of the opinion that it will often be the case that the QPA represents an appropriate out-of-network rate."

However, there is a win for providers when it comes to downcoded claims.

A major plus for providers is the agencies’ decision to require payers to include both an original and an altered QPA for the claim if the payer has downcoded it by switching a code so that the claim is reimbursed at a lower rate.

Now, the payer must not only admit and describe the downcoding but also explain its reasoning, this will then be considered among the factors in the IDR decision. The new rule should help some downcoded providers on price, but it will also create extra work from the IDR entities, Part B News reported.

Extra work is not ideal for IDR entities.

In fact, a recent IDR process status update showed that between April 15 and August 11, the federal IDR portal has received over 46,000 claims, "which is substantially more than the Departments initially estimated would be submitted for a full year." According to the status update, only 1,200 of those claims have received a payment determination.

Clarification on other important No Surprises Act regulations were not covered in these rules, such good faith estimates, but more guidance is expected in the coming months.

The health system's value-based care model is built around home-grown population health technology.

Crossover Health, a primary care provider catering to self-insured employers, has built its own population health tool to improve patient and clinician experience alike.

The San Clemente, California-based healthcare organization, which counts Amazon among its customers, launched its tool to show clinicians how they were improving the health of their patient populations, says Stephen Ezeji-Okoye, its chief medical officer.

Crossover Health has 42 clinics throughout the United States, a mixture of on-site and near-site clinics, as well as a national virtual medical practice. The organization built its population health tool to overcome what Ezeji-Okoye calls the "tyranny of the visit" that dominates traditional electronic health record software.

"We don't work in a fee-for-service arrangement," he says. "What we're focused on is how do we improve the health and well-being of the population because that's how we show our value."

Such considerations impact Crossover Health's design of its clinics and its exam rooms, he says, so it made sense to extend design considerations to the population health tools utilized by its physicians.

Crossover Health employs traditional primary care providers as well as specialists offering mental health, physical therapy, and chiropractic services -- all augmented by nurse practitioners, health coaches, and care navigators.

"A lot of programs in advanced primary care don't actually include all of the elements I've just described," he says. "We have a very holistic approach. We believe that you've got to go beyond the biomedical model of just treating disease. You've got to get into the things that really affect health."

Ezeji-Okoye says 80% of the factors affecting health are not medical interventions. They might include the behaviors of patients and their living environments.

Stephen Ezeji-Okoye, chief medical officer of Crossover Health. Photo courtesy Crossover Health.

"We brought all of this together in a measurement system that allows us to have a good view of what's going on in the practice and allows providers to understand the impact they're having on the patients they see," Ezeji-Okoye says

An example of that impact: One of Crossover Health's clinics uses the population health dashboard to identify gaps in care among patients undergoing colonoscopies to screen for colorectal cancer.

"The population was one where people were primarily hourly workers," Ezeji-Okoye says. "They needed to be able to be at work as much as possible. Taking a day off for a colonoscopy was actually a huge barrier to care."

To address that gap, the clinic began providing those workers with at-home colonoscopy kits.

"One of the benefits of the tool is it makes these care gaps visible and allows us to work in a proactive fashion to be able to improve the quality of care of the population," Ezeji-Okoye says.

The platform enables clinicians to factor social determinants of health into care management, he says, identifying instances where the root cause of a health concern might not be clinical.

Crossover Health collects data from within its Elation electronic health record system to populate its population health dashboard, he says.

"Then we also use other measurement tools to capture things such as the therapeutic index and the severity index, to help measure how we're doing in those domains," he adds.

For now, Crossover Health's system does not send alerts back to the EHR.

"Certainly, alert fatigue is a real thing," Ezeji-Okoye says. "You'd need to limit the alerts to the ones that are most important. We don't do that at this time, but we're looking at that."

The system helped Crossover Health deal with the pandemic as well.

"Pre-pandemic, we were probably 3% virtual," Ezeji-Okoye says. "During the pandemic, we were probably 90% virtual. Now we're about 70% in person and 30% virtual. Regardless of how members choose to use us, they can expect the same quality of care, and we're going to have the same proactive approach to care."

Over time, he says, Crossover Health will continue to incorporate more data from its patients' visits to other health systems, including claims data.

"We need to make sure that we provide the human intelligence behind the data feeds, to make sure we've got the right treatment plan for each member," Ezeji-Okoye says.

Another feature of the tool allows Crossover Health to measure how quickly patients can get appointments. This drives the company's hiring decisions and helps to avoid overburdening current providers.

When the primary care team must initiate referrals, Crossover Health's care navigators curate lists of medical specialists outside the company who most identify with the company's proactive health values, Ezeji-Okoye says. Health records from such specialist visits then come back into Crossover Health's population health system, to drive further quality of care.

In time, Crossover Health may expand its offerings beyond self-insured employers. It has a commercial offering on a subscription basis, but so far that is a small portion of the company's business.

"Our goal is to be able to make Crossover accessible to anyone who's interested in having a better healthcare experience," Ezeji-Okoye says.

Chris Belmont, vice president and chief information officer for Mississippi's Memorial Health System, says any new program should begin small and focus on the patient.

To Chris Belmont, innovation isn't just a strategy. It's a commitment to improving patient care.

"It's not something you have, but actually something you do," says the veteran healthcare executive who now serves as vice president and chief information officer for the Memorial Health System, a two-hospital network based in Gulfport, Mississippi.

And for innovation to really work, he says, it has to lead back to the patient.

"We're great at creating things, and technology, and processes … but are we really paying as much attention to the patient as we should?" he says.

Belmont has more than 35 years of experience in executive leadership, business development, and consulting, the last two of which have been spent at Memorial Hospital at Gulfport. In the past he's served as vice president and CIO at the University of Texas MD Anderson Cancer Center in Houston and system vice president and CIO for the Ochsner Health System in New Orleans, leading EMR transformation projects at both health systems while helping to revamp their Information Services departments.

At Memorial Health, his strategy for trying out new programs and technologies is to start small, with very specific outcomes, goals, and participants.

"Don't launch these big initiatives," he says. "If we had done that, we would have slowed things down and missed some opportunities."

Chris Belmont, vice president and chief information officer of the Memorial Health System in Gulfport, Mississippi. Photo courtesy Memorial Health System.

In some cases, that might mean starting in a clinical department, rather than IT, to give a program a chance to establish roots before marrying it to a specific technology. Once that base is established, data is gathered, and results are proven, he says. Then, a health system can scale a program out, adding more departments and serving more populations.

"We start with an idea, and we put a program together than can be part of our portfolio," Belmont says. "Once it's in our portfolio, we have the opportunity to put it onto a platform and ask, what can this platform do?"

By taking a tiered approach to innovation, he says, a health system can focus on patient interactions and care. A large project tends to overlook small details, but those details may be what the patient looks at or experiences. As a result, a big program might look good and meet the goals set forth by the health system, but it doesn't necessarily address what the patient wants.

"Don't let the bureaucracy get in the way," he says.

As an example, Memorial Hospital has been working with Emmi digital health technology developed by Wolters Kluwer for patient engagement efforts, with a goal of reducing avoidable ED visits and hospitalizations and improving follow-ups. The hospital had launched a handful of small, concentrated programs and wanted to combine them on one digital health platform.

"It was at a time when we were all distracted by COVID," Belmont says. "Our nurses were busy with screenings and vaccinations, and we wanted to help them. This wasn't a robocall project; we wanted comfortable interactive technology that could improve the experience."

Using interactive voice response calling and multimedia videos to reinforce discharge or care instructions, monitor adherence to care management plans, and remind patients about follow-up appointments, Memorial Health developed a rapport with patients, encouraging them to take a more active role in their care.

"A lot of times [patients] don’t remember what was said [in visits with their doctor]," Belmont says. "We created a more effective messaging platform that engaged with them. It was more comfortable for them than the traditional automated reminders. I was surprised at how quickly patients reacted to the new platform."

According to data supplied by Wolters Kluwer, the program reduced unnecessary ED visits by 26%, which, in turn, reduced ED costs by about $89,000 over 1,000 patient discharges. The 30-day readmission rate also dropped between 27% and 65%, depending on patient adherence to prescribed programs. In addition, patients were 50% more likely to attend follow-up care appointments with their provider within 21 days of discharge.

"This was so much more effective than anything we'd done before in getting patients to [follow their care plan]," Belmont says.

The key to establishing that relationship, he says, is in listening to and understanding what the patient wants, rather than creating some shiny new toy or program and asking the patient to accept it.

"We have to look at this from the patient's point of view," he says. "Just think what would happen if we did too much of this. Would the patient be overwhelmed if we communicate too much? How do we make sure that we're not contacting them [to the point that] they're turning away?"

Belmont calls this a conundrum that every health system will face as it adopts more technology and programs that create more connections with patients outside the health system. All these channels will be great for collaborating on care management and passing information back and forth, but when will it be too much? How do healthcare providers create a conversation with the patient that meets the demands and expectations of both parties?

"Feedback is vital," he says, "both direct and indirect." Aside from asking patients how they want to interact with their care teams, providers need to gather data on how often patients communicate, on what channels, and whether those communications make an impact.

"My metric is if they keep coming back for more," Belmont says. "My role in this is the platform manager. I'm here to connect all the points, to make sure they're secure, and especially to make sure that they are reliable, and that the data we're getting is making a difference."

As Belmont looks to broaden those platforms with new programs and technology, he's focused on creating services that continue, rather than one-time interactions. He wants patients to look at this platform as an ongoing relationship with their care team, as well as a library of resources that they can access whenever they need help.

"We as a health system have to make sure we're taking advantage of all the tools in the toolbox," he says.