Rush University Medical Center is applying data technology in several areas, including documentation improvement, value-based care, dashboard development and implementation, readmissions reduction, and cost of care.
At Rush University Medical Center, an effort to investigate low quality scores has blossomed into a highly ambitious data analytics and machine learning initiative.
In early 2015, the Chicago-based medical center had three stars in Medicare's Hospital Compare rating system, and the organization's new CMO, Omar Lateef, DO, wanted to know why, says Bala Hota, MD, MPH, vice president and chief analytics officer.
"We are both practicing physicians. We saw patients at Rush, and we knew the quality of care for a lot of the service lines was excellent, but we weren't seeing that reflected in the ranking systems," says Hota.
While systematically reviewing documentation data, Hota and his colleagues found clinicians were underreporting the severity of patient illness. "We were consistently seeing that our severity of illness ranked among the lowest—in the bottom decile," he says.
The need for documentation improvement became even clearer after a review of patient transfers from other facilities, Hota says. "Patients were getting transferred to us and they were getting a lower acuity than they had at the hospital they were transferred from, which made no sense."
Documentation improvement that has improved severity of illness reporting has helped raise Rush's Hospital Compare rating to five stars.
Documentation is the key ingredient in most ranking systems at the Centers for Medicare & Medicaid Services, he says. To help find opportunities to improve documentation, Hota's team developed customized algorithms and gathered documentation data.
"We do see variation between different provider groups and different providers. There is more opportunity with some, with others there's less. Just being armed with that information helps us to educate, guide, and change behavior," Hota says.
Rolling out dashboards
After using data analytics to delve into Rush's quality ratings, Hota's team continued to seek opportunities for data to drive change.
A primary effort has been harnessing key performance indicator [KPI] data and displaying the data on dashboards, often in real time. "We have a level of detail needed to drive behavior change," Hota says.
The dashboards track several KPIs:
Documentation
Care variation
Cost of care
Length of stay
Mortality
Patient safety indicators
Quality domains
"We have about 200 key performance indicators in executive dashboards that we have rolled out over the past four months. These dashboards are shown on large monitors in the offices of our president, chief operating officer, and chief financial officer," he says.
Predictive modeling
Rush is conducting predictive modeling with its Epic electronic medical record and with a cloud-based Big Data capability.
With Epic, Hota's team has developed five predictive models for illnesses, including congestive heart failure.
With the cloud-based technology, data can be drawn from any IT system in the cloud's "environment" such as sensor data and clinical engineering. "The advantage of this approach is we are using machine learning. Deep learning models allow us to customize models to our unique situation," Hota says.
Predictive modeling is being used primarily in three areas at Rush:
Cost of care to identify high-risk patients and help ensure they are on the best care pathways or protocols
Emergency department throughput to drive reductions in the length of time patients are spending in the ED
Readmission reduction to identify negative factors after discharge
Data drives value-based care
Data analytics are playing a crucial role in value-based care at Rush, which features four acute-care hospitals.
In the Medicare Shared Savings Program (MSSP), Rush is using data analytics to track access to care, patient residence, in-network versus out-of-network utilization, and total cost of care.
Documentation is a key to MSSP success, Hota says. "We are looking at how documentation relates to our severity of illness and our care. We are looking for opportunities to improve what we document."
Data analytics is helping Rush manage the impact of the Hospital Readmissions Reduction Program and the Hospital-Acquired Condition Reduction Program.
For readmissions, Rush uses predictive modeling and risk adjustment to anticipate and affect readmission rates, which have improved. "We have seen readmission declines over the past four years, which has switched Rush from a Medicare penalty to a bonus for our academic medical center," he says.
Focusing on outcomes data is important to limiting hospital-acquired conditions, Hota says. "We are measuring every case of a condition. We are looking for where we have outcomes that we need to fix."
Scaling paced to growth
Rush has contained the costs for its data analytics initiative by leveraging internal resources and scaling growth strategically.
"We have tried to use existing staff and existing resources. We started out by dipping our toes in the water, [to] see whether there was value, and scaling it as we moved along," Hota says. "There has not been a lot of upfront expense."
Utilizing cloud technology is financially advantageous, he says. "From the start, we planned an in-the-cloud implementation because that allows our costs to scale as the data scales. So, we do not have a large capital investment for infrastructure on-site."
The cost of the initiative has increased over time, Hota says. "We were able to keep the costs relatively low—almost at a pilot-project level of funding—for the first six months. Since we have seen some successes, we are scaling the budget as time goes by."
Over the next few years, he expects Rush's investments in data analytics capabilities to reach "millions of dollars, not tens of millions of dollars."
"We want to grow this program and make it the source of truth for data and analytics at the medical center and the Rush system," says Hota.
In first blow to a CMS 2017 Final Rule, a court ruling in Missouri has invalidated the agency's attempt to deduct Medicare and private insurance payments as offsets when calculating outlays to hospitals under the DSH program.
A federal District Court ruling has invalidated an attempt to change the payment formula for the Disproportionate Share Hospital program in a way that would reduce payments for hospitals across the country.
If the ruling withstands an anticipated appeal, it could spare hospitals nationwide DSH payment recoupment ranging into hundreds of millions of dollars.
The case was filed by the Missouri Hospital Association against the secretary of the federal Department of Health & Human Services and the Centers for Medicare & Medicaid Services. The primary issue is CMS rule-making, including 2010 FAQ guidance and a 2017 Final Rule requiring hospitals to deduct private insurance and Medicare payments as offsets when calculating outlays to hospitals under the DSH program.
The CMS 2017 Final Rule, "Disproportionate Share Hospital Payments—Treatment of Third Party Payers in Calculating Uncompensated Care Costs," became effective June 2, 2017. The is the first time the Final Rule has been invalidated in federal court, and it is also facing federal District Court challenges in Washington, D.C., and New Hampshire.
Under federal Medicaid law, hospitals in states participating in the Medicaid program receive federal DSH payments to cover some of the Medicaid-payment shortfall associated with care of Medicaid-eligible patients.
In his Feb. 9 ruling, District Court Judge Brian Wimes highlighted the competing DSH formulas favored by MHA and CMS:
MHA formula based on laws and regulations prior to 2010: Total cost of treatment for Medicaid-eligible patients – total payments from Medicaid not under the DSH program = Medicaid shortfall
CMS formula based on 2010 FAQ guidance and 2017 Final Rule: Total cost of treatment for Medicaid-eligible patients – (total payments from non-DSH Medicaid + total payments received for Medicaid eligible treatments from Medicare and private insurance) = Medicaid shortfall
In a declaration submitted to the court, an executive from St. Louis-based Barnes Jewish Hospital said deducting payments received for Medicaid-eligible care from Medicare and private insurance would cost the hospital millions of dollars annually. Larry Kayser, vice president of finance at Barnes Jewish Hospital, wrote the new CMS formula would result in recoupment of $5.9 million for fiscal year 2011 alone.
Under the FAQ guidance, CMS conducted DSH hospital payment audits under the new formula from 2011 to 2014. For the 2011 and 2012 fiscal years, Missouri hospitals face recoupment of $95.7 million if the new DSH payment calculation formula withstands legal challenges, according to the MHA.
National impact uncertain
While last week's ruling blocks recoupment of DSH payments in Missouri, it is unclear whether the decision will have a national effect, says Jane Drummond, general counsel of the MHA.
"We asked for a nationwide injunction in our lawsuit, but the opinion that was rendered just says our motion for summary judgment was granted. It is not specific on whether the court intended the ruling to apply nationwide."
Unless Judge Wimes issues a national injunction, CMS' reaction to the ruling will determine whether it has a national impact, she says. "There was an injunction issued on the FAQs in the federal District Court in Washington, D.C., but CMS took the position that the injunction only applied to the parties in that case, so it did not have nationwide effect."
Drummond expects the Missouri ruling will be appealed. "We are one of three cases that have challenged the Final Rule and this is the first decision invalidating it, so they will most certainly appeal to preserve their position in those other two cases."
If MHA prevails in an appeal, the hospital association expects the DSH payment audits conducted from 2011 to 2014 under the new calculation formula would be repeated under the old formula, sparing hospitals nationwide hundreds of millions in recoupment. If it loses an appeal, CMS would have to seek legislation from Congress to include Medicare and private insurance payments in the DSH outlay formula, Drummond says.
MHA pevails in federal court
Wimes sided with the MHA's claims against the 2017 Final Rule as well as FAQ 33 and FAQ 34 of reporting and auditing guidance promulgated in 2010. Both the Final Rule and the FAQs seek to establish the new CMS DSH formula.
In his decision, Wimes first invalidated the FAQs on the basis that they were promulgated without any notice or consent process such as publishing them in the Federal Register.
While the judge did not make a formal ruling on two other claims the MHA had made against the FAQs, he did write that those additional claims were valid:
Wimes wrote that the FAQs exceeded DHHS' statutory authority because they "substantively alter the formula for the calculation of uncompensated care costs for DSH hospitals"
Wimes wrote that the FAQs are contrary to the "unambiguous language" of the Medicaid statute, which does not include private insurance and Medicare payments in the formula that determines outlays to hospitals under the DSH program
Drummond says the judge's commentary on the FAQs regarding the Medicaid statute formed the basis of his invalidation of the 2017 Final Rule.
"Even had DHHS moved forward and done this change with substantive rulemaking, the FAQs would be invalid anyway because they are contrary to the Medicaid statute," she says. "While this was not a holding of the court, the judge did discuss those points and agree with our arguments, then used that rationale to invalidate the Final Rule."
The health system is confident of success based on performance in its first Medicare ACO contract as well as recent improvements in care coordination, skilled nursing partnerships, and care access.
Cleveland Clinic is taking on downside risk in the Medicare Shared Savings Program, shifting from the upside-only Track 1 of the program to Track 1+.
"The migration toward risk is something we realize is happening across northeast Ohio and the country," says James Gutierrez, MD, president and medical director of Cleveland Clinic Medicare ACO. "We know that we need to be ready to embrace greater risk and we need to be ready to do it successfully if we are going to survive as an organization."
Cleveland Clinic Medicare ACO, which manages a population of 105,000 beneficiaries, participated in MSSP Track 1 from 2015 to 2017 and posted strong financial performance. In 2016, the ACO achieved $42.2 million in savings, which was a 24.5% increase over 2015 performance. Also in 2016, the ACO received $19.9 million back from MSSP in shared savings, a 19.8% increase over 2015.
In its three-year MSSP Track 1+ contract that starts this year, Cleveland Clinic Medicare ACO faces a 30% loss-sharing rate if the ACO fails to meet its spending benchmark and as high as a 50% gain-sharing rate.
Anticipating Success
In addition to its strong performance in MSSP Track 1, Gutierrez says the health system expects to perform successfully in Track 1+ because of recent capability improvements in care coordination, post-acute care, and patient access.
He says the 11-hospital health system took a major step toward improved care coordination last fall, with the launch of Cleveland Clinic Community Health.
"Although we talk about one Cleveland Clinic and we are a unified enterprise, there are two populations that we serve," he says. "One is the regional, national and international referral base that we serve for tertiary care, the other is a large segment of the local population in northeast Ohio."
Cleveland Clinic Community Health features a newly formed leadership team designed to unify several classes of caregivers who serve the local population:
Adult and pediatric primary care services
Urgent care
Social workers
Behavioral health
Pharmacy services
Support services including analytics and finance
"It brings together many, if not most, of the types of individuals and services that we need to do well in the ACO," Gutierrez says.
Other care coordination investments have been made at primary care practices, where Cleveland Clinic has been focusing on managing the health system's high-risk and highest-utilizing patients. Adding registered nurse care coordinators to the staff is one example, he says. In addition, Gutierrez says the health system has improved care coordination for inpatient services with bolstered transitions of care in the hospital, specialty care, and primary care settings, but while rewards from these investments may be significant, costs may be as well, and the Clinic declined to provide that information.
While Cleveland Clinic does not own skilled nursing facilities, the health system has been placing physicians and nurse practitioners at SNFs with the highest-volume of its patients, he says. Skilled nursing is one of the bigger buckets of spending for the Medicare population, he says.
Gutierrez says having the health system's clinicians work with SNF patients has generated several quality and financial benefits for the ACO and its patients, including:
Decreased length of stay
Improved quality and outcomes such as a 16.7% decrease in the 30-day all cause readmission rate from 2016 to 2017
Smoothed transitions of care, both from the hospital to the SNFs and from the SNFs to the home and primary care
Patient access is a key component of meeting MSSP spending benchmarks because managing patients effectively at low-cost settings such as primary care practices can avoid expensive emergency department and inpatient care, he says.
In addition to expanding access to primary care and specialty care practices, the health system has opened several urgent care clinics, Gutierrez says. The Express Care clinics are walk-in settings that handle a range of medical issues beyond coughs, colds, and rashes.
In 2016, Express Care visits increased by 76% to 133,333, with the increase attributed mainly to the opening of six new sites, according to Cleveland Clinic's 2016 annual report. In another measure of improved patient access, same-day visits increased 10% in 2016, to 1.3 million.
Patient Attribution
Unlike MSSP Track 1, which attributes patients to ACOs retrospectively at the end of a performance year, Track 1+ features prospective patient attribution at the beginning of a performance year.
"It is in some ways akin to getting answers to the test ahead of time and being able to take it home to work on it," Gutierrez says.
In Track 1+, prospective patient attribution helps ACOs manage the care of their patients, he says. "Knowing the population that we are accountable for is going to help us make sure we manage that population effectively and don't let people slip through the cracks."
Since joining MSSP, Cleveland Clinic has developed new population health analytics capabilities, which the ACO will be able to use more effectively with prospective patient attribution, Gutierrez says.
"Knowing who our population is will allow us to use clinical and claims data, then risk-stratify the population to identify the high-risk patients who need special attention."
Top finance executive wants growth in complex-care cases, control of supplies and drug utilization, an ongoing shift to value-based care, and investment in technology to optimize revenue cycle.
After serving in a transitional role as deputy CFO at Mission Health, Paul McDowell, MBA, is now CFO and senior vice president of finance at the Asheville, North Carolina–based health system.
McDowell's deputy CFO role was created about two years ago in anticipation of the retirement of CFO Charles Ayscue, who stepped down in early January. The deputy CFO role was created to hand over responsibilities to McDowell over time.
Before coming to Mission Health in January 2013 as vice president of finance, McDowell was senior vice president and CFO of King's Daughters Health System in Ashland, Kentucky.
HealthLeaders Media recently spoke with McDowell, and the following is a lightly edited transcript of that conversation.
HLM: What are the primary growth opportunities at Mission Health this year?
McDowell: Complex-care cases. We want to grow at the top end of the acuity scale. Over the years, we have developed programs in advanced cardiac care, for example, to alleviate the need for patients to travel outside of western North Carolina. We have also added pediatric specialties so that children and their parents can receive excellent care closer to home and avoid having to travel to Charlotte or Raleigh.
In addition to growth at our tertiary hospital here in Asheville, we are surrounded by five much smaller hospitals that are part of our system. We are focused on making sure they take on the lower acuity cases that can be safely and effectively treated in those more rural communities and closer to the patient's home. It's more convenient for patients.
We want to make sure we have our patients in the right setting. It is not only good for the patients but also frees up capacity at our tertiary hospital for more acute patients.
HLM: What are Mission Health's primary financial challenges in the coming year?
McDowell: Mission Health has a difficult payer mix. Almost 75% of our payer mix is Medicare, Medicaid and self-pay. Medicare, Medicaid and certainly self-pay have not increased their rates very much in the past few years; and with a small commercial component in our mix, it is hard make up revenue.
When you do the math, we may have a 1.5% annual revenue increase; and meanwhile, expenses are going up 3% to 5% depending on the category. So, we have an imbalance between inflationary pressures in expenses and the low rate increases on the revenue side that create a continual need for cost savings.
HLM: Is it possible to achieve cost savings that will make up that gap?
McDowell: The next generation of cost savings relates to supply and drug utilization. We have been working the unit-cost side of supplies and drugs for a long time—trying to make sure that we have the best contracts and the lowest prices.
Now, we have transitioned to focusing on the utilization of supplies and drugs. So, we have much more standardization and make sure we are using a supply that not only has a good price but also represents the best supply item for a particular need. We are getting physicians to work together to use the same supplies in the same circumstances, which creates buying power for us.
One of the most important clinical advancements at Mission Health over the past two to three years is the development of dozens of care process models, where groups of clinicians determine the best, most evidence-based approach to a given disease or condition. These models are then imbedded in the EMR and tracked through our data warehouse. The development of these care process models has systematically standardized care, improved quality, and reduced cost.
HLM: Are there other ways to close the health system's finance gap?
McDowell: We also are focused on making improvements to revenues. This includes reducing payment denials, improving the accuracy of clinical documentation, and reducing patient outmigration so that they can have care closer to home. Over the past four to five years, revenue improvements have made up approximately 30% to 40% of our annual margin improvement initiatives.
HLM: How are you preparing for the shift to value-based care?
McDowell: We are preparing for the future and the value-based world, but most of our business is still in fee-for-service. So, living in that dual world is a challenge every year and we are systematically preparing for the future. We have an accountable care organization that has more than 60,000 members—that is a significant population and an interesting opportunity from the gain-share perspective. Despite having a low spending target compared to others nationally in the Medicare Shared Savings Program Track 1, we saved the federal government just more than $11 million last year.
Our performance level is indicative that we are successfully transitioning to the value-based world. Looking forward, we are continuing to focus on improving performance and outcomes.
HLM: Do you have any other optimization goals?
McDowell: We have goals for IT investment in the revenue cycle to make sure that we are continuing to improve our performance.
One goal is getting the entire organization on the same IT system. Our acute care hospitals all are on the same system, but some of our physician practices are not. We have acquired practices and they have come into the system in various ways, and having multiple IT systems creates an incredible amount of inefficiency. You can't leverage your scale when you are on six or seven IT systems in your ambulatory settings.
A second goal is leveraging technology to optimize the revenue cycle. That includes getting all care settings on the same payment portals, getting patient scheduling on the Internet so patients can self-schedule, and adopting other patient-facing technology that can both improve efficiency and improve patient satisfaction.
Since starting cost estimations for a wide range of inpatient and outpatient services a decade ago, Oklahoma-based INTEGRIS Health has achieved a 22-fold increase in point-of-service collections.
Providing pre-service cost estimates to patients has markedly increased point-of-service collections at INTEGRIS Health, from $900,000 in 2007 to $20.55 million last year.
"It most definitely contributes. Providing financial information prior to the scheduled appointment gives the patient an opportunity to pay during the pre-registration call or at the time of service," says Veronica Hughes, administrative director for patient access services.
The Oklahoma City-based health system started providing out-of-pocket cost estimates for patients manually in 2006.
The majority of cost estimates are partially automated because fully automated estimates available through the health system’s website have not been widely adopted, says Brent Grimes, administrative director of revenue cycle. Most patients get cost estimates either over the phone or in person at inpatient pre-registration or when they appear for outpatient services such as laboratory tests.
Providing cost estimates has become a standardized procedure for patients at INTEGRIS' seven acute-care hospitals, Hughes says, noting estimates not only boost point-of-service collections but also engage patients as financial partners.
"We have an access center with centralized pre-service financial counseling and pre-registration. They contact upcoming scheduled patients to notify them of potential financial liability."
Technology and specificity
The key technological component of both fully and partially automated cost estimates is Franklin, TN-based Experian Health's Passport platform, she says.
Passport has most of the data required to make accurate cost estimates such as payer contract information, patient benefits, medical procedure pricing, CPT codes, and physician information.
"It looks at all of those elements for an estimate," Hughes says.
Specificity is crucial to providing accurate cost estimates, particularly for services with wide variability such as surgical procedures, Grimes says. Several specific components are required to provide an accurate surgery estimate:
Contracted rates with the payer
Identity of the physician, because different clinicians use different surgical supplies
Supply chain information to ensure pricing accuracy of surgical supplies
Historical claims data to help predict procedure costs
"Our estimation accuracy rate for surgical procedures today equals our other procedures," Grimes says. "We don't have any more variation in surgery than we have in radiology, for example."
Emergency care is the only hospital department where INTEGRIS patients do not get cost estimates.
"Even when we are asked, there is no financial communication or information before the patient is triaged, checked by a provider, and stabilized," Hughes says.
In emergency medicine, there are too many variables to provide cost estimates before services are provided, Grimes says.
"When people call in, we have to explain there is a triage process and we can't give out quotes before the triage process."
Monitoring accuracy
The health system's customer service group leads the effort to monitor the accuracy of patient cost estimates. A panel meets every week to go over logs that are kept on patient questions and concerns, including cost estimate complaints, Grimes says.
Inaccurate cost estimates are investigated.
"An analysis sees whether we had the proper information and whether it had been loaded properly," he says. "We see whether the patient understood that they had an estimate instead of what they would actually owe."
A refund team is part of the customer service group.
The issuing of refunds is an indicator of "root-cause" problems that need to be corrected, Grimes says. "If we are giving money back to the patients, we are failing at the process."
An example of a root-cause problem that can necessitate a refund is a health plan contract change that the estimate did not include.
"This could change the patient responsibility and create a situation that our estimate and payment upfront was more than the new contract allowed," Grimes says.
The response to this kind of problem includes researching the credit and communicating the corrective action throughout the cost-estimation team, he says.
An important step to avoid disappointing patients is consistent scripting when estimates are given, Grimes says.
"We try to be very clear with the patients that there are variables—some we can control and some we can't control—and we push the point that we have given an estimate."
Whenever possible, patients are asked to sign a copy of their cost estimates.
Lessons learned
INTEGRIS, which posted $1.55 billion in total operating revenue for the fiscal year ending June 30, 2017, devotes considerable time and resources to its cost-estimation capability.
"It takes an enormous amount of resources and people to do this well and keep up with it. There is continual maintenance and quality assurance," Grimes says.
INTEGRIS staff inside and outside the revenue cycle division are involved in cost estimation:
IT maintains files and transfers data
The charge master team manages pricing
Contracting updates payer contracts
The business office oversees customer service
The refund team plays a customer service role
The billing team handles the challenge of serving insured patients vs. uninsured patients such as helping patients obtain Medicaid coverage
The charity team ensures compliance with 501(r) federal tax requirements
The legal team reviews policies and documents
Clinical teams provide diagnosis information
"There are behind-the-scenes pieces that are very easy to miss in the flow of business," Grimes says.
To maintain a robust cost estimation capability, Grimes says Passport must be continually updated with changes to payer contracts and medical-service price adjustments.
"Another key is consistency," Hughes says. "You need to standardize processes such as scripting for collection techniques—what a patient experiences at one facility should be the same as what a patient experiences at another facility. Also, you want consistency in important policies and procedures."
Consistently following up with patients who have received cost estimates helps drive point-of-service collections, she says.
"For the check-in staff, if there is an arrangement to pay, they can see that quickly and collect."
Challenges at the Michigan-based health system include revenue cycle optimization after the installation of a new medical record system and finding ways to match cost increases with the rate of general inflation.
Matthew Cox, CPA, MBA, has a lengthy list of goals as the new senior vice president and CFO of Spectrum Health, including optimization of a new electronic medical record, expansion of consumer-oriented programs such as online platforms, containing costs, and increasing risk-based contracting.
Prior to joining the 13-hospital Grand Rapids, Michigan-based health system, Cox served as senior vice president of finance operations at Phoenix-based Banner Health. Spectrum also owns a 783,000-member health plan, Priority Health.
HealthLeaders Media spoke recently with Cox, who is succeeding Ron Knaus after his retirement. Following is a lightly edited transcript of that conversation.
HLM: In 2018, what are Spectrum’s primary financial challenges?
Cox: Tactically, we just went live on Epic clinical and billing systems in our Grand Rapids hospitals, and our community hospitals and the remainder of the health system will go live in May. So, in my first 90 days, I will create a comprehensive assessment of the current state of revenue cycle. After that assessment, I will put together a 24-month work plan. We understand that we won't be able to maximize the functionality all at once, so we have asked our consultants to help our revenue cycle leadership develop a 24-month work plan to keep our improvements on track.
HLM: Why are you conducting the comprehensive assessment?
Cox: As a result of this system conversion, we have experienced a temporary increase in receivables, as expected. I expect we will see receivables return to historical levels by the end of our fiscal year in June.
We need to make sure we are optimizing the system, so it is easy for our providers and employees to use, and we get bills out to patients with the information they need in a way that's not confusing.
Patient-balance responsibility, co-pay and coinsurance, and pricing transparency in healthcare is not on par with other industries, and that is something I am going to be working on.
HLM: What is Spectrum's primary strategic challenge?
Cox: Strategically, the biggest challenge is shared with the entire industry—our insurance products and clinical services are becoming too expensive. The prices of services continue to outpace general inflation.
The entire industry is ripe for disruptive innovation, and we have to be better at controlling our costs and eliminating unnecessary utilization, then pass those improvements on to our customers.
There are a couple areas where we have been reducing costs. We have MedNow, where you can do virtual visits, and that helps drive down costs.
By implementing [the] Epic [medical record system], we are reducing duplication. When you have an electronic medical record that spans the entire health system, the providers can see the services that have already been done with patients, so they can avoid ordering unnecessary or duplicative tests.
We need to maintain our current financial strength, while lowering the cost to patients. Spectrum will continue to be strong into the future, but we have to operate in a way where our costs do not increase at a rate much greater than general inflation.
HLM: This year, what do you think are the biggest financial opportunities for Spectrum?
Cox: We're one of the few integrated health systems in the country that has a large and successful insurance company, which gives Spectrum operational and strategic advantages such as having our costs for patients lower than comparable health systems.
We also can continue to expand price transparency through Priority Health's cost estimator tool, which is an example of making healthcare easier and more affordable for patients.
We want to increase Spectrum's risk-based contracts with all major payers. We do a good job now on risk with Priority Health; but beyond that, we have very few risk contracts.
HLM: What are examples of consumerism growth at Spectrum Health?
Cox: We have MedNow, the MyHealth patient portal, and the Strive wellness platform, which are higher-end primary care that help patients manage their health. We've also got new integrated-care campuses that are close to patients' homes.
HLM: What is the key to managing growth?
Cox: You need to increase the level of benchmarking and financial accountability. This is an overarching goal: As we grow, I want to make sure there is strong financial rigor and our managers are held accountable to the plans that they put together. We want to be best in class when we grow and benchmark ourselves against the best in class performers.
I also want to increase the number of our partnerships, joint ventures and collaborations, both nationally with large companies that have deep experience that we might not have, and locally. We want to increase our collaboration with other organizations in our communities that provide healthcare services to the same population.
HLM: What have been the key elements of managing Priority Health profitably?
Cox: Managing utilization, managing our network to make sure we have people who are striving to provide a high-value service, and being price-competitive.
Most consumers pick health plans when they are not sick, and most consumers pick plans based on price. So, price is important, but when patients utilize health plans, you want them to be happy with the network, the services, the billing, and all the blocking and tackling at their health plan. We focus on all of that: making sure the coverage is affordable and it operates well, so our customers are happy.
University of Utah Health, a patient experience transparency pioneer, has raised its national patient satisfaction score from the bottom to the top quintile.
University of Utah Health used data sharing both internally and externally to lift its Press Ganey patient experience ranking from the 18th percentile in 2008 to the 84th percentile last year.
"We have more compassionate, connected care for patients, and a more satisfying workplace for providers where they get feedback from patients," says Mari Ransco, the Salt Lake City-based health system's director of patient experience.
She attributes the long-term gain to three milestones dating back 15 years:
2003: Patient experience data was shared internally with clinic leaders
2008: Patient experience data was shared internally with physicians
2012: Patient experience data was shared with the public on the UUH website
When the health system launched the transparency initiative in 2003, patient experience data shared with clinics revealed relatively basic, but extremely important, shortcomings, Ransco says.
The data showed patients were concerned about long wait times in waiting rooms and exam rooms, subpar courtesy at clinic front desks, and difficulty making an appointment. Addressing shortcomings at the clinic level was relatively easy compared to tackling issues at the physician level, she says.
"We started with the things that were easy—bureaucratic and system process failures."
The sharing of patient satisfaction data with physicians that started in 2008 was rolled out in two phases.
"Initially, it was anonymous, but you could see how your peers scored relative to you," she says. "Eventually, it was unblinded after a couple of years."
A key element of the physician transparency effort was a higher degree of access to patient experience data, Ransco says. For inpatient services, the health system started collecting data at the patient level that could be attributed to a particular physician.
The data was collected with Press Ganey medical practice surveys. The surveys were mailed to patients after their visits and included a visit identifier that tied the data to the health system's electronic medical record, which matched patients with specific clinicians.
Publishing patient reviews online
The decision to publish patient experience data and reviews online in 2012 was a giant leap for transparency at UUH, which posted $1.67 billion in total operating revenue for the fiscal year ending June 30, 2016.
Physicians were skeptical about making the information readily available to the public, Ransco says.
"It was very hard. Ultimately, we had a strong leader who pushed it, supported it, and believed it was in the best interest of patients and healthcare in general," she says.
Vivian Lee, MD, PhD, the UUH senior vice president for health sciences, has been a crucial transparency champion at the organization.
In addition to strong leadership, many UUH physicians were open to sharing patient experience data online because the data had been shared with growing intensity internally for a decade.
An external factor also helped physicians embrace publishing UUH-generated patient reviews online, she says.
"There were many other websites—Healthgrades and Vitals—that were publishing one or two patient comments about our physicians that were negative, and it was detrimental to those physicians' reputations."
Just as in 2008, new access to a wealth of data was a key factor in the decision to publish patient experience data online, Ransco says. In 2011, the health system pioneered Press Ganey's all-electronic survey, which generated more data at a faster pace.
Today, UUH receives about 3,000 patient experience surveys electronically per week, and the health system publishes both positive and negative reviews.
"Patients are typically satisfied with their healthcare experience," she says. "And when they don't have something positive to say, you can put that online because people are savvy about what they see online. It builds trust."
The health system has "exclusion criteria" that disqualify some reviews for publication online. These criteria include:
Reviews that reveal the identity of patients
Reviews that question a diagnosis or prescribed medications
Patients who criticize clinicians who are not their providers
For physicians who oppose reviews that appear online, there is an arbitration process to determine whether the reviews should be removed. Members of the arbitration panel are medical providers.
Lessons learned
Commitment to patient experience transparency is an ingrained value rather than a matter of employee training, Ransco says.
"We offer training when people request it and when people want it, but elevating patient experience has really been a cultural shift, with pressure within departments and within clinics that this is really something that is important to everybody."
At UUH, strong physician leadership has helped cement the culture change, she says.
"We have had a series of physician leaders who have talked about this authentically [and] not as a way to earn more market share, [or] to improve the overall standing of the university. They have shown what it means to them personally and how it fits with why they chose to go into medicine."
A systemwide initiative involving physicians, nurses, laboratory operations, and pharmacists has helped the nonprofit reduce its sepsis mortality rate.
OhioHealth has lowered the health system's sepsis mortality rate by 4.3 percentage points over the past two years through staff education and a new diagnostic tool.
"Our estimate is that we have saved about 250 lives," says James O'Brien MD, director of quality and patient safety at the Columbus-based health system.
Sepsis is the body's extreme reaction to an infection, which can result in life-threatening symptoms such as multiple organ failure. Annually, more than 1.5 million people get sepsis in the United States, with about 250,000 fatalities.
Starting in July 2015, OhioHealth has reduced sepsis mortality by educating staff members, utilizing a new diagnostic test, reducing the medication response time from hospital-based pharmacists, and creating a clinical culture that tolerates false diagnosis alarms.
Education effort
The effort required engaging thousands of health system workers about sepsis and highlighting an opportunity for care improvement, O'Brien says.
"A big piece has been making the case that this work is important to us as an organization by looking at the underlying data of what our baseline mortality rate was and how many people it was affecting across our health system," he says.
When OhioHealth launched the sepsis effort in 2015, the sepsis mortality rate was 24.3%. Last year, mortality in sepsis patients was 20%.
The health system’s wide range of hospital size, from critical access hospitals to its 800-bed tertiary care hospital, has been a significant challenge, O'Brien says.
Emergency care has been a focal point for the initiative, both internally in the health system's ERs and externally among emergency medical service workers, he says.
"We've worked through the Central Ohio Trauma System to get into the mindset of the emergency medical responders because they are significantly as likely to be transporting a patient to one of our hospitals with sepsis as with a heart attack or stroke."
New diagnostic tool
A new sepsis test developed at Salt Lake City–based BioFire Diagnostics has significantly reduced the laboratory time required to diagnose sepsis and narrow down the best antibiotic treatment, O'Brien says.
"It's gone from a day or more to a couple of hours."
The previous generation of sepsis tests requires a lengthy two-step process: A blood culture tests positive for sepsis, then the blood culture is "challenged" with multiple antibiotics to see which antibiotic would be best for treating the patient.
With the new test, once a blood culture tests positive for sepsis, molecular testing quickly narrows down the best antibiotics to treat the patient.
"It helps us to more rapidly identify the bacteria or organism that might be causing sepsis. Once a culture is positive for sepsis, this test helps us to very quickly get to which antibiotic will work best for the bacteria, and, just as important, which antibiotic won't work," O'Brien says.
Quicker to the bedside
Once an OhioHealth clinician has prescribed an antibiotic, pharmacists are expected to have the medication at the bedside in less than an hour, he says.
"In pharmacy, you need engagement with the medication safety pharmacist and the antibiotic stewardship pharmacist," he says "They are the folks who tend to be most in tune with our pattern of resistance to antibiotics and what is appropriate based on where the clinician thinks the patient was infected."
As has been the case with the health system's sepsis awareness and education campaigns, there has been no one-size-fits-all approach to boosting pharmacy response times for sepsis patients, and a crucial element of achieving quicker pharmacy reaction times has been including pharmacy representatives on Sepsis Improvement Teams that have been formed at every OhioHealth hospital.
Each team features about a half-dozen members, including the following:
A healthcare information technologist
A laboratory staff member
A pharmacist
A physician
A nurse
Forgiving climate for clinicians
Achieving rapid treatment for sepsis patients requires creating a clinical climate that does not penalize caregivers for "false-alarm" diagnoses, O'Brien says.
"We have to be really careful to understand that clinicians are doing a difficult task in trying to figure out what to do, because this is a disease for which there is no single test that says, 'This is absolutely sepsis,' says O’Brien. “They are making decisions with uncertainty."
Given directives from the Centers for Disease Control and Prevention and other organizations to avoid overuse of antibiotics, one of the keys to creating a forgiving climate for clinicians is being supportive of their diagnoses and medication decisions, he says.
"If you go back and beat up the clinicians for having given antibiotics when they were uncertain what the problem was, that's just unfair to them."
Adventist Health's new CFO discusses the challenges and opportunities facing the health system, including cost-cutting, expansion deals, and cuts to the 340B prescription drug program.
The new CFO of Adventist Health views cost-cutting in areas such as labor and supplies as the most daunting challenge facing the health system, with mergers and partnerships viewed as the most attractive opportunities.
Adventist has promoted Joe Reppert, CPA, MBA, to CFO of the Roseville, CA-based health system, which features 20 acute-care hospitals on the West Coast and in Hawaii. Reppert is succeeding Jack Wagner, who is retiring.
Reppert previously served as CFO of Adventist's Northern California region, where the health system operates seven hospitals. His experience also includes working as CFO of Tupelo, MS-based North Mississippi Health Services.
HealthLeaders recently spoke with Reppert, who officially begins his new role Feb. 1. Following is a lightly edited transcript of that conversation.
HLM: How will your system CFO role be different than the Northern California CFO role?
Regional roles are closer to operations and the daily challenges that come with managing hospitals and ambulatory businesses. You are closer to patient care…as opposed system roles in a corporate office. That is why rounding is so critical.
The move to system CFO will bring a new set of challenges. I will never step too far from operations, but I enjoy the strategic elements of healthcare finance such as balance sheet management, developing partnerships, and longer-term planning.
HLM: What was the most important lesson you learned from your experience as CFO of Adventist's Northern California region?
Reppert: In Northern California, Adventist Health is in the process of cementing business relationships with other healthcare partners. Most significantly is the acquisition of Rideout Health in Marysville, Calif., which will likely be effective this March.
Rideout is a … health system with revenues of $400 million. Its addition to Adventist will strengthen our geographic presence north of Sacramento. The addition of Rideout Health will enable more effective coordination of certain services and specialty care among our hospitals in that geography. That circles right back to better care for our patients. As a result of this new affiliation, other partnerships are developing for further expansion of services, locations, and covered lives.
Relationships with other providers, payers and outside resources should be repeatable in other markets.
HLM: In 2018, what are the primary financial challenges for Adventist?
Reppert: Some of our health system executives and I recently attended a national healthcare conference to hear presentations from several prominent health systems. A consistent theme among most was the imperative for cost reductions.
We will be going methodically through expense line items. Typically, the larger opportunities lay with labor and supplies. Those are the expense categories where we have the greatest influence. Wherever there are opportunities for efficiencies or labor management, we will be turning those rocks over.
We will push for more effective management tools and relentless accountability throughout every operating unit and department, which is critically important to achieve the panacea of low-cost/high-value.
We work with Premier on the [group purchasing organization] side, and we have several opportunities and projects under way right now to not only reduce our supply cost per unit, but also to reduce utilization by working with our medical staff on physician-preference items.
Every hospital has some rent costs and lease costs, which are recurring expenses. If you have the time, you can turn that rock over to see whether the expense is necessary and whether it is something you can possibly eliminate.
Everyone in this business also knows the regulatory-related challenges that affect hospitals. The 340B reductions alone will cost Adventist Health $5 million, which is a negative annuity that needs to be made up elsewhere. This specific change relates to a 22.5% reduction in payments to hospitals for pharmaceuticals.
HLM: That covers expense reduction, but what will Adventist do to grow the revenue side this year?
Reppert: Adventist Health will grow in scale. One example is with our newly expanded business relationship with Cerner to quicken the EMR optimization cycle and revenue cycle performance. There is accountability to deliver results leading to increased yield and cash acceleration. Reducing the billing cycle and further improving clean-claim rates are opportunities within our grasp.
Additional affiliations with other acute and post-acute care providers will likely continue into the future.
HLM: What are the key financial metrics for you and your team?
Reppert: The fundamental financial metric is [earnings before interest, taxes, and amortization] performance. Our EBITA percentage is fundamental and we stay very focused on it.
Underlying that overall metric are certain expense metrics, such as labor metrics and supply costs. We look at worked hours per unit of service and we look at supply costs as a percentage of net operating revenue.
The health system's metrics are not just financial. We also have a balanced scorecard. Our managers are accountable for patient satisfaction, quality indicators, and employee engagement.
HLM: Adventist has post-acute care facilities, including hospice. What are the primary challenges of integrating acute care and post-acute care facilities?
Reppert: As we transition into capitation, the financial incentives align appropriately. Adventist Health currently manages nearly 200,000 capitated lives. Most of our acute-care operations are across a wide geography, so aligning all post-acute care services is a challenge but worthy of cementing further.
This is partially addressed through program development within our hospitals, home health agencies and physician practices. In some markets, we affiliated with partners that have distinct experience and expertise in programs for seniors. The result has been the development of senior communities, some of which are adjacent to our hospital campuses. Those communities offer housing for seniors as well as a complement of services that add to the continuum of care such as home health, rehabilitation, and memory care.
Stepping up efforts to address the opioid crisis, Northwell Health expanded 'universal' drug screening to its children's hospital.
As part of efforts for early detection and diagnosis of opioid addiction, Northwell Health has expanded alcohol and substance abuse screening beyond adults to include patients aged 12 to 18 at Cohen Children's Medical Center.
Expansion of the addiction screening last week is part of the New Hyde Park, NY-based health system's commitment to help all patients address substance-abuse disorders, says Sandeep Kapoor, MD, director of the health system’s Screening, Brief Intervention and Referral Treatment program (SBIRT).
Northwell conducts SBIRT screening for every patient at all of the health system's emergency rooms and primary care practices, he says. "It's been a universal approach."
SBIRT is a key component of Northwell's response to the opioid addiction crisis because of the importance of early detection and diagnosis, says Joseph Conigliaro, MD, chief of general internal medicine at the health system. "The whole idea behind SBIRT is you can get at addiction early as opposed to getting it late, when the horse is out of the barn."
SBIRT, which Northwell launched in December 2013, features self-reported screening for alcohol and substance abuse with evidence-based tools. Northwell clinicians have been using two SBIRT evidence-based tools at primary care practices and emergency rooms for adults, and they are using one screening tool for children.
Self-reported screening features patients responding to screening-tool questions. For example, adults are screened for opioid and other illicit drug use with the Drug Abuse Screening Test, which qualifies and quantifies prescription and illicit drug use, then risk-stratifies patients.
At Northwell, Kapoor says brief interventions are the primary focus of SBIRT for patients detected with possible opioid addiction:
The essential element of the brief intervention is a conversation that engages the patient about their opioid use. The conversation features four pillars of motivational interviewing: compassion, acceptance, partnership, and evocation.
The interviewer seeks to build rapport and trust, then provides feedback on the screening with the patient's permission.
The conversation serves as a starting point to help the patient gain insight and self-identify any consequences related to their opioid use.
At the end of the conversation, the interviewer determines whether the patient is ready and willing to make a change, then helps the patient formulate a plan that could include referral to specialty care.
"It's a nonconfrontational conversation during a clinical visit—either in an emergency room or a primary care office," Kapoor says. “Even though it is busy, you pause and speak with the patient to better understand where they are at with their substance use."
The key to implementing SBIRT at Northwell primary care practices has been integrating the program into clinical workflows, Conigliaro says, noting that efforts with medical assistants and nurses helped screening for addiction become essentially another vital sign.
Northwell's effort to implement SBIRT in both the ER setting and at primary care practices is a significant achievement, Conigliaro says. "This in itself is a measure of success, demonstrating organizational awareness and acceptance that substance use needs to be handled as any other disease process."
The universal nature of SBIRT screening at Northwell's primary care practices and ERs is also crucial, he says.
"We screen everybody. We don't try to pick out people who are more likely to be addicted. So, if you are a 75-year-old nun, you are going to get screened for alcohol and drugs."
Opioid Crisis Task Force
Another addiction initiative at Northwell is starting to roll out new programs.
Launched in 2016 with six members drawn from interdisciplinary fields, Northwell's Opioid Management Steering Committee is developing a "battery of solutions" to help address the opioid crisis in New York, Kapoor says.
The steering committee has four focal points:
Limiting the supply of opioids
Raising awareness of opioid addiction
Identifying and managing the dependent population
Treating the opioid-addicted population
Several steering committee work groups have been formed:
Community and school-based outreach
Pain management
Data mining to help monitor and evaluate Northwell's opioid-addiction programs
Addiction protocols for standardizing inpatient treatment
Practice guidelines for opioid-medication prescriptions
Emergency medicine not only to identify patients who are addicted to opioids but also to start treatment in the ER before handing off patients for specialty care
Currently, two of the steering committee's pilot programs that focus on the safe disposal of opioid medications are being expanded.
One pilot program started with a safe-disposal receptacle for medications being installed in the main lobby at Southside Hospital in Bay Shore, NY. A contract was recently signed to have the receptacles installed at other Northwell hospitals, Kapoor says.
The other medication-disposal pilot program features Northwell's commercial pharmacy partner, Vivo Health Pharmacy.
Starting in November, all Northwell opioid medication prescriptions filled at a Vivo Health Pharmacy have gotten a special sticker on the bottle cap. The sticker has a message for patients, advising them that if they have any unused medication they can call the pharmacy, which will mail a safe-disposal pouch.
The pouches, which contain a neutralizing agent, can be used to dispose as many as 15 pills. Patients place pills in the pouch, add a few drops of water, then throw the pouch in the trash.
The safe-disposal pouches have been popular with patients and the program is expected to expand when new Vivo Health Pharmacies open, Kapoor says.
Opioid Addiction Treatment
In 2016, Northwell provided substance-abuse disorder services to 6,000 inpatients and 90,000 people in outpatient settings, says Jonathan Morgenstern, PhD, assistant vice president for addiction services.
At Northwell, which has five tertiary hospitals, 10 community hospitals, three specialty hospitals, and four affiliated hospitals, Morgenstern says most opioid-addicted patients follow a three-step trajectory:
Inpatient detoxification for three to seven days to withdraw from physical dependence on opioids, usually with the assistance of medication such as Suboxone.
Inpatient rehabilitation for 10 to 14 days. "Typically, when a patient comes out of detox, they are not experiencing withdrawal, but they are in a vulnerable and somewhat shaky state. … They need a protected environment and therapy," Morgenstern says.
Outpatient services for three to six months, including medication and a combination of individual therapies to help patients transition from a protected environment back into their communities.
Even though treatment for opioid addiction can take months, most insurance plans cover the treatment and there is funding for uninsured patients, Morgenstern says. Under the Patient Protection and Affordable Care Act, substance use disorders treatment, including opioid addiction care, is considered an essential benefit that commercial plans must cover. Also, many states provide direct subsidies to SUD treatment programs to fund treatment for uninsured patients.
