Researchers have developed algorithms that can scrub EHR notes for references to specific social factors, giving providers the data they need to improve care management and treatment.
Researchers have developed natural language processing tools to pull data from clinical notes that will help address social drivers of health.
The technology aims to help healthcare providers address SDOH in care management and treatment plans for patients.
“Health and well-being are not just about medical care," Joshua Vest, PhD, a faculty member at both the Regenstrief Institute and Fairbanks School of Public Health and the study leader, said in a recent press release. "Mostly, they are about our behaviors, our environment, our social connections. More and more healthcare organizations are having to deal with social determinants because it is factors like financial resources, housing, and employment status that really drive costs that make people unhealthy. The challenge for healthcare organizations is effectively measuring and identifying patients with social risks so that they can intervene.”
Vest and his team developed three rule-based NLP algorithms and scanned notes from two different Indiana-based health systems, targeting keywords specific to three social factors.
"The demand from payers, policy-makers, and advocates for information on patients’ social factors and needs is substantial and multiple approaches are requested to obtain this information," they noted in their study. "In recent years, coding standards for recording social risks as structured data within EHRs using ICD-10 or LOINC codes have advanced substantially. Nevertheless, these structured data are very underutilized in practice."
The study noted that this technology would work best as part of an overall social health measurement strategy.
"It is important to not discard clinical text in favor of screening or other structured methods for data collection," the researchers noted. "However, social factors extracted via NLP could be utilized to impute missing survey results, augment survey data, or—given the ability to apply retrospectively—provide a longitudinal description of social factors. As products of a clinical encounter, these patient interactions and the information within clinical notes are important. However, it is also critical to remember that the text is, by nature, selective, filtered, and containing omissions (either left unrecorded by the provider or never volunteered by the patient). A comprehensive health measurement strategy will include formalized screening as well as information garnered from clinical documentation."
Vest said the study is one of the first to apply NLP tools to SDOH collection, and it points to the value of using a "relatively simplistic" tool to collect data from notes rather than more sophisticated AI tools that many health systems can't use or afford.
“We purposely designed a system that could run in the background, read all the notes and create tags or indicators that says this patient’s record contains data suggesting possible concern about a social indicator related to health," he said in the press release.
"Our overall goal is to measure social determinants well enough for researchers to develop risk models and for clinicians and healthcare systems to be able to use these factors—housing challenges, financial security and employment status—in routine practice to help individuals and to provide a better understanding of the overall characteristics and needs of their patient population.”
Payer scrutiny won't be letting up anytime soon, in fact, expect it to intensify.
The COVID-19 public health emergency has come to an end, which means more audits will be coming your way.
To prepare for a potential increase in payer audit activity, especially from CMS, it’s essential for revenue cycle leaders to examine upcoming trends so they can best protect an organizations’ bottom line.
In fact, organizations should expect heavier scrutiny from Medicare risk adjustment data validation (RADV) auditors in the near future, Rose Dunn, chief operating officer of First Class Solutions Inc. in Maryland Heights, Missouri, told NAHRI. “We are definitely going to see an uptick in activity because the RADV auditors have a few years to catch up on,” she said.
Telehealth will be looked at more intensely moving forward, Sandy Giangreco Brown, director of coding and revenue integrity at CliftonLarsonAllen LLP in Minneapolis, Minnesota, said in the same article. “I’ve done a fair number of audits for telehealth over the last three years and identified some things,” she says. Now that the public health emergency is over, leaders need to determine what will and won’t be allowed by different payers, she said.
To help with telehealth policy compliance and avoid potential payer audits, Brown suggests conducting internal audits as soon as possible. “I think we’re going to have to do our due diligence and make sure we are following who is allowing what,” she says.
Telehealth audits will likely focus on whether provider organizations were billing appropriately based on what rule was in place at that point in time, Dunn says. Auditors will look for documentation issues, as well as whether it was appropriate to treat a patient via telehealth. “I think this area is ripe for audits,” she says.
Going forward, Dunn emphasized to NAHRI that the need for national rules that preempt state requirements, especially for providers who are located near state borders.
Providers should also expect heavier scrutiny on reimbursement for COVID-19 claims, according to Brown. “We’ve seen some really sick patients who had COVID-19 on top of comorbidities,” she says. “And those are some long lengths of stay with very complex patients.”
Responding to COVID-19 audit requests shouldn’t be different than responding to any other audit requests based on diagnosis, such as sepsis or malnutrition, Brown noted to NAHRI. As long as the documentation is thorough and the audit response is complete and timely, there shouldn’t be any surprises.
Interwell Health CEO Bobby Sepucha joins HealthLeaders editor Jay Asser in this week's episode to share how the physician-centered organization is utilizing value-based care to set the standard in kidney care. Sepucha also discusses Interwell Health's strategic partnerships, the future of value-based care, and the operational challenges he deals with at the helm of the company.
With a Medicare-supported model as a blueprint, health systems are finding a lot to like in an acute care at home strategy. But they also have plenty of room to be creative.
Healthcare is embracing the trend of shifting care from the hospital to the home, and forward-thinking health leaders are finding there's plenty of room for flexibility.
Hundreds of hospitals across the country have launched an acute care at home program, focused on treating patients at home versus in a hospital bed. Many of those hospitals are following the Acute Hospital Care at Home model developed by the Centers for Medicare & Medicaid Services (CMS), which sets strict guidelines for in-person care to qualify for Medicare reimbursement.
This strategy, which combines virtual care with in-person services, could be a mainstay in healthcare. But it's a complex process, with an ROI that may take years to show itself.
At a recent HealthLeaders NOW virtual summit, participants from eight different health systems said the future may lie in modifying the model to suit each organization's specific care needs and resources, even if that means bypassing Medicare reimbursement for now.
"We're constantly tweaking it," said Eve Dorfman, vice president of NYU Langone Health, which stood up an acute care at home program less than a year ago that focuses solely on acute care rather than post-acute care. "It's very much a hybrid model."
Dorfman said it took a while to iron out the wrinkles, including infection prevention at home and remote patient monitoring. The health system even used a simulation lab to help nurses "look at the healthcare delivery model differently."
"This is a collaboration," she said. "It is different."
While acute care at home programs have been around for more than a decade (one of the first was launched at Brigham and Women's), the strategy burst onto the mainstream during the pandemic, when health systems created programs to treat COVID-19 patients at home and reduce stress on overtaxed inpatient services.
The CMS Acute Hospital Care at Home program was launched in November 2020 to address those needs. The program sets rigid rules for Medicare reimbursement and requires hospitals to apply for a waiver of the Hospital Medicare Conditions of Participation, which mandate round-the-clock nursing coverage on the premises.
More than 270 hospitals in more than 120 health systems are currently following that model, with the CMS waivers remaining in place until the end of 2024. Lobbying efforts are underway to make those waivers permanent, but the uncertainty of continued Medicare support is affecting how health systems map out scalability and sustainability.
Because the concept is so new, some states haven't caught up to it yet. Eve Cunningham, MD, MBA, group vice president and chief of virtual care at Providence, said its program was almost shut down before it started because Washington state law has strict definitions on hospital-level care. And Penni Kyte, digital care strategy officer for Ballad Health, said her health system had more problems working with Tennessee state officials to OK a program than they did with CMS.
Lauren Hopkins, MPH, assistant vice president of virtual care and community engagement at Augusta University Health, said the health system started with an all-virtual platform to treat COVID-19 patients and has since pivoted to focus on the transition from acute care to post-acute care, including chronic care management. The health system hasn't applied for CMS waivers yet, she said, because Georgia hasn't amended its state laws to accommodate the care model.
With the uncertain policy and regulation landscape as a backdrop, health systems are developing their own acute care at home programs. Some are using their own nurses for home visits, while others are partnering with home health or mobile integrated health programs. Some are monitoring patients around the clock, while others are collecting data from patients at certain times of the day. Some are using wearables, and some are integrating pharmacists, physical rehab, even health and wellness services to address social drivers of health.
And not everyone is going with the CMS model. Cunningham says some programs are seeing success with bundled payment models and other services that payers are willing to reimburse.
In a separate interview with HealthLeaders, Tina Burbine, vice president of care innovation and enterprise analytics at HealthLink Advisors, which has advised many health systems—including negotiating with payers—to set up these types of programs, said there's no set definition of acute care at home.
"There are many different flavors of care at home," she said. "And hospitals are seeing a lot of success … as long as they mindful of incorporating their value-based care goals."
"There's so much learning that has to happen" with the CMS model, adds Burbine, who recommends that hospitals start small and build up their program slowly and incrementally with lesser-acuity patients, to see whether high-acuity care will work for them. "This has become such a competitive market that we're even seeing payers compete with health systems."
Some say the acute care at home model will evolve significantly as COVID-19 fades away and hospitals take back some of those inpatient services to bolster their bottom line. In that scenario, the platform shifts more toward post-acute care, including rehabilitation and chronic care management.
Jared Conley, MD, PhD, MPH, associate director of the Healthcare Transformation Lab at Massachusetts General Hospital, said during the HealthLeaders virtual summit that acute care at home may eventually surpass inpatient care as the highest quality acute care platform. The challenge lies in navigating the complexities to create a program that fits well within the health system.
"Think of this as building another brick-and-mortar hospital," he added. "It is very challenging work, but it is so beneficial."
"They've really been helping to drive this," he said of KP's provider base. "There's a general excitement to do this."
Burbine says the model could someday replace the rehabilitation center as a better and more cost-effective post-acute care pathway and create better alternatives to skilled nursing facilities. It might also be used in prisons, substance abuse treatment programs, and for other populations where hospitalization is difficult.
"Ideally, we want our patients' care to be managed by their health system," she said. "And we're seeing new ideas [for] how that can be done. It changes not only the definition of a hospital, but the definition of a home."
FAIR Health reports that declines in telehealth claims were seen in all four U.S. census regions.
Overall private insurance telehealth claims fell 5.4% nationally in April, representing 5.3% of all medical claims, compared with 5.6% of claims in March, according to FAIR Health's Monthly Telehealth Regional Tracker.
The drop in telehealth claims was seen in all four U.S. census regions—the Midwest (4.7%), Northeast (6.3%), South (6.8%) and West (6.4%). The average patient visit lasted between 20 and 29 minutes, the median charge was $167.77, and the median allowed amount was $89.70.
Audio-only telehealth fell in both rural and urban areas nationally and in every region except the West, where it fell in rural areas but rose in urban areas.
The data was taken from privately insured population, including Medicare Advantage and excluding Medicare fee-for-service and Medicaid.
Mental health conditions continued to be the top-ranking telehealth diagnosis nationally and in every region, rinsing from 67.4% of telehealth claim lines nationally in March to 68.4% in April—the fourth straight month of national increases.
Claims for acute respiratory diseases and infections, the second most-common telehealth consultation, fell nationally in April from 3.2% in March to 2.7% in April, the fourth straight national monthly decrease for this diagnosis.
Developmental disorders rose to third place while joint/soft tissue diseases and issues fell to fourth place.
Among the top five diagnoses nationally via asynchronous telehealth places with urinary tract infections, rising to third place while UTI fell to fourth.
Asynchronous telehealth claims for hypertension increased to 12.5% nationally in April, up from 9.7% in March, and in every region. Hypertension rose from second to first place in the West and from fourth to second place in the South. It maintained its position nationally (second place) and in the other regions—second place in the Northeast and first in the Midwest.
Sleep disorders climbed in the rankings of asynchronous telehealth diagnoses from fifth to fourth place in the Northeast and from fourth to second place in the West. Diabetes mellitus rose in the rankings in three regions: from fifth to third place in the Midwest, from fourth to third place in the Northeast and from fifth to fourth place in the West.
According to the Entertainment Software Association, 70% of gamers surveyed say games could be used for medical treatment, and many see the benefits in addressing mental health and isolation.
A new survey of video game players finds that a pastime enjoyed by some 212 million Americans could be used to improve healthcare access and treatment—particularly in mental health.
Those are good numbers for an entertainment genre that has danced along the edge of the healthcare market for many years, with companies like Akili Interactive, Level Ex, and Deepwell Digital Therapeutics offering a broad array of games aimed not only at patients but providers. Gaming technology and video and interactive games have long shown promise in addressing key pain points like engagement, chronic care management and adherence.
And they're popular. The survey estimates that 65% of Americans play video games.
“Video games remain a mainstay in American households, as they have for decades,” Stanley Pierre-Louis, president and CEO of the Washington DC-based ESA, said in a press release highlighting the survey results. "Playing video games has become the norm, as those who first learned to play on early consoles now share their joy of play with their own children and grandchildren, resulting in an expansive and diverse player community. The Essential Facts report demonstrates that video games not only connect us, but also enhance our sense of wellbeing.”
Among the results highlighted by the survey, which was distributed online in April 2023 and taken by roughly 4,000 respondents, were the effects of gaming on mental health and wellness. About 90% of those responding said video games provide mental stimulation and stress relief, while 88% said games help improve cognitive skills, 81% said they help build problem-solving skills, and 75% said they help boost collaboration skills.
They can also be used to address isolation and loneliness. Some 88% of survey respondents said games expand their social circles and 82% said they were introduced to new friends and relationships through game platforms (half of those responding said they met a good friend, spouse or significant other through games). In addition, 60% said video games help them stay connected to friends and family, and 71% reported developing a feeling of community through gaming.
Finally, while video games and gaming are most people among the younger generations, a significant number of seniors are playing them as well—and seeing specific healthcare benefits. According to the survey, 62% of adults play video games (32 is the average age of a player) and roughly three-quarters of adults play games with their children.
Healthcare leaders are interested in video games because they offer a mobile platform that allows users to access content at the time and place of their choosing. They also provide an entertaining platform to learn new ideas, along with rewards to foster engagement and metrics that would enable executives to measure progress and continued adherence.
Kaiser Permanente's Ramin Davidoff, MD, explores how new ideas in healthcare are actually old concepts brought back to life with new technology.
[Editor's Note: Ramin Davidoff, MD, is executive medical director and chair of the board for the Southern California Permanente Medical Group; chair of the board and chief executive officer for The Southeast Permanente Medical Group; chair of the board and chief executive officer of the Hawaii Permanente Medical Group; and co-chief executive officer of The Permanente Federation.]
Tech pioneers, venture capitalists, and innovators are perpetually pursuing the next big thing in healthcare. The imperative to improve outcomes and revolutionize the patient experience, while lowering costs, drives this endless quest.
There is no doubt that innovation is critical to moving the health system forward. What’s more surprising is seeing so many approaches from the past continue to drive progress. Health systems are reaching back—as far back as the advent of modern medicine—to solve the quality-cost conundrum. As William Faulkner wrote, “The past is never dead. It’s not even past.”
Ramin Davidoff, MD, medical director and chair of the board for the Southern California Permanente Medical Group, chair of the board and CEO for The Southeast Permanente Medical Group, chair of the board and CEO of the Hawaii Permanente Medical Group, and Co-CEO of the Permanente Federation. Photo courtesy Kaiser Permanente.
Let’s look at three approaches to delivering care that are making a comeback.
House calls: The phrase evokes the not-so-recent past. In the 1930s, house calls made up nearly 40% of physician-patient interactions, but by the 1980s the figure dwindled to as low as 1%. Health systems are turning back the clock to deliver a full spectrum of care in patients’ homes, from telemedicine right up to hospital-level acute care. It’s care that was more convenient and safer for the patient while hospitals were stretched to their capacity by patients with COVID-19, and it delivers better outcomes.
House calls connect homebound seniors and others facing mobility challenges with their primary care providers to manage chronic conditions. Physical therapy appointments are also taking place in the home. Due to the pandemic, nearly 100% of talk therapy sessions now occur over video.
The pandemic expanded health systems’ thinking around the types of care that could be delivered in patients’ homes, with the goal of keeping patients safe during spikes in infection rates. COVID-19-era waivers that were recently extended for two more years encouraged systems to expand the house call concept to deliver acute-level hospital care in the homes of patients. It is bringing hospital care to areas that may not have a brick-and-mortar hospital nearby.
The model has serious momentum behind it. More than 100 health systems and 250 hospitals have been approved by the Centers for Medicare & Medicaid Services (CMS) to receive Medicare reimbursement to deliver hospital-level care in the homes of patients, and thousands of patients have benefited already. As technology and innovation increasingly enable patients to receive even advanced care in their homes, health systems likely will focus more on emergency care and surgeries.
Value-based care: The Affordable Care Act, which celebrated its 13th anniversary in March, didn’t invent the concept of value-based care, but it kicked the movement into high gear. The law laid the groundwork for systems to test new approaches for delivering higher quality care in return for incentive payments and bonuses. Meanwhile, the federal government set ambitious goals for moving payment arrangements away from quantity-oriented fee-for-service models to models that prioritized better outcomes delivered at a lower cost.
Over the intervening decade, varying degrees of success were achieved across performance and participation targets, but it’s clear the federal government and health systems are committed to value-based care models.
The foundation of this commitment is the growing body of evidence that value-based care delivers on the promise of improving patient outcomes while lowering the cost of delivering that care. Value-based care may have lost its place as the next big thing in health, but it is still front and center in health systems’ plans for innovating care delivery.
Care coordination: Health systems decided at the turn of the 21st Century that it would be better for the patient if the metaphorical left hand (the patient’s primary care provider) knew what the right hand (a patient’s many specialists and other members of their care team) was doing and vice versa. The emergence of electronic health records paved the way for a more efficient flow of information between these many points of patient contact, and patients are reaping the rewards.
Health systems are building on the early successes of coordinating care to instill this practice throughout a patient’s journey. Health systems are acquiring or merging with community-based services and physician practices, enabling clearer, more effective lines of communication and coordination on behalf of the patient. The movement toward coordination has the added benefit of improving the quality of care while making it more affordable.
Health systems should remember that new doesn’t always translate to best. As the United States continues to search for healthcare’s holy grail of better care at a lower cost, let’s consider that what’s worked in the past can work in the future.
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The bill would protect access to home health care by preventing CMS from making cuts to the Medicaid Home Health Program.
U.S. Sens. Debbie Stabenow (D-MI) and Susan Collins (R-ME) recently introduced the Preserving Access to Home Health Act, preventing the Centers for Medicare and Medicaid Services (CMS) from implementing dire cuts of 7.85% to the Medicare Home Health Program, safeguarding access to essential, clinical home-based healthcare services.
The bill has bipartisan support.
"We strongly support this essential legislation as current policy positions of CMS put access to home health services for the over three million beneficiaries that utilize this care in jeopardy," William A. Dombi, president of the National Association for Home Care and Hospice, said in a statement.
"The Medicare home health benefit has shrunk over the last decade due to various payment cuts, the most recent of which is the subject of the legislation."
The bill addresses CMS cuts specifically with two policy changes: repealing permanent and temporary payment adjustments and instructing the Medicare Payment Advisory Commission (MedPAC) to analyze the Medicare Home Health Program to consider the impact of all payers on access to care for beneficiaries.
The Preserving Access to Home Health Act is needed to protect the future viability of the Medicare home health program, according to the Partnership for Quality Home Healthcare and National Association for Home Care and Hospice.
Going forward, the home health leaders want lawmakers to consider the following:
Medicare home health spending is projected to drop to $18 billion to $16 billion this year, and $15 billion in 2024 onward, according to the Congressional Budget Office (CBO).
Most Medicare beneficiaries prefer to receive post-hospital, short-term care at home.
Home health saves the Medicare Trust Fund $1.38 billion over six years due to avoided hospitalizations and skilled nursing placements.
Without home health, hospital lengths of stay are increasing, and patients are unable to transition easily from hospital to home.
"We applaud Senators Stabenow and Collins for their leadership in introducing this bill and their ongoing efforts to protect the Medicare home health benefit," Joanne Cunningham, CEO of the Partnership for Quality Home Healthcare, said in a statement. "This legislation offers the stability the Medicare home health community so urgently needs."
Heather Dlugolenski is SVP of commercial strategy and solutions for Cigna Healthcare, one of two growth businesses within parent company The Cigna Group. In her role, she supports the company's employer-sponsored health insurance group and related services, which include nearly 15 million customers.
The SVP sat down with HealthLeaders for this exclusive Q&A.
HealthLeaders: What is your role and focus at Cigna Healthcare?
Heather Dlugolenski: My role is to create the strategy that defines what value we can provide to our stakeholders over time: where are we going to place our bets and what are the concepts and ideas we can bring to life. This is all to support the highly integrated services we go to market with to help members stay healthy and productive.
HL: Can you paint a picture of that strategy timeline? How do you narrow from a large number of solutions to what you execute?
Dlugolenski: First, we evaluate our strategy every year. We're looking forward five to 10 years and saying: What changes do we make from one year to the next, which gives us a new architecture to hang our innovation on. When we're doing that, we're looking at what opportunities the market suggests.
The companies we're doing business with are constantly trying to thread the needle around affordability: to their employees, their respective family members, and to themselves as an employer. That's number one.
Two is access, helping employers give their employees better access to care than they can get on their own (e.g., mental health, prescription drugs).
Number three is experience. Employers are constantly trying to extend experiences, services, and features to their employees that help them be the best people they can be—things that also connect to the mission, talent strategy, and culture of the company.
Some of these value levers are not as clear cut. They may take a longer timeframe to play out, and they may be more existential in nature.
It's a tightrope that a person in the employee benefits seat is walking. They want a trusted partner that has a solution for all of those value levers. Our strategy is constantly iterating across value lever dimensions and the real opportunity statements for employers.
Heather Dlugolenski, senior vice president of commercial strategy and solutions, Cigna Healthcare.
Dlugolenski: Some 60% of adults are living with a chronic condition. The cost of care for people who have both a chronic and a mental health condition is two to three times higher than the average cost of those with a medical condition alone. In addition, the median cost of lost productivity for a single employee with depression is $3,200.
As an example of how the company delivers value across access, affordability and experience, Dlugolenski cites Cigna Pathwell Specialty. Pathwell "helps control specialty spend across the medical and pharmacy benefit, where specialty drugs are obtained, and by coordinating care and supporting customers."
Dlugolenski, continued: Pathwell Specialty helps patients get their specialty infusions in convenient infusion centers or even in their homes rather than in a hospital where it can be really expensive and sometimes hard for people to access.
I have a real-life example of a member who was diagnosed with a rare form of cancer. Their treatment plan called for a specialty medication injection every month at a local hospital. The member was having a hard time being adherent because it was difficult to get transportation back and forth from the facility. Through Pathwell, an employed nurse was able to administer the injection in the member's home and improve his medication adherence and overall experience. That reduced the cost of his treatment by almost $350,000.
HL: You speak with such clarity around these issues. Is that a part of your leadership style?
Dlugolenski: I am thankful for the opportunity to talk about influence and for the slightest possibility that my mother could see me talking about my father, who I have tremendous respect for and who I lost last year.
My dad [Robert Messina] worked at Cigna as a software engineer, and I followed him to this company right out of college. My dad was a math major so he was highly analytical, but he also loved music and watching things made and having those things made be beautiful. They call that golden brain, when both sides of your brain work equally.
There's a part of how my brain works that I 100% believe my father gave to me—either through DNA or demonstration. It allows me to play in this space in which both of those things [the analytic and creative] are important: building a strategy and the solutions that support it with a leadership and communication style that's relatable.
HL: You mentioned that it would be nice for this article to mention your father—in part for your mother. What did you acquire from her and how does that influence you as a leader?
Dlugolenski: In life, women make many decisions: childcare, aging parents, the household. My mother made a lot of decisions in front of me. She was great at acknowledging when it was decision time, knowing what was more right than wrong, and then evaluating afterward if there was something to pivot from. A lot of women have that tenacity in their lives. I apply that to my life too, including my professional career.
HL: What are Cigna Healthcare's priorities over the next two to five years?
Dlugolenski: To innovate across affordability, access, and experience and to do that through the lens of a member's physical, pharmaceutical, and behavioral care. We recently adjusted our mission statement to "To improve the health and vitality of those we serve." Vitality is a measure of someone's ability to be happy in their life and is the fundamental anchor point of what Cigna will execute in the future.
