Healthcare

CMS has used the opportunity brought in by the increased specificity of ICD-10 codes to increase the granularity of DRG codes. This will help CMS streamline Medicare payments. Since significant number of Medicare and commercial claims is paid based on DRG codes, the added granularity is bound to cause uncertainty around provider reimbursements. This uncertainty combined with the payment reductions under SGR (Sustainable Growth Rate) has the potential to significantly impact providers’ bottom-line. Payers are not immune to the impact either. It’s crucial that payers and providers simulate claim payments, compare the payouts between I9 and I10, and be better prepared for the change.

Take for example the I9 code 304 (Radical Laryngectomy). 304 now maps to 36 I10 codes that specify whether the procedure is resection or excision, the approach used and the device(s) used. This increased laterality will allow the claim payments to be more aligned to the actual resources consumed during the procedure and the payments could vary significantly among these thirty six I10 codes.

Let’s hypothesize few numbers around negotiated rates, number and distribution of claims to project the potential impact on financials post transition.

As can be seen from the above tables, hospital-A will receive $10,000 less in claim payments for Radical Laryngectomy after transitioning to ICD-10. At the other end, plan-A will pay $400,000 less for Radical Laryngectomy after transitioning to ICD-10. This is a simple hypothetical example of how financials will be impacted. Modeling the organization wide or business line wise impact in a multi-specialty hospital or a large multi-state plan will be very complex.

However complex it might be, given the impact on bottom-line, both payers and providers will need to do some kind of modeling to project the impact of ICD-10 migration on their financials. Impact on financials due to increase in medical costs and inflation will need to be insulated from the impact due to ICD-10. That’s a pretty complex challenge in itself.

Finally, once the impact on financials has been projected, payers and providers will either need to re-negotiate their contracts, find some other way to negate the impact or accept the impact on profit/loss.

Posted by Vijay Kumar B at 04:51 AM | Permalink | Comments (0) | TrackBacks (0)

Physicians, nurses and case managers spend time with patients to educate them on self-health management; however, technology is increasingly playing an important role in enabling patients lead a better quality of life. Two key dimensions of patient enablement are:
• Access to care at the right level and the right time
• Access to information that helps them manage their health
Technology is addressing both the dimensions of patient enablement. E-Consultation is enabled via internet, IP TV, kiosks and mobile devices which gives patients anytime, anywhere access to care for certain conditions that do not require physician office visit.  E-Consultation can happen in synchronous mode over video/web chat or in an asynchronous mode over email. Some payors are reimbursing for eConsultation making this form of care a viable option for their members.

With remote monitoring technology, patients now have access to high quality care in home setting. Wireless sensors and medical device integration enable patients to recuperate at home post discharge while their vitals are constantly monitored for any signs demanding intervention. Post-surgical care and long-term care have been made more comfortable for patients and care-givers by enabling access from home. Telehealth has made specialty care easily accessible to patients living in remote areas. They can now avoid inconvenience and expense of traveling to cities when they need medical care that can easily be supported by telehealth.
Advanced technologies are enabling patients lead a better quality of life and reducing their helpless dependency on others. Sensor networks supporting activity recognition coupled with sophisticated business intelligence capabilities of behavior modeling and predictive modeling  can help in intelligent monitoring and interventions for geriatric care. For eg- Senior citizens need not be confined to old age home but can continue to live in their own homes where intelligent monitoring system learns their activity patterns over a period of time and alerts care-givers if any aberration is observed. If a person usually spends not more than 20 minutes in a bathroom, the system will alert caregivers if patient spends more than the threshold level of time there and check can be done for an accidental fall. Similarly, mildly cognitively-impaired patients can be enabled to lead a close to normal life leveraging sensor technology and advanced analytics. Such patients can venture out of their home on their own with a Personal Digital Assistant which can guide them if they are lost. It can provide them basic information of date, time, location along with guidance to reach back home from where they are. At a click of a button, they can also be connected to helpdesk that can arrange any necessary intervention. The technology-backed promise of access to care when it is needed is a strong patient enabler.
The other dimension of patient enablement is providing them information that helps them to take better care of their health.  Simple interventions like sms reminders or automated phone call reminders to take medication on time can help improve medication compliance significantly.  Lifestyle changes can be reinforced by constant guidance and encouragement for proper diet and exercises leveraging technology. Podcasts, videos and wellness applications can be downloaded by patients to empower themselves with information and tools for self-health management. A more interactive and personalized health education and health management experience can come from internet and IP TV. Telcos are experimenting with innovative health and wellness services to offer over IP TV. Whether you are looking for gluten-free recipes for a Celiac aunt’s birthday party or you want an effective exercise regime for post-pregnancy weight-loss, your TV may have the answer.  The day may not be far when age-old adage can be rephrased to “A bit of TV a day keeps the doctor away”
Is there a risk of technology-driven enablement of patients resulting in hypochondria or some unintentional action which is detrimental to health? Well, the possibility cannot be entirely negated. This is why technology is not enough for true patient enablement. Patients always need physicians as trusted advisors to guide and support them on self-health management.

Posted by Seema Pandey at 08:09 AM | Permalink | Comments (1) | TrackBacks (0)

To begin diving deeper into interoperability within healthcare, let’s talk about interoperability within the healthcare provider sector.  The healthcare provider industry is suffering from, what a colleague has very eloquently described as, ‘extreme heterogeneity’ of IT systems even within a single provider.

While I was working with a marquee healthcare provider – we had over 30 different applications, 10 different databases, 8 different server operating systems and more than 40 vendors supporting this ecosystem!!  This is an extremely common scenario in this industry and is part of the great difficulty healthcare faces in managing it’s operations efficiently through technology.

The provider industry is approaching this problem through two different and competing paradigms

a) Rip out all these diverse applications and replace with a single monolithic end to end Hospital Information System / EMR / ERP.

This would work well for small organization with little investment in a few systems that have been recently (less than 5 years) implemented.
For those organizations which are large, complex, with long standing ingrained behavior patterns and processes – it becomes an absolute nightmare.  Almost none has succeeded in successfully implementing such a strategy with a semblance of achieving the goal at reasonable cost, within reasonable timeframes and without impacting their businesses negatively.

 b) Continue to work with disparate systems, optimize the number of applications through selective, prioritized consolidation, work with world class integration engine implementation and reach the most optimal mix of applications and systems necessary to provide the organization with an efficient and interoperable data flow.

This is the approach that most organization who wish to achieve true integration and seamless data flow with minimal costs and impact to the business, are moving towards.

It is thus becoming increasingly apparent that interoperability projects will very soon become the cornerstone of a provider’s IT strategy in supporting it’s business needs.  With ARRA and the funding conditions that accompany it – meaningful use would be impossible without seamless data flow and therefore impossible without creating true interoperability.

The necessary products, solutions, platforms, skills and capabilities will very soon move from being a commoditized service currently delivered to low end IT players, to true value adds for the provider industry in it’s move towards automation and electronic data capture.  This is very different from what will happen to HIS/EMR products and services – which will purely be associated with transaction data capture and delivered by a vast landscape of vendors and products.

Posted by Dr. R Balaji at 08:45 AM | Permalink | Comments (0) | TrackBacks (0)

Observation

As we enter the next decade, it is interesting to reflect on where the leading healthcare provider and payer organizations were in 2000 and what has been accomplished to solve the evasive dilemma of creating a truly integrated Electronic Medical Record (EMR) that can provide a complete picture of an individual’s health available on demand.

In the 1990s most of the world became familiar with and began using ATM machines to give us access to our financial data and also to provide cash resources. Now it is 2010 and the healthcare industry leaders are still embroiled in the definition of the EMR and implementing a complete one merely within a single Integrated Delivery Network (IDN), much less having global capabilities.  The complicated nature of healthcare organizations and their focus on decisions by diverse committee creates politics that struggle to agree on definition and rules necessary for complete integration.

Solutions

Many organizations have completed the first and most costly step which is implementing the software that is capable of hosting the basic functionalities for entering and tracking data to perform clinical workflow, financial, billing and decision making functionalities. Now we are entering the next steps which include;

 Optimizing the implemented Product;
 Warehousing Data;
 Applying Business Intelligence Tools for researching operational efficiencies, improving quality, safety and development of new techniques and protocols;
 Medical Device Integration of data directly to the EMR;
 Interoperability that allows for accessing data wherever it exists and creating on demand views (EHR, PHR, P4P, EPM);
 Compliance for Regulatory and Safety standards’
 On going support and maintenance for Clinical and Financial applications.

Conclusion

The requirements for a true integrator will require the provision of service solutions that can leverage leading edge solution sets from internal and external sources. The understanding of the clients needs is paramount, shaping the solution that leverages horizontal services, Centers of Excellence (CoEs) and creatively teaming with leading edge organizations that provide domain specific products as a part of the overall solution set. This allows “World Class” healthcare organizations to depend upon a “World Class” Tier One integrator to supply all of its technology needs. These are necessary requirements for a “World Class” provider of services to compete in the next decade.

Posted by Gary O. Claytor at 06:51 AM | Permalink | Comments (2) | TrackBacks (0)