The Atlantic provides a breakdown of various approaches to malpractice reform, including a chart that rates each method's effectiveness in reducing premiums and defensive medicine while fairly compensating patients and improving safety. Specialized health courts look to be the most effective individual approach, according to the analysis.
While there is almost universal agreement on the need to transform our nation's healthcare system, few stakeholders agree on specific solutions. From pundits to politicians, everyone has recommendations on to how to fix healthcare, including expansion of access, increased individual responsibility, more competition, less competition, more government control or less government control.
One area of growing consensus, however, is that the information technology infrastructure underlying our healthcare system is woefully inadequate to the task of transformation. Evidence of this recognition was recently reinforced by the Obama White House and its inclusion of expanded funding for electronic medical records as part of the economic stimulus package.
In any case, healthcare transformation will require new models for sourcing, processing and distributing richer, more complex data in ways that facilitate collaboration, real-time decision-making and hands-free automation. Numerous obstacles lie on the path to real-time digital collaboration, however, including healthcare claims clearinghouses that remain the dominant electronic conduit among providers and payers.
In a 2004 Harvard Business Review article, "Redefining Competition in Healthcare," renowned strategy expert Michael Porter and innovation expert Elizabeth Teisberg argue that with the right kind of competition "the healthcare system can achieve stunning gains in quality and efficiency." The authors argue that relevant information is key to any well-functioning competitive market but is all but absent in our current healthcare system.
Imagine how an information-driven healthcare system might look and feel. Not only would consumers be better equipped to make informed decisions, but those decisions could influence other aspects of their healthcare experience, such as the cost of services or adjustable rate premiums.
In this information-rich environment, coaching and advisory services firms would emerge to guide consumers faced with making critical care decisions. Physicians would prescribe treatments based on the latest protocols and the patient's up-to-date longitudinal health record.
During recent years, vendors have leveraged their experience and assets to provide enhanced cleansing and transformation services to help payers achieve regulatory compliance at a fraction of the cost of internal development. These economics proved favorable as clearinghouses maintained their dominant position of connecting hundreds of payers with thousands of providers who lacked sufficient technology and know how.
Challenges extend well beyond technology, however, because of a business model that incentivizes exclusive relationships and controls the flow of critically important information. This situation is incompatible with the demands of today's consumer-directed health plans, incentive-based reimbursement models and the retail revolution for providers.
Valuable lessons that could be applied to healthcare transformation can be learned from other industries that have undergone similarly disruptive digital transformations. The advent of the Internet, supported by expanded availability of broadband services, gave fuel to the dot-com revolution of the 1990s. We have every reason to expect the same is possible in healthcare if the roadblocks of funding and common standards can be overcome.
The healthcare industry can gain insights from an examination of the changing IT landscape and its ability to increase efficiency, enhance quality and empower people to take responsibility and make informed decisions for themselves and their families. Why is it that healthcare seems unable to follow new business models based on today's information technology?
For the most part, middleware-based integration methods have proven too complicated and expensive for even the most sophisticated enterprises. Instead, a strategy of integrating disparate touch points at the transaction level, independent of user interfaces and technology preferences, is much more practical.
To achieve anything close to an integrated e-health transaction will require healthcare "transaction integrators," a new class of IT professionals whose skills and domain expertise extend far beyond electronic data interchange, messaging and networking.
Healthcare transaction integrators will possess specialized knowledge of emerging technology, business, healthcare, financial and regulatory standards. The transaction integration model emphasizes automation of virtually every element of the patient encounter life cycle from verification of coverage through real time settlement. The healthcare transaction integrator must understand the context in which these domains can be meshed to facilitate new processes.
Transformation of our healthcare delivery and support systems is an economic and social necessity. Digitization offers wondrous opportunities for greater access to better quality, lower cost care. Delivering on the promises of a 21st century healthcare system will, however, require new thinking, expertise and business models that facilitate collaboration among all participants.
Barry Byrd is president of Secure EDI, a healthcare information technology company. He can be reached at bbyrd@secureedi.com .
Revenue cycle management is the backbone of a profitable medical practice. Many physicians struggle with the idea that they are businessmen as well as medical professionals, and are continually looking for ways to improve practice operations.
Below I have outlined four of the most common problem areas for physicians when it comes to revenue cycle management. These issues can be problematic on both a small and grand scale, and offer areas of opportunity for physicians to improve their revenue stream.
1. A disconnect between the physician and office manager. The lead physician should be fully committed to engaging in the revenue cycle process, even if a competent office manager is on staff. Bi-weekly meetings should occur between the physician and financial staff to review billings, collections, and office revenue to help ensure a "top-down" approach to maintaining practice operations.
Without this high level of "executive sponsorship," a disconnect can form over time between the physician and the financial state of the practice. Small problems can quickly turn into large ones. On a recent evaluation, we determined that a group practice was losing $350,000 a year—20% of the practice income—in flawed business processes related to rejected claims, unaccounted payments, and timely turnaround. None of these problems were unmanageable individually, but over time they had gotten away from the office manager and led to the practice losing a significant portion of its overall revenue.
In addition, should the physician choose to implement a new technology or process in the cycle, many times an office manager will lead the effort and then be involved in a back-and-forth on some important issues with the physician(s). This can lead to inefficiencies in the process, extended timelines, and slower adoption by the staff. With a fully engaged physician, it becomes clear that any changes or improvements are of the utmost importance to the overall success of the practice and that the entire team needs to be on board.
2. Untimely follow up in A/R, or no follow up at all. It may seem surprising that many practices would leave money sitting on the table, but that is exactly what they are doing when there isn't diligent follow up on A/R. Lagging collection times, inconsistent follow up, and improper insurance coordination all contribute to a "slow leak" of revenue.
In the aforementioned evaluation, by implementing thorough and consistent A/R processes, the practice was able to reduce A/R from $385,000 outstanding to $68,000.
Physicians should also be careful not to take excessive write offs that make A/R look favorable at the expense of overall income. If this is a current policy, or it is discovered to be a current policy of the office manager, this practice should be immediately discontinued. While it may be an attractive short term solution, it is not healthy for the longterm sustainability of the practice.
3. Lack of staff education. At a minimum, each member of the staff should be trained as to how their role fits into the overall revenue cycle. Front end reception should be diligent about collecting co-pays up front at the time of the patient's visit. Inaccurate coding can cost the practice tens of thousands of dollars a year. Technologies like card scanners to reduce data entry errors, and billing automation to provide reception access to patient financial information, are helpful tools in capturing every available dollar.
However, even in the absence of such tools every member of the team should understand how their actions impact the practice's bottom line. In addition, staff should be measured by established metrics in productivity and performance.
4. Inconsistent forms and processes. In order to have the most profitable practice possible, efficiency is key. Every form and touchpoint throughout the cycle should be standardized. For instance capturing patient data, filing a claim, and communicating with patients should follow the same process each and every time.
There are always ways to improve consistency. It is even possible to create overriding rules about primary and secondary insurance coverage to reduce confusion on how the patient is covered, and create auto-crossover. With greater attention to denial management beforehand, it's possible to reduce denial rates. Physicians can uncover many areas for improvement that may seem basic at first glance but can make significant impact to the practice.
RCM Problem Area Checklist
In addition to outlining the above problem areas in Revenue Cycle Management, here is a simple checklist for physicians in evaluating practice operations.
Are all your patient encounters are being billed in a timely manner (or at all)?
Are you getting paid quickly and appropriately?
Are your co-pays actually being collected?
Are treatments appropriately pre-authorized?
Are you taking excessive write-offs that make your A/R look good at the expense of your income?
Are you getting critical information about your payor performance?
Are your payors paying in a timely fashion?
Do you have a high denial rate?
Is a higher percentage of patient responsibility costing you additional time and money in collection?
Is a payor is paying more or less than your other payors for the procedures you perform?
These questions can help identify areas of improvement within the process, and allow physicians to formulate an approach to Revenue Cycle Management that will help streamline operations and increase revenue.
Chittaranjan Mallipeddi is CEO of MedPlexus, a developer of financial, administrative, and clinical software for physicians. For more information, visit www.medplexus.com.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
A few weeks ago, I wrote a column about the divisions between physicians on healthcare reform, particularly when it comes to the public option. At the time, I didn't have a recent survey of the general physician population to gauge the sentiment, so I placed the dividing line somewhere between the AMA's endorsement of a bill despite reservations about a public option and some of the more vocal opponents who are actively campaigning against reform.
Turns out, the split between physicians isn't as close to the middle as I initially thought.
More than 72% of physicians support a public option, according to a new study in the New England Journal of Medicine. Nearly 63% surveyed favored a combination of public and private plans—similar to what's being proposed in two of the current healthcare reform bills—and 9.6% preferred only public options. The remainder, 27.3%, supported private options only.
I initially fell into the trap of listening too closely to the loud voices of special interests and political extremes—it's like taking a drug rep's word for the effectiveness of a new treatment without data from an actual trial.
But I also misjudged the level of physician support for a public option because as long as I've been writing about physicians, I've been covering annual potential Medicare reimbursement cuts and hearing complaints about Medicare payment levels, in some cases even threats that physicians would begin dropping Medicare en masse.
If physicians don't like Medicare, which is a public payer, then why would they welcome another similar plan into the market that will likely reimburse at similar (albeit slightly higher, according to current legislation) rates?
The survey, which was conducted by researchers Mount Sinai School of Medicine and published by the Robert Wood Johnson Foundation, asked physicians about their payer preferences and confirmed what I had been hearing anecdotally. Physicians ranked Medicare very poorly on adequacy of payments and other financial factors, like timeliness of reimbursements.
But, physicians actually slightly preferred Medicare to private payers when it comes to autonomy in decision-making and the ease of obtaining services that patients need. It's not all about the money, at least outside of the associations and lobbyists representing physicians in Washington.
"I think the fact that physicians would be supportive of a public option, even in the face of feeling it in their pockets . . . speaks very positively of their overall experience with Medicare relative to private insurers, from a clinical standpoint," says Alex Federman, MD, MPH, assistant professor at Mount Sinai School of Medicine and coauthor of the survey.
That statement initially surprised me given all the complaints I have heard about Medicare, but not as much as this next finding: More than half (58.3%) of physicians surveyed would support expanding Medicare to individuals 55 to 64 years of age.
The study didn't even find the substantial divisions in support between specialties noted in surveys from before the healthcare debate began. "We were mostly surprised by the consistency of the support," says Federman. "There was support of a public option in the southern regions of the United States, there was support for it among surgeons, there was support for it even among AMA members, and that's what really what surprised us."
The survey was conducted from June 25 through the end of August, when the public debate was at a fever pitch, and physician responses remained consistent throughout the period, explains Federman.
Of course, support for a public option doesn't necessarily translate into support for the other specifics of the reform legislation. And it doesn't discount the fact that there is genuine physician opposition to both.
But while the debate, even on the physician side, has been driven by the loudest voices, the survey suggests there is a largely silent majority of physicians that could have an impact on the outcome.
I keep going back to a poll conducted earlier this year by Gallup, only because it is so revealing: The public trusts physicians more than anyone else—politician or otherwise—to inform them about healthcare reform.
In that context, this week's survey showing physician support for the public option could prove more influential in its ultimate fate than even President Obama's endorsement during his address to Congress last week.
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California has unveiled a Web-based tool to track use of dangerous drugs so that any doctor, pharmacist, midwife or registered nurse can instantly determine whether writing or filling another prescription for a patient would perpetuate addictive abuse.
The database, called CURES (Controlled Substance Utilization Review and Evaluation System), was announced this week by Attorney General Jerry Brown, in an effort to stop trafficking and abuse of Schedule II, III, and IV drugs, which include addictive painkillers or anxiety medicines such as Oxycontin, Valium or Vicodin. Some 100 million prescription entries are already logged in.
"With 7,500 pharmacies and 158,000 prescribers reporting prescription information annually, CURES is the largest online prescription-drug monitoring database in the United States," Brown said in a statement.
Brown wants to reduce the number of disabling and potentially lethal overdoses that send people to the hospital emergency room and unnecessarily add to health care costs. A 2005 study by the Drug Abuse Warning Network estimated that non-medical use of pharmaceuticals accounted for more than 500,000 emergency room visits in California, "an enormous drain on the state's healthcare system," the statement said.
He said the recent deaths of Anna Nicole Smith and Michael Jackson "have made it clear to the whole world just how dangerous prescription drug abuse can be."
"CURES has been available for some time," explains Brown spokeswoman Christine Gasparac. "But it used to be that if you are a doctor, and a new patient is coming in and you wanted to verify the drug history, you'd fax the request to our office, we would first verify that you were a doctor, and then we would send that patient activity report back to you in the mail. It could take a week."
Now care providers in those four specialties can register for access to the site, and view the entire history of Schedule II, III or IV drug usage for any patient within minutes.
"Under the new system, a pain-management physician examining a new patient complaining of chronic back pain would be able to instantly look up the patient's controlled-substance history to determine whether the patient legitimately needs medication or is a 'doctor shopper,'" who visits dozens of doctors to obtain multiple prescriptions," Brown's statement said.
Certain law enforcement officials and medical profession regulatory boards will be able to access the site as well.
The database does not have photographs of each person who filled a Schedule II, III or IV prescription, but it soon well.
With so many providers and others able to view potentially confidential information, there is concern about patient privacy violations. But Gasparac says that providers who register to use the site may do so only for patients under their care, and there are criminal penalties for abusing the database to violate a person's medical privacy.
Using it to snoop into records of people who are not that provider's patients could result in the loss of one's professional medical license, she says. She added that celebrities and public figures will have extra security attached to their drug records.
Gasparac adds that anyone who accesses the database will have to register, and the amount of time spent on the site, and which records were reviewed, are all recorded.
Another concern about such a system is that some providers may not want to use it because of the time it takes away from their clinical setting to log on and look up the patient's history. The practitioner may also not wish to turn down a potentially disruptive or violent patient.
But now that the system is available and relatively easy to access, practitioners who fail to use it may be legally liable if the patient or someone else—say an occupant of a vehicle who is struck by the patient—is harmed as a result of the use of that prescription drug.
Brown believes that the database's ability to prevent many of the deaths and accidental overdoses and other harmful or violent events caused by the abuse of such schedule drugs makes the system worth the risk.
Already the system has had success stories. Last year, Brown and the CURES team targeted 50 doctor shoppers who averaged more than 100 doctor and pharmacy visits to collect "massive quantities of addictive drugs like Valium, Vicodin, and Oxycontin."
The effort led to the arrest of dozens of suspects, including Frankie Greer, 53, who allegedly visited 183 doctors and 47 pharmacies to feed a prescription-drug habit. Greer was reportedly able to persuade emergency room doctors to prescribe her "more than 4,830 hydrocodone tablets, 2,210 oxycodone tablets, and 156 Oxycontin pills, along with a variety of additional addictive painkillers."
California is not the only state to have such a database, but it is the largest. Other states with online programs include Idaho, Illinois, Kentucky, Utah, Alabama, Arizona, Louisiana, North Carolina, North Dakota, South Carolina, Vermont, Colorado, Maine, Wyoming, Connecticut, Indiana, Iowa, Mississippi, Nevada, New Mexico, Ohio, Oklahoma, Tennessee, Virginia, and Michigan.
Gasparac says she does not know whether other providers in other states will have access to the California database, or whether California providers will see the other states' databases.
Six national organizations representing thousands of healthcare professionals nationwide have joined together to create the Hospital Care Collaborative (HCC) to examine pressing needs and outcomes related to hospitalized care.
The HCC includes members from:
American Association of Critical Care Nurses
American Association of Respiratory Care
American Society of Health System Pharmacists
Case Management Society of America
Society for Social Work Leadership in Health Care
Society of Hospital Medicine (SHM)
"The collaborative really represents the coming together of organizations with similar mindsets and similar philosophies about the way patient care should be delivered—vis a vis teamwork, collaboration, true respect, and recognition for the talent and experience that others bring to the healthcare team," said Russell Holman, MD, a member and past president of SHM, which represents hospitalists.
"We thought that a great way of modeling collaboration and teamwork would not be to just to look at pockets of excellence on a grassroots level, but also to look at modeling this at a professional organizational level"—including the efforts in hospitals of physicians, nurses, case managers, pharmacists, social workers, and others, said Holman, who is also the COO of Cogent Healthcare.
He added that much of the discussion around healthcare reform has "ignited a great deal of conversation" within the collaborative. "There is more and more interest, for example, in terms of incentivizing hospitals and other providers based on quality instead of volume of services," he said. "We're very much interested in the process of healthcare being reflected of the outcomes that patients expect."
As part of the launch of HCC, the group has established 13 guiding principles for delivering team-based care in the hospital. It represents the consensus of the HCC members.
The new principles emphasize the need for collaboration, a focus on patient-centered care, accountability, and information sharing. They also recognize systemic issues in hospital care, such as gaps in healthcare education and the pressing need for hospital culture to better promote teamwork.
The final principle states that "the HCC recognizes that today's hospital cultures do not foster true teams of healthcare professionals" and it calls on all stakeholders—such as payers, providers, administrators, patients—to work together "to create a new hospital culture that nurtures and rewards high performing teams."
Using its members and common principles as the foundation for its work, the HCC is beginning to engage in new activities designed to improve care for hospitalized patients, including:
Identifying and promoting best practices in multidisciplinary teamwork
Promoting continued and expanded collaboration among the HCC organizations to develop and implement strategies for teamwork among health professionals
Developing and promoting education programs, specifically for interdisciplinary teams
"This has been a landmark even for us and for the other organizations involved," Holman said. We're looking forward to pushing these principles into both application as well as the broadening of the inclusion in this group. I think there's a lot more to follow."
Sen. Max Baucus (D-MT) released the highly anticipated Senate Finance Committee bill on Wednesday, which has reignited the healthcare reform debate. The Congressional Budget Office estimates the plan would cost $856 billion over 10 years. This amount would be paid for mostly through "increased focus on quality, efficiency, prevention, and adjustments in federal health program payments, without adding to the federal deficit," according to Baucus in a statement.
What do health leaders think of the bill? Here are comments from five leaders:
Chris Van Gorder, FACHE
President/CEO
Scripps Health
"From my perspective and the perspective of most healthcare providers, the current system is broken. Without a doubt, it is too fragmented, costly, and there are too many of our citizens who are uninsured.
"I and my organization clearly support the concept of universal coverage. Senator Baucus' bill clearly moves us in that direction and it does so with individual mandates and without a government controlled option—which gives us great concern.
"Senator Baucus builds on the current system and starts to correct some components of the system, which are clearly broken but does so in a reasonable manner. As always, the details will be important and we are still analyzing the bill—but from our initial read, this bill moves us in the right direction and in a reasonable manner."
A. Mark Fendrick, MD
Co-director
University of Michigan's Center for Value-Based Insurance Design
"In addition to providing affordable coverage to 29 million uninsured Americans, several provisions in the Senate Finance Bill aim to produce meaningful improvements in both the quality of care provided and efficiency of the healthcare system.
"Investments in prevention and wellness programs, health information technology, patient-centered care systems, and research into what medical services work, will hopefully shift the dialogue from how much we spend on healthcare, to how much health we receive for the money spent."
Bob Coli, MD
Physician
Founder, chairman, and CEO
Diagnostic Information System Company
"Unfortunately, it is another classic ‘government control solution,' which is exactly the opposite of the consumer-centered, value-driven ‘private market solution' that is needed. Some of the most convincing proof of this opinion are the sections on healthcare cooperatives, prescription drug coverage, and the proposed revenue provisions."
J. James Rohack, MD
President
American Medical Association
"The AMA applauds Chairman Baucus and his colleagues for their hard work and important contribution toward our mutual objective of comprehensive health system reform. Expanding coverage through tax credits, insurance market reforms that protect patients if they get sick or lose their job, and offering more affordable choices through new health insurance exchanges will significantly improve our healthcare system.
"The AMA will continue to work with Chairman Baucus and his colleagues to strengthen this proposal. The AMA continues to call for permanent repeal of the current Medicare physician payment formula that threatens seniors' access to care. The House has already recognized the importance of this action by including it in pending legislation.
"Without permanent repeal of the current formula, physicians face cuts of 40% over the next few years that will erode access and choice for America's seniors. A recent AARP poll found that 90% of people 50 and over are concerned that the current Medicare physician payment formula threatens their access to care.
"After further review of the proposal, the AMA will continue ongoing discussions with Chairman Baucus and other Finance Committee members regarding policies of concern to physicians."
Karen Ignagni
President and CEO
America's Health Insurance Plans
"Senator Max Baucus has led an unprecedented and rigorous bipartisan process to enact healthcare reform this year and challenged all stakeholders to contribute to this process. The introduction of legislation in the Finance Committee is a very important step in the healthcare reform process.
"Health plans have stepped up and proposed robust insurance market reforms to ensure nobody falls through the cracks and a complete overhaul of administrative processes that will improve efficiency, reduce paperwork, and free up time for doctors to focus on patient care. We also advocated and support a new reinsurance mechanism to assist in the transition to new market rules.
"We are committed to working with policymakers and stakeholders to find savings in the Medicare program, including Medicare Advantage, but it is important to ensure seniors' healthcare choices are protected.
"New health insurance reforms and consumer protections will guarantee access for all Americans without the need for a new untested government-created co-op that could disrupt the quality coverage on which millions of Americans rely today. We believe there is an opportunity for additional system-wide cost containment to ensure coverage is more affordable and to put our healthcare system on a sustainable and fiscally responsible path. New taxes on healthcare coverage will have the opposite effect by making coverage less affordable for families and employers across the country.
"As the process progresses, health plans will continue working with members of Congress to enact bipartisan legislation this year that will cover all Americans, make coverage more affordable, and improve quality."
Senate Finance Committee Chairman Max Baucus has released his healthcare reform bill, and there was a sense that the coalition of major industry leaders and interest groups central to healthcare reform remains intact, according to the Washington Post. Many of the most influential players found elements to dislike, but not necessarily reasons to kill the effort.
The Obama administration said Medicare will help fund state pilot projects that use primary-care doctors and teams of coordinators to manage patient care and reduce costs. Under this "medical home" model, physicians are paid more for coordinating care for their patients. The goal is to help patients stay healthy enough to avoid hospital trips and expensive treatments, saving money in the long run.
A proposal requiring drug and medical-device companies to disclose their often-controversial consulting agreements with doctors is now part of healthcare legislation unveiled before the Senate Finance Committee. The provision is tucked within an $856 billion healthcare overhaul that was introduced by Sen. Max Baucus, the committee's chairman. The legislation calls for drug and medical device companies to file annual reports showing payments to doctors for services such as marketing, education and research beginning March 31, 2012. The information would be available to the public on the Internet.
