Researchers have charted a nearly 26 percent drop in the ratio of general surgeons to patients since 1981, creating the potential for a "severe shortage" of such doctors in the United States. The findings come at a poor time, with aging baby boomers starting to need the skills of general surgeons for various procedures. In rural areas, the decline could mean more deaths from car accidents because patients will have to be transported farther or delays in elective surgery as people are forced to travel out of town.
Profound, transformative challenges are making healthcare more accessible, improving the quality and efficacy of patient treatment, and revolutionizing the way valuable information is collected, exchanged and applied.
According to the Agency for Healthcare Research and Quality, there is a growing demand for healthcare data from many sectors. Key drivers for this demand have been surging interest in healthcare performance measurement and the information systems needed to aggregate, process and transmit healthcare data from which measures of healthcare quality may be developed. Healthcare is moving toward an evidence-based, decision-making model. Employers, consumers, payers and providers are demanding credible and actionable data. This is the time to move towards collaboration instead of competition.
It’s an exciting time for technology and innovation in the healthcare industry. The transformation of healthcare can be enhanced through information sharing and technology, leading to a focused, knowledge-based healthcare system. By providing data aggregation, data warehousing, performance management and analytics, healthcare executives can arrive at deeper insight. They can devise more effective strategies to increase quality and control costs.
Today, more data is available than ever before, but is this data transformed into actionable information? Is data being used to either reform the healthcare system or "out-think" your rivals? If not, you may be missing out on a powerful competitive tool.
Measuring value has become imperative to understand healthcare delivery in the U.S. Identification of high performing healthcare organizations, plans, networks and providers supports the focus on improvement. Purchasers, consumers and patients continue to demand increased transparency concerning the cost, quality and service of healthcare delivery. At the same time, expenditures on healthcare continue to escalate while evidence persists on avoidable costs and the gap between how medicine should be delivered and current practice. Measuring healthcare and providing incentives for high performance are critical tools in addressing differences in the cost and quality of care.
The Dialog on Quality and Transparency
There are many initiatives seeking to utilize a pool of rich data to address the difference in quality and cost. A step in addressing this issue is the perception of the providers (both hospitals and physicians). One continuing issue is the evaluation of provider quality when there are not enough occurrences for evaluation. With the creation of a multi-payer data repository, the ability to evaluate provider performance is not dependent on just one source of data.
Even Tricare for the retired military is focused on channeling to the high quality, low cost providers. The question remains--how can these providers be identified? No single entity--whether payer, employer or provider has sufficient data to grade broad networks. There are several data aggregation initiatives at the state and regional level. These varying initiatives are focused on organizations like Blue Cross and Blue Shield Association and employers.
The Louisiana Care Quality Forum has identified unwarranted variation from its data repository, which includes three of Louisiana’s major payers. According to Karen DeSalvo from Tulane University in an article in Healthcare Finance News, January 20, 2008, “One of the problems for us is we haven’t had a clear picture whether quality or cost problems are pervasive. We have a better picture from the multi-payers.”
Health plans have introduced high-performance networks to encourage use of top physicians in the area of quality and efficiency. Early adopters of these networks are large employers and, while others are interested, actual adoption has lagged. According to Health Systems Change, May 2007, enrollment in products using high performing networks is lagging due to the lack of objective evidence on the impact of service use, cost and quality.
There is often disagreement with the methodologies and lack of data. That leads to skepticism about these networks and the data used to create them. Due to these controversies, the growth of the high performance networks has not extended much beyond the large employers who were the key stimulus for their creation.
The key is to move toward uniform provider performance measurement. One plan executive, for example, expressed that physician quality determinations should not be based on data from one plan but rather on industry collaboration from both the private and public sector to make informed decisions on the quality of a practicing physician. In the eyes of the consumer, it would be damaging for different payers to have competing definitions of quality.
Benefits of Data Aggregation and Sharing
This joint effort of the aggregated data will create the first comprehensive and consistent source of data. This data will support measurement and apply both efficient technology and valid methodologies and be a significant contribution to performance measurement and transparency around healthcare and improving value.
Benefits through the data aggregation are many:
Trending
Greater confidence that the data is both reliable and balanced
Identification of prevalent health problems and the ability to customize by client type, location and size
Product development (expansion of business and modification of current geography and services) can be enhanced through pinpointing membership and service use beyond a single data source
Enhanced data for benchmarking to assist in conducting comparative analyses
Creation of a “multi-payer information highway” in place of current information silos
Enhanced monitoring of healthcare trends and identification of potential epidemics, providing a head start in responding to bio-threats, pandemics or natural disasters (like Katrina).
“One-stop-shopping” for consumer transparency through multi-payer data aggregation
Confidence that individual proprietary contract rates and other intellectual property will not be put at risk with the data security disciplines that often occur with other data aggregation initiatives
Information about the efficacy and safety of certain treatments and new medical technologies as well as emerging trends
Create multi-payer and multi-employer disease registries
Physician Performance Management
Access to more claims data on each physician allowing the ability to characterize physician-specific clinical and economic performance with greater statistical confidence and precision
Credibility through a shared view, rather than a single payer or employer view of an individual provider for quality and resource efficiency
Application of benchmarking tools for best practice for physician relations and data sharing, gap identification, consumer transparency and decision support
Identification of treatment variation by region, state or individual provider
Enhanced ability to apply clinical quality rule sets through evidence-based medicine
Predictive Modeling
Ability to pinpoint trends through predictive modeling
Strengthen the movement to greater healthcare transparency through unmatched detail about healthcare trends and best practices
Lack of Data Quality and Quantity
Sharing of data with other industry participants can ensure statistical validity. The application of provider quality rankings is just one application. The quality and cost of healthcare have suffered. Many quality and pay-for-performance initiatives address problem compliance rather than the quality of results. The problem lies in the lack of sufficient data to measure the quality of care.
It is difficult to determine data collaboration capabilities. Here’s what is needed:
Experience with data standardization and enhancement--beyond just aggregating the data it is necessary to standardize across sources for valid analytics
Analytical capabilities ready to perform business intelligence reporting
Capacity to handle volume of data required for the initiative
Ability to match members and providers across data sources, often without unique and consistent identifiers in the above sources
This joint effort--the collaboration of payer, employer and provider data--creates a comprehensive source to support performance measurement resulting in improved value for all.
Marybeth Regan, PhD, is an expert in disease and care management. She has written numerous articles on strategies for care and disease management. She may be reached at mb@yleen.com. Robin Randall-Lewis is an expert in Consumerism and Transparency strategy. She may be reached at robin.randall-lewis@reden-anders.com.
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Reader David E. Rogers, MD, a physician in McKinney, TX, sent me a pithy observation after reading my HealthLeaders magazine article “Claims Quagmire.”
Just read your article and have a question/comment.
Q: Who do you think benefits from this inefficiency?
Comment: That is all you need to answer to figure out why, despite all of our glorious technology, that it isn't likely to get better anytime soon. And furthermore, I contend that this whole quagmire was planned long ago by those who designed claims processing software. I believe they knew very well what they were doing and have ridden the wave for over a decade now.
There is profit in confusion.
David’s not the first physician I’ve spoken to with such a contrarian view about the way the industry operates. While I don’t know if the claims mess was “planned ” to be the way it currently is, I do know that in healthcare, one person’s inefficiency is another person’s bread and butter. The reporting I did on this claims article (the second part will run in the May issue) was some of the most challenging I have ever encountered. It seems like the claims food chain is kind of like the elephant being described by the blind men. Everyone has a peculiar view of it—and no one seems to fully understand it from end to end.
I think it is fair to say that many parties along the way have their finger in the claims pie. And the PNC study that spurred my story points out a high degree of administrative overhead can be attributed to the inefficient processes around claims. Even a few pennies on the dollar can become an astronomical sum when you factor in the size of the industry. So it would be no surprise to encounter resistance to streamlining a highly tangled process when so many people are economic beneficiaries. I think this is one of the points that Dr. Rogers is making in his short letter.
All the reworking adds to the administrative overhead, which accounts for 30% of healthcare costs, according to the PNC survey. “There is tremendous complexity in the claims submission and remittance process,” says Paula Fryland, the PNC executive vice president who explained the scenario using an analogy. “A hospital is like a busy restaurant. Only the price of a hamburger is different for virtually every customer. The waiter must get in the order, deliver a tasty hamburger, and figure out what to charge. It’s a challenge to get all the information in the right format for each payer.”
Fryland cited consumerism as one of the driving forces behind this health plan complexity, noting that the tangled—and highly individualized—benefits packages have been created in response to employee demand. Here, it’s not like a universal, single payer model, wherein everyone has the same benefit package. In the U.S., plans vary widely. And even when people ostensibly have the same benefits, such as in the Medicare world, providers struggle just to understand what constitutes a permissible charge. The coders and billers who must interpret Medicare rules are like machinists working the most complicated Rube Goldberg machine imaginable (I know because I am married to one, a coder--not the machine!)
Fryland says electronic data interchange is the way out of the claims quagmire, but allows that plan complexity can derail the benefits. In her view, consumers are becoming increasingly sensitive to the amount of money spent by nonprofit enterprises on administrative overhead, noting that many charities now routinely reveal such figures. In time, consumers may indeed demand the same of hospitals and health plans. Claims transactions and software programs do not always mesh well. The endless decision tree of the former does not fit neatly with the yes/no logic of the latter. Trying to harmonize the two does keep many people—like my wife—employed. As Dr. Rogers so eloquently stated, “there is profit in confusion.”
Private-equity firm Apax Partners will acquire healthcare-software maker TriZetto Group Inc. for $1.4 billion. TriZetto customers BlueCross BlueShield of Tennessee and Regence Group are providing an undisclosed share of the deal's funding and will be equity investors in the new company. Regence is a combination of several BlueCross BlueShield health-insurance plans in several states.
Healthcare services company Cardinal Health is making an increased push for increased patient-safety initiatives in the hopes that it will lead to higher-quality care and lower costs for the nation's healthcare providers. Cardinal Health has recently unveiled $1 million in grants to 34 hospitals nationwide to help advance patient safety improvements.
Proponents of a $50 million pilot project that developed a paperless medical records system in three Massachusetts communities are hoping legislators will help continue and expand the program.
The initial pilot funding, pledged by Blue Cross Blue Shield of Massachusetts, will last through the end of 2008. State Senate President Therese Murray has included $25 million in funding to begin expanding the program statewide in an effort to control healthcare costs.
A high-fidelity mannequin will be used by students at Reading (PA)Hospital School of Health Sciences to hone their pediatrics techniques. "Students seem to enjoy learning by doing. And adding the simulation to the clinical is just a huge benefit," said Debbie Rahn, RN, director of the school's nursing program.
The owner of a Boca Raton, FL-based medical imaging center chain has agreed to pay $7 million to settle a healthcare fraud lawsuit. The suit charged that the center billed for CT scans that were never performed and offered payments to doctors to refer patients to its facilities. Medicare and insurers pay as much as $16 billion annually for unnecessary imaging tests ordered by doctors who profit from them, according to estimates from the American College of Radiology.
MIAMI— Computer files holding confidential health and financial information on more than 2.1 million patients at University of Miami health facilities since 1999 were stolen from a storage company contracted to secure the records. UM officials say they believe it is unlikely that the thieves will be able to access the files because of the "complex and proprietary format in which they are written."
"Even though I am confident that our patients’ data is safe, we felt that in the best interest of the physician-patient relationship we should be transparent in this matter,” says Pascal J. Goldschmidt, MD, senior vice president for medical affairs and dean of the University of Miami Miller School of Medicine.
Patients of a UM physician or a UM facility since Jan. 1, 1999, are likely included on the tapes. The data includes names, addresses, Social Security numbers, or health information.
The university will be notifying by mail the 47,000 patients whose data may have included credit card or other financial information regarding bill payment. The box of computer records was stolen on March 17 from a van parked in downtown Coral Gables.
UM hired Terremark Worldwide, a computer security company, to determine the feasibility of accessing and extracting data from a similar set of back-up tapes. "For more than a week my team devised a number of methods to extract readable data from the tapes," says Christopher Day, senior vice president of the Secure Information Services group at Terremark. "Because of the highly proprietary compression and encoding used in writing the tapes, we were unable to extract any usable data." Day says that even if a thief had a copy of the same software used to write the tapes, "it would require certain key data which is not stored on the tapes before the software would make the data readable."
Alan Brill, senior managing director at Kroll Ontrack, a data recovery firm hired by UM to review the theft, says it’s "not impossible to access the data.” But he quickly added "in this case there are many barriers that stand between a thief and being able to actually get usable data from the tapes.”
—John Commins
In a statement, representatives from the American Medical Association say a "sneak attack" on specialty hospitals in the farm bill will hurt patients. "Opponents of physician-owned specialty hospitals are trying to slip a provision to ban specialty hospitals into the farm bill conference report, well after the bill has been passed by both the House and Senate," said William G. Plested III, MD, AMA Immediate Past-President, in a statement. "It is bad policy to take away patients' healthcare choices by banning specialty hospitals-especially under the cover of the farm bill," he added.
