Healthcare Economy

In continuation to my previous blog on Meaningful use  Assessment,  post the final rule being released (for the meaningful use ) with much more laxed norms providers must view this wind of change as a opportunity to  implement and transform the organization by viewing the holistic value equation.

With the current mandates the use of electronic health records (EHRs) is inevitable for providers organizations which  will improve the decision making for the clinician and outcomes.

But inevitability does not mean easy transition and change . Providers need to view this transition as  investment in technology , change in processes, technology adoption, training and minor productivity adjustments to see significant improvements in over all care coordination/delivery process and outcomes.

But with this change it is imperative for  a provider organization to balance the investment and incentive equation by assessing current capability, MU stage 1 compliance and also take into consideration that the stage 2 compliance requirements are going to be much more stricter and higher in number. They must take care of defining this transformation by defining appropriate operational & clinical levers (that shall define their measurable core metrics ) tied to various outcomes which would lead into the process changes , then deploy the appropriate (certified)EHR technology and measure the outcomes. The operational & clinical levers shall help in defining  holistic view of the metrics encompassing the Meaningful Use measures and shall also set the stage for the various MU stages. This  process shall yield the maximum value as providers shall define the metrics , redesign  organizational processes  which shall be tuned much before to the technology deployment, which shall result in much more productivity gains and benefit the provider organization by maximizing their ROI and clinical outcomes.

Posted by Shishir Kumar at 11:56 AM | Permalink | Comments (0) | TrackBacks (0)

Implementing CCHIT-certified EMR is only the first step; for achieving Meaningful Use (MU). It's very logical that EMR has to be used first before we can expect meaningful use. Starting to use EMR that an organization has implemented sounds deceptively simple and a non-issue but the truth is EMR adoption in US has been significantly low. Umpteen reasons have been attributed to lower adoption of EMR including dollar investments required, unclear ROI, lack of interoperability infrastructure for healthcare data sharing, reduction in face-time with patients at point of care, longer visit times that directly impacts revenues and ineffective training of staff and physicians.

US government's commitment of USD 19.2 billion under ARRA HITECH Act has spurred providers into seriously considering EMR adoption. History has many examples of healthcare IT implementation failures due to lack of user adoption. Enabling healthcare staff to meaningfully use EMR requires focused approach to sustained end user adoption and learning. There is no one-size-fits-all solution for EMR adoption and different organizations may need different set of strategies to ensure MU. So, how do providers ensure EMR adoption for Meaningful Use?

First step would be to generate awareness amongst EMR users regarding the ARRA HITECH Act's vision of leveraging healthcare IT to reduce healthcare costs and improve quality of care. They need to be sensitized about the important role each one of them has to play in turning this vision to reality. Secondly, EMR users need to be engaged during EMR implementation and their constructive feedback should be incorporated in EMR configuration. While the EMR system cannot be configured for each user's preferences as it compromises efficiencies that results from process standardization, a balanced level of personalization can be offered. Third and most important aspect is training for sustained end user adoption. Many large services organization recognize the significance of training in IT adoption and now have dedicated knowledge services units that bring in know-how of latest knowledge management technologies and behavioral science to ensure IT adoption.  Training should be made accessible to EMR users anytime, anywhere so that it does not interfere with their job and they have flexibility to go through training based on their schedules at a pace comfortable to them.  Multiple approaches of training delivery (like classroom training, Computer Based Trainings, one-click online help, helpdesk call center, online chat with helpdesk staff, user community forums, FAQs etc.) can be used to allow increased flexibility to EMR users. A successful best practice for healthcare IT adoption has been to identify physician and nurse champions who will be early adopters.  Early adopters will be able to point out practical challenges that are faced by EMR users at point of care. The training plan developed in collaboration with physician and nurse champions must provide guidance on overcoming these practical challenges. Last but not the least, provider organization's policies must promote and encourage sustained use of healthcare IT.

Posted by Seema Pandey at 9:35 AM | Permalink | Comments (0) | TrackBacks (0)

With the incentive induced ARRA, it has been easy for Providers to focus on the implementation of EHR and consequently lose their sight on the impending ICD-10 mandate. But, the rigid ICD-10 compliance date leaves no room for procrastination. There is no doubt that on the industry's ICD-10 trail, far by most the payers have been leading the race. The watch game is over. In my opinion, Providers just can't afford to remain in the backseat.
Even realizing the overhauling ICD-10 impacts in the fabric of the provider business processes, when the time is to establish and execute the strategic transition plans, i think majority of the providers are still grappling with how to integrate the new codes throughout their business spectrum. Also the significant challenge confronting many of them is probably a lack of definitive information about where to start? How to start? It is noteworthy to mention that a considerable chunk of providers are vouching on some form of external help to prepare for ICD-10 implementation- either through package vendors upgrades or outsourcing the most vulnerable HIM piece. "Buy vs. Build" is also a viable option for many. Some are even prioritizing to stabilize on the 5010 platform before they kick start for ICD-10.

Still with all such complacence, I feel it will be wrong to say that Providers are completely silent or sluggish about their ICD-10 concerns. Even keeping all the external options open, some has already started evaluating their remaining in-house functions, reimbursement processes and disparate vendor, system data. A few early movers have already completed their assessment and are now deciding on the remediation strategies, determining the necessary additional manpower, training need, vendor readiness and budget plans. But, settling on the remediation approach: code-swap, neutralization, hybridization or crosswalk- what suits them best, in my opinion is still a daunting task.

It's a realized fact that ICD-10 implementation may not have a one-size-fits-all solution neither can it be achieved through a big-bang approach. It is a "mission critical project" that might compel one to downgrade from being strategic to pragmatic. Yet one thing is clear: there are still opportunities that afford proactive providers the chance to become industry leaders & be the market differentiators, while less forward-thinking ones may wait themselves out of business. Time is exactly to gravitate towards ICD-10, and stop speculating on its do-ability. The dilemma should end. Timeline is stringent, providers need to gear up for the impending new code compliance.

Posted by Dr Suman De at 12:20 PM | Permalink | Comments (1) | TrackBacks (0)

Be it the healthcare reform, requiring payers to use at least 80% of their premium revenues to pay claims, or the insurance exchanges driving competition to their doorsteps, the message to US health insurance industry is clear - either run your business efficiently, or go out of business.

Running the business efficiently is easier said than done, especially for payers running their business on inflexible legacy systems. There has been significant effort from some of the largest payers in the past few years to consolidate multiple platforms and migrate to agile and flexible platforms. Others need to follow suit and ICD-10 is the perfect opportunity.

At the outset, it might appear that "inflexibility of the legacy platform to adapt to ICD-10" should be the primary driver for such a migration. In other words, it might not seem like a good bargain to migrate, as long as it is not cost prohibitive to implement ICD-10 in the legacy environment. This is a very narrow and one-dimensional perspective.

Implementing ICD-10 the right way is really about transforming the business itself; it is about doing different things and doing things "very differently" than they are done today. Therefore, to get a broader sense of the opportunity, the following questions must be asked:

•Is the legacy platform flexible enough to align with such a major transformation of the business itself?
•Will the legacy platform be able to meet the organization's objectives of ICD-10 implementation?
•Will the legacy platform play any part in making the "new" business processes efficient?
•Will the current platform be able to accommodate the hundreds of new opportunities ICD-10 brings to the table?
•Will it be cost effective to align the legacy platform to the new business model?
•Will we need to migrate to a new platform in couple years post the ICD-10 implementation anyways?

Answers to these questions will provide insights that will make the decision-making comprehensive and in most cases point to the fact that "ICD-10 is indeed the perfect opportunity to migrate to cutting edge platforms".

Posted by Vijay Kumar B at 12:12 PM | Permalink | Comments (0) | TrackBacks (0)

My shameless plagiarism aside, the question is definitely being asked in all the circles of healthcare industry, from payers to providers, from IT to business, from CIOs to those medical policy reviewers who actually have to ascertain the medical necessity of the procedure. And trust me, there is no consensus. Did you think for a second that there will be? If yes, then you must not have been living in US and sure as heck, have never been to a hospital or gotten an explanation of benefits.

I have participated in mild, civilized discussions about the topic and I have been unfortunate middle man in mud-slinging matches where blood-letting was avoided only due to lack of sharp objects in the room and the width of the table. So why is the topic so explosive and is there a final conclusion. I definitely don't mean a consensus, neither am I naïve enough to hope for one. Just a simple majority-supported conclusion. And once the question of cross-walking has been answered, will there be a standard implementation approach that will be adopted by the industry?

First question, first. At the risk of going through my own March of Ideas, I propose that a crosswalk is going to be mandatory requirements come 1st of October 2013. I will try to plead my case using certain business scenarios here, and not simply point you to what the analysts have been saying, though more and more of them are leaning towards a crosswalk based solution. And so are the executives.
Let's take a simple example. Let's assume that through some miracle, every single one of the payers and every single one of the providers is ready with ICD10 codes on 1st October 2013. What more, let's assume that they can actually code in ICD10 without much of a productivity loss. Obviously this scenario will rule out the crosswalk. Or would it? Let's now fast-forward to 1st of April 2014 (I think I am watching too much of the ABC show 'FlashForward'). A large employer comes to a payer and asks for a quote for insuring 150k employees of theirs. What does the payer do? To quote, one needs historic data and at that point of time, the payer has 6 months of historic data in I10 and 20 years of historic data in I9. One can't ignore the 20 years of history because of chronic trends and one definitely can't ignore the latest 6 months.  And you thought that the job of actuaries was difficult now. The only option at that point is to have some kind of harmonization to be done on the two historic data sets. Well, there is your crosswalk. Granted, it is not an in-transaction crosswalk wherein one has to convert an inbound claim from I9 to I10, which requires a heck of a lot more accuracy, but still it is a crosswalk nonetheless. It could be a statistical trend based crosswalk using some kind of weights, but it will be a crosswalk.

Let's take another example, wherein a pre-auth comes in before 1st October 2013, for a long-term procedure, say maternity. The actual procedure takes place post the transition date and the claim comes in after 1st October 2013. How does one validates the medical necessity or even reconciles the claim against the prior auth. Well, one needs a crosswalk. Maybe not a very exhaustive one, may not even be a clinical rules based, but a crosswalk all the same.

Also, the conservative estimate in the industry is that around 60% of the providers are not going to be ready with I10 on the transition date. Even if I take 50% of that, we are talking about close to one third providers not being able to generate I10 codes. So what is one going to do? One is within the legal rights to reject those claims but can one afford to do so and in the process push those already-cash-starved providers to bankruptcy. What happens to the healthcare system in the country under that scenario? So, me thinks, even an in-transaction crosswalk is definitely in play to avoid such massive anguish across all stakeholders.
On the provider front, if one needs to leverage the massive knowledge of coding that has been built over the years of I9 usage in order to avoid the great productivity loss (Australia and Canada being prime examples), one must have a crosswalk to transition the I9 codes to I10 codes. Also, if one wants to maintain any kind of consistency in their clinical decision support systems (that leverage historic clinical data) or still provide effective EHR support, one better figure out how to harmonize historic data. And as of yet, the answer seems to be a crosswalk and this time the real complicated one, i.e. clinical rules based.

And I have not yet talked about the benefits of the crosswalk, pre and post transition date. In a previous post I had talked about contract negotiations and payout/reimbursement neutrality. There is no better mechanism than using trends/weights based crosswalk-driven simulation model to figure out the potential impact on payout and/or reimbursement, depending upon from which side of the table one is looking at it. Also, the possibility of doing extremely granular stratification of member population for disease management purposes while maintaining administrative simplification for financial purposes, is a definite possibility with the use of a well-designed crosswalk.

Now on to the second question, i.e. Is there going to be a national cross-walk? Me thinks, it is just a pipe dream. It is extremely difficult to establish a consensus across such a gargantuan landscape of varied stakeholders. In any case, the situation will vary from payer to payer and provider to provider. Even if the business scenarios were not that discrete, who will take up such a massive undertaking of creating and maintaining such a crosswalk, and by the way take abuse from every conceivable stakeholder in the process. What a thankless job that will be.

I believe that there will be multiple crosswalks, dependent upon once business parameters, lines of service, contract structures, and last but not least appetite for inaccuracy in auto-adjudication. There might be community based or association based crosswalks (such as Blues might all join hands) but even those will have their own variants at each individual organization.

So, bottom line? Be ready for a crosswalk, whatever shape or format and start planning towards creating one of your own, lest you end up using one that aligns to your business like BP's oil rigs to the Gulf coast shrimp business.

Posted by Rajiv Sabharwal at 12:06 PM | Permalink | Comments (0) | TrackBacks (0)