ANIHFMA lauds 150 healthcare providers for leading in patient financial communications

HFMA lauds 150 healthcare providers for leading in patient financial communications

A major complaint of patients is they are unable to obtain accurate costs for their health care and visits to the hospital.

Hospitals also have good reason to join patients and complain about predictive pricing. A typical explanation of benefits (EOB) is laden with misleading information. Furthermore it makes no sense, except to perhaps an accountant or health administrator on the inside. A Medicare EOB is quite different than one from a private insurer or  a managed care program. Furthermore there are no public documents that relate true costs for each service to the amounts on explanation of benefits.

Patients must insist on receiving a full explanation of benefits and questioning the numbers as well as how they are derived.  The present system is corrupted and every patient should become a "whistleblower"

Managed care programs have different contractual reimbursement models, 

MANAGED CARE PAYMENT METHODS 

Many methods exist to pay for provider services, including discounted fee-for-service charges, and capitation. Listed below are some common terms used in insurance plans to define payment obligations on the part of a patient, provider of services, or the insurance company. 

Capitation A payment system in which health care providers (physicians, hospitals, pharmacists, etc.) receive a fixed payment per member per month (or year), regardless of how many or few services the patient uses. 

Coinsurance An insurance policy provision under which both the insured person and the insurer share the covered charges in a specified ratio (e.g., 80% by the insurer and 20% by the enrollee). 

Co-payment A cost-sharing arrangement in which the managed care enrollee pays a specified flat amount for a specific service (such as $15.00 for an office visit or $10.00 for each prescription drug). It does not vary with the cost of the service, unlike coinsurance which is based on some percentage of charges. 

Deductibles Amounts required to be paid by the insured under a health insurance contract before benefits become payable. 

Discounted Fee-For-Service An agreed-upon rate for service between the provider and payer that is usually less than the provider’s full fee. This may be a fixed amount per service or a percentage discount. Providers generally accept such contracts because they represent a means of increasing their volume or reducing their chances of losing volume. 

Fee-for-Service (FFS) Reimbursement Payment in specific amounts for specific services rendered. Payment may be made by an insurance company, the patient, or a government program such as Medicare or Medicaid. The form of payment is in contrast to payment retainer, salary, or other contract arrangements (to Physicians or other suppliers of service); and premium payment or membership fee for insurance coverage (by the patient). 

Out-of-Pocket Expense The amount not reimbursed by insurance coverage and paid by the patient such as co-payments, deductibles and premiums. 

Pharmacy Benefit Coverage of prescription drugs by an insurance company. Often, beneficiaries will have an identification card designating their eligibility and will have to pay partially for the drug in the form of co-payments, deductibles, or coinsurance. Also referred to as a “Prescription Drug Benefit.” This benefit may be offered through a company other than your health insurer. 

Premium The amount paid to an insurer for providing coverage, typically paid on a periodic basis (monthly, quarterly, etc.). 

Prevailing Charge This is a fee based on the customary charges for covered medical insurance services. In Medicare payments for services or items, it is the maximum approved charge allowed. 

Reasonable Charge A methodology used by Medicare to determine reimbursement for items or services not yet covered under any fee schedule. Reasonable charges are usually determined by the lowest of the actual charge, the prevailing charge in the locality, the physician’s customary charge, or the carrier’s usual payment for comparable services. 5 

Reasonable Cost A methodology used by Medicare to determine reimbursement for items and services that takes into account both direct and indirect costs of providers such as hospitals, as well as certain Medicare HMOs and competitive Medical Plans. 

Reimbursement Reimbursement Refers to the actual payments received by providers or patients for benefits covered under an insurance plan. 

Third-Party Payment (a) Payment by a financial agent such as an HMO, insurance company, or government rather than direct payment by the patient for medical-care services. (b) The payment for health care when the beneficiary is not making payment, in whole or in part, on his/her own behalf. 

Usual, Customary, and Reasonable (UCR) Charges Private health insurance offers the basis for reasonable-charge reimbursement of physicians. This approach was developed before the introduction of Medicare and was adopted by Medicare. “Usual” refers to the individual physician’s fee profile, equivalent to Medicare’s “Customary” charge screen. “Customary,” in this context, refers to a percentile of the pattern of charges made by physicians in a given locality. “Reasonable” is the lesser of the usual or customary screens.

Contrary to opinions of most pundits, the American health system is strong and robust. The strength can be measured by the survival of any system, at all given the proclivity for congress to make law that has little to do with enhancing patient care.

Because our health system(s) are so diverse is it's main strength. When one segment gets out of balance another one rises to the occassion. Just recently the head of the Veterans Administration forecast that many of their beneficiaries would be sent out to civilian providers in order to meet the demand of primary and specialty care.  (they must not be aware of the dire situation of civilian primary care givers.)

At its 2016 ANI event, the Healthcare Financial Management Association on Sunday named 150 healthcare providers as leaders for adopting best practices when it comes to patient financial communications, an important benchmark as patient financial responsibility rises.

The award program was developed in 2013 to call attention to providers who excel at communications around billing, costs and payment options.

"Adopting the best practices promotes trust and helps prevent misunderstandings between patients and healthcare providers," said HFMA President and CEO Joseph J. Fifer, in a statement. "In a time when patients are paying more out of pocket for their health care, clear communication about financial matters is crucial. We encourage all provider organizations to seek Adopter recognition."

The organization said 85 hospitals and 68 clinics earned the recognition, though the bulk of the awardees were part of nine major healthcare systems. Those are Carolinas HealthCare, the Duke University Health System, Essentia Health, the Geisinger Health System, Intermountain Healthcare, Novant Health, St. Luke's Health System, The Metro Health System of Cleveland and UAB Medicine. Two critical access hospitals, Henry County Health Center in Mount Pleasant, Iowa, and Maury Regional Medical Center in Columbia, Tennessee, earned recognition.

According to Rodney Williams, senior manager of patient revenue management organization at Duke University Health System, the system makes it priority to understand how the cost of care affects its patients.

"We perform a comprehensive analysis to make sure that patients are not going to be surprised by the costs they are responsible for on the back end," he said in a statement.

Providers must attest to a range of patient communication best practices to earn the adopter status, the HFMA said.

The Revolution in Magazine Processes "How not to fall behind in an era when everything you think you know might be wrong."

The title could have just as well read

The Revolution 

in 

Health Processes

Conventional print magazines, newspapers have weathered a sea-change in their business model.
And so has medicine and health process.

Health care financing, and administration also are struggling to change even as our current medical system is overwhelmed with increased expenses.  The similarity between magazine process and health process are remarkably alike.

Prominent news publishers, such as the Washington Post, New York Times and many others went out of business at the same time re-inventing their 'product' in a more efficient manner.  In some cases ownership shifted quietly behind the scenes. There were major reductions in staff, overhead and outright elimination of tasks that served no purpose or had been replaced by digitalizing the industry.

Even as this is occurring health organizations are burdened with daily organizations while being mandated by government, CMS, the Affordable Care Act, Insurers, and expansion of new covered benefits such as remote monitoring, telehealth and mobile health care.  The uptick in  expenditures for health IT is overwhelming many, both large and small.  There is no room for error. During the past five years some large institutions spent millions of dollars to purchase EHRs only to find they could not perform as advertised. Providers, and hospitals did not know or have experience in systems that were new and untested in a real world setting.

Health care operated mostly on a cash basis until the birth of managed care, capitation, and other obtuse forms of risk management.  In health affairs risk management used to have to do with risk of disease and/or treatments. Insurance companies were required to have an actuarial basis for setting premium rates against history of their insured disease risks.

Today this risk is carried not just by the insurance company, it has been shifted to hospitals and providers. Other calculations are being considered such as quality of outcomes, measured by re-admission rates to the hospital. The latest in the quirky world of health high finance is the 'accountable care organization. (ACO).

The name was coined by Elliott Fisher as a philosophical term during it's germination period.  Theoretically the organization that saves the most gets a 'kickback' a larger reward incentive than the rest of the providers/hospitals.

The health care company of 2005 is gone. its processes, procedures and priorities would be nearly unrecognizable today. In fact, the medical practice that existed in 2010 is gone too. In a period of accelerated transformation, nothing is more striking than the scope—and pace—of change in the processes through which these companies engage their customers (patients)  The very terms physician and patient devolved into provider and consumer. Physicians are no longer generalists or specialists they are primary care providers. It’s not just peripheral or incremental change, either. What the industry is going through in 2015 is a revolution in processes. In advertising, content creation, marketing, back-office functions and everything in between, what was done just a few years ago has been rendered obsolete, as new ways to interact with and serve stakeholders push the old ways into the trash bin. 

What’s changed is that technology is transforming every single phase of the business. It’s ubiquitous. It’s impacting the business on a wholesale level.”  It’s a new world of “VUCA,” says Lenny Izzo, group president of legal media at ALM. “That’s an acronym for Volatility, Uncertainty, Complexity and Ambiguity. It’s an old military term

Providers and hospitals have become 'punch-drunk' much like boxers and football players suffer from TBD or traumatic brain disorder.

Uncertainty comes in the form of new competitors. It comes with the decline in traditional branding-based display advertising, and the rise of new formats like cost-per-lead sales and programmatic advertising. Complexity comes in the form of tying together new expensive technologies that cross email, web, billing, production, ad-management, and content creation. Ambiguity comes in the form of not having the expertise to evaluate expensive new systems, and sometimes not knowing the right KPIs. Volatility? How about not knowing whether a new software system that cost $1 million will be relevant in 18 months?

This report is an on-the-ground look at process change in magazine media companies and how it’s affecting, well, nearly everything, from organizational structure and staffing needs, to assumptions about efficiency and newly essential skillsets. We’ll look at overall philosophies and approaches, and then explore, mainly through case studies, what publishing companies and executives are actually doing. 

Radical changes in process are driven by several things, of course. But mostly, it’s a function of two things: emerging technologies that enable new methods of serving markets, and a quest within companies for efficiency driven by economic necessity.

The revolution in health is not just in health IT, it includes changes in medical group administration, payment reform, relationships between providers, hospitals and providers, referral patterns and a new dynamic between regulators, licensing boards and providers of health care.

Interestingly, for health provider and magazine publishers, there’s a significant paradox in process change. Because the business model is in a seemingly permanent state of flux, and because technologies become obsolete so quickly, both types of companies find themselves betting huge amounts of money on unproven ideas. “Maybe the paradox of process is that you’re forced to be hyper-efficient in the things you understand, to finance what you hope is our future,” 

Note: Much of this article has been taken word for word from anaticle found on FOLIO  an internet magazine about the publishing business. It was a simple task to substitute health for magazine or publishers.. A true example of 'convergence'

Physician Experience vs. Expectation

During the past decade we have witnessed the corporatization of medicine.  Solo private practice physicians in the U.S. are dwindling rapidly in the United States, except perhaps for a few selective specialists and in underserved areas. Some physicians are experimenting with the new "Direct Payment" model or "Concierge Medicine"

Although private solo or small group practices offer autonomy and control, there are disadvantages. Those who join an integrated health system, or become employed by a hospital gain administrative support and the ability to negotiate insurance contracts with more bargaining power than a small provider. However there are serious trade-offs. Physicians who sell their practice to a hospital find that hospitals receive failing grades in their prowess to run medical practices.

This is a relatively new phenomenon and hospital management may improve in the next several years. Kaiser seems to have met the challenge by forming a separate entity for a medical group which then interfaces with the hospital.  The governance structure is distinctly separated.   This allows the providers negotiating power and the abiity to make more decisions for themselves.

There are other issues in making this transition to a group practice.  Cultural clash  and generational difference can also affect the new relationship.

 Modern Health Care presents this case

"Dr. Janet Chipman worked for more than a decade in a busy surgery practice she owned with three other physicians, treating patients and sharing the responsibility of running a multimillion-dollar business. She says she valued the autonomy of private practice, which was a common career path among her peers and one she sought when she finished her training.

"But nearly three years ago, Chipman and her colleagues signed an employment contract with Baptist Health, a Kentucky hospital operator that has doubled its number of employed doctors to 485 in the past three years. They felt that joining a sizable health system would boost their negotiating leverage with health insurers and make it easier to recruit surgeons into the practice. They'd also have more bargaining clout with vendors. And it would be more viable to participate in one of the new alternative payment and delivery models, such as an accountable care organization

Even so, Chipman had plenty of doubts before signing the deal. “The decision was incredibly hard for me personally,” she said. “I came from the culture of having your own practice and your independence.”  

Not so for Dr. Nicole Lee. The first-year fellow in maternal and fetal health at the University of Mississippi will enter the workforce in two years. She expects to go directly into hospital employment. That's because working for a large health system likely will mean less on-call duty, allowing her to balance work and personal life. “If I have a family, they will definitely be my priority,” Lee said. “Being on call every other week is not feasible to me.”

Other factors enter decisiono making processesRegular work hours, enhanced family life
Guaranteed on call coverage
Working for a large health system likely will mean less on-call duty



Younger physicians work ethic has changed, largely bevause of new workoplace rule setting strict liits for work hours, and call schedules, caliing for controls much like the airline industry for pilots to reduce risks of error due to fatigue. When thes physicians enter the workforce they carry over this new ethic in private prctice.

Doctors moving from independent practice to employment may be more autonomous, business-savvy and likely to prioritize work over other obligations. But they also may chafe under bosses and rules. “They're used to setting the rules,” said Dr. T. Clifford Deveny, Catholic Health Initiatives' senior vice president for physician services and clinical integration. “One of the things you give up is that complete independence.” 

Younger doctors may have no experience with or desire to take on demanding call schedules or leadership roles. “They're looking for lifestyle,” said Danise Cooper, manager of physician recruiting specialists for Cejka Search

Thrown together, once-independent physicians and younger doctors may clash over how to share the

workload and rotation duties. In addition, physicians may differ in how they respond to their employer's invitation to participate in quality improvement or strategic efforts. And since physicians may treat one another's patients, some doctors may worry about how their colleagues' work ethic and attitudes and accessibility to patients may reflect on them and influence their patients' satisfaction. 

Cultural discord among doctors can lead to costly turnover. Culture conflict ranked in the top five reasons for turnover among doctors in the most recent retention survey by the American Medical Group Association and Cejka Search. Hospitals lose revenue when doctors depart.


The shift is taking place relatively quickly, and may accelerate even more with the mandates of the Affordable Care Act, as more physicians are saddled with non-medical responsibilities.

Twenty percent of U.S. doctors worked for a hospital in 2012, according to the American Medical Association. That figure rises to 26% if you include doctors in a medical practice partly owned by a hospital. Six years earlier, 16% of doctors were hospital employees..

The growth in direct hospital employment of physicians has accelerated for a variety of reasons, including new payment models offered by public and private insurers that bundle payments for hospitals and doctors for entire episodes of care or establish financial incentives for providers to coordinate care and achieve better outcomes and lower costs. These new models require closer collaboration between hospitals, physicians and other providers, and may be easier to achieve when physician practices are more closely integrated with health systems.

Affordable Care Act.......The Missing Link....It is not Australopithecus

Houston, we  have a problem  "Failure to Launch"

Despite a goal of access to health care for all, however the hinge on the door for acccess is squeaking. News such as this are appearing in medical news.

Family Planning Clinics In Calif. Squeezed By Health Law KQED - February 10, 2014 Millions Trapped in Health-Law Coverage Gap Wall Street Journal - February 9, 2014 They quit their jobs, thanks to health-care law Washington Post - February 9, 2014 Enrolling in Covered California is not for the weak of heart, or spirit.  For those who were previously uninsured for a variety of reasons the affordable care act raise spirits with the elimination of the fear of not being able to pay for health care. The current system was not sustainable financially, however health care is available taking away the financial morass of insurance companies, bureaucracy and government.  Neither government, nor insurance companies provide health care. Physiciains, nurses, hospitals and many other providers care for patients. A consequence of the change will be the marked reduction in 'free care'. The old model of those fortunate enough to pay for their own care, and providers and hospitals having deep pockets to finance care for the less priveleged of our society. In order to assure health care and security for all the down side is forfeiting freedom. The tyranny of absolute security is freedom. Some of  us understand the concept and the reason for opposition to the affordable care act.  Others see it as an opportunity   for free health care.   Those whol will receive this generosity are often not only uninsured, but also un-empowered, and have little impact, are passive and do not have resources, nor influence to make changes. The U.S. Constitution (    )  guarrantees the pursuit of life, liberty and the pursuit of happiness.  That statement places us in a conundrum.  Does that mean care to avoid illness, or treatment to keep one alive? This is not some ephemeral abstract thought embodied in our founding document. Other constitutional guarrantees in the past have been manipulated to make change The Affordable Care Act in Californa is known as  'Covered California'.  Patients who sign up are screened for eligibilty based on income and household size. Those who's income is greater than........are required to purchase a subsidized health insurance policy or face a fine.  Some of these policies look nice, offered by stable companies, such as Blue Shield, Healthnet, Anthem and their providers are listed under providers for Covered California.  However with a more in depth search you will find they did not receive contracts and are not providers.  (small details).....this will reduce access to providers (and some hospitals). None of this has been adequatly explained  Some who look forward to using Covered California should call their chosen provider and ask if they are a provider for Covered California.   Many of them are not, and some may not even know if they are signed up for it.

ACO Expectations may be Unrealistic

According to a survery of  115 Hospital C-Level executives reveal that about 18% are participating in accountable care organization activities.  This figure is increased from 5% % in 2012.   Half of respondents expect to be in an ACO by the end of 2014.

Whether that lofty figure can be reached remains to be seen. Provider alliance Premier Inc. conducted the new survey in August but only recently released results. The spring 2012 survey found that nearly 52 percent of respondents expected to be in the ACO arena by the end of 2013. Now, Premier estimates only 23.5 percent will reach that goal.

A further analysis of hosptial size revealed: 

Non-rural hospitals are most likely to participate in an ACO, followed by hospitals in integrated delivery systems; and rural hospitals are least likely to participate, followed by standalone facilities.

Large hospitals are moving more quickly toward ACOs than smaller ones, although the majority of surveyed hospitals are making infrastructure investments to manage population health.

This may be effected by the availability of capital resources which are often lacking in smaller institutions, and a much smaller group of medical providers and/or a lack of specialty access.

These investments include lifestyle and wellness coaching by more than 70 percent of respondents, telemedicine by almost half of rural facilities compared with one-third of non-rural hospitals, and patient-centered medical homes, which are popular for all types.

The efforts include a wide variety of investments to increase utiilization of the ACO as a public health resource. 

* The investments include lifestyle and wellness coaching by more than 70 percent of respondents, telemedicine by almost half of rural facilities compared with one-third of non-rural hospitals, and patient-centered medical homes, which are popular for all types.

* Fifty-one percent of responding hospitals are partnering with large local employers to improve care.

* Large numbers of respondents are gearing up for analytics to support population health. More than 72 percent are integrating claims and clinical data, half are using predictive analytics to forecast needs and 46 percent are using a data warehouse to reduce information silos.

* More than 40 percent are partnering with insurers, particularly for upside-only shared savings programs.

The programs require strategic rethinking of hospital scope of care.  The effort will require integration of previously unlinked services in preventive medicine, and health, wellness and nutrition.

The full report from Premiere Inc can be found here.