This document describes a population health management system that medical providers can access to manage healthcare for self-insured employers. It allows providers to take control of healthcare delivery and costs in their community. The system has been in place for over 12 years and has successfully reduced healthcare trends and costs for over 1 million members. It provides tools for providers to identify high-risk patients, implement treatment regimens, monitor compliance, and share in savings through gainsharing arrangements with employers. Medical providers who implement this turn-key system can diversify their payer mix and increase revenues.
The document discusses emerging value-based healthcare payment models in the US and provides recommendations for stakeholders. It outlines recent legislation like MACRA that aims to shift Medicare payments from fee-for-service to value-based models. MACRA establishes the MIPS program which combines existing quality programs and the APM program which incentivizes participation in alternative payment models. It also describes various CMS pay-for-performance programs focused on readmissions, hospital value, and hospital-acquired conditions. The document concludes with recommendations for stakeholders to collaborate across the healthcare system to effectively transition to value-based models.
Value-based healthcare aims to increase quality and decrease costs by tying reimbursements to performance outcomes rather than fee-for-service payments. A survey of healthcare CEOs found that most believe value-based models should dominate over fee-for-service and can increase revenues and profit margins. However, some CEOs are concerned it may decrease revenues or margins. Measuring patient satisfaction, health outcomes, and costs will be important for value-based reimbursement. Integrating and analyzing data on populations, processes, and responses can help create high-value healthcare delivery systems.
mHealth Israel_US Health Insurance Overview- An Insider's PerspectiveLevi Shapiro
Presentation about the US Health Insurance Sector by Lori Rund, VP, Product Management and Market Intelligence at Health Alliance Plan, a managed care organization owned by the Henry Ford Health System, with 650,000 lives. Lori is responsible for the identification, concept building, researching and business case developments for new products, services and markets. She develops and leads comprehensive market intelligence functions to help the organization better understand industry trends and identify business opportunities.
Prior to joining Health Alliance Plan, Lori was Director of Product Development and Market Intelligence at Health Alliance Medical Plans in Illinois and Director of Market Research and Strategy at Carle Clinic Association, also in Illinois.
Todd Berner: Assessment of Payer ACOs: Industry's RoleTodd Berner MD
This document summarizes key points about payers' accountable care organizations (ACOs) and the industry's role in partnering with ACOs. It finds that ACOs with commercial contracts tend to be larger and more advanced. They have more experience with pay-for-performance initiatives and other reforms. The document also discusses various strategies for ACOs to better manage costs, such as considering drug acquisition costs, utilization management, and developing care coordination programs. It notes opportunities for specialty pharmaceutical companies to partner with ACOs in areas like managing high-cost conditions and supporting patient care.
Using Advanced Analytics for Value-based Healthcare DeliveryMichael Joseph
Promoting Value-based Healthcare Delivery
The fundamental principles of the Affordable Care Act recognize that the volume-based, fee-for-service payment model is unsustainable and that a value-based healthcare delivery system is essential. With the emergence of Accountable Care Organizations (ACOs), providers are incentivized to implement payment reforms and participate in shared savings programs that seek to balance quality of care, access to care and cost of care.
Our healthcare analytics payment model uses predictive analytics to assist ACOs in patient attribution, budget development, bench-marking and performance monitoring to maximize incentives through shared savings and quality improvements.
The document provides an overview of health insurance in India. It defines health insurance and describes what a typical health insurance policy covers, including room and boarding expenses, nursing costs, surgeon fees, and medical treatment costs. It notes that over 80% of Indians lack health insurance coverage. The major types of health insurance policies in India include hospitalization plans, pre-existing disease plans, senior citizen plans, maternity plans, daily cash plans, and critical illness plans. The document also outlines several government-run health insurance schemes in India like RSBY, Ayushman Bharat, and state-specific programs. It concludes with a discussion of public and private agencies involved in providing health insurance in India.
MACRA consolidated several existing Medicare quality programs and introduced new payment models. It established two tracks for physician payment and quality programs starting in 2017 - MIPS and Advanced APMs. MIPS consolidated existing programs into four categories and allows physicians to gradually increase their participation over multiple years. Advanced APMs provide incentives for participation in alternative payment models and include models like Accountable Care Organizations. MACRA aims to reform Medicare payments to physicians and transition to value-based models.
The document discusses emerging value-based healthcare payment models in the US and provides recommendations for stakeholders. It outlines recent legislation like MACRA that aims to shift Medicare payments from fee-for-service to value-based models. MACRA establishes the MIPS program which combines existing quality programs and the APM program which incentivizes participation in alternative payment models. It also describes various CMS pay-for-performance programs focused on readmissions, hospital value, and hospital-acquired conditions. The document concludes with recommendations for stakeholders to collaborate across the healthcare system to effectively transition to value-based models.
Value-based healthcare aims to increase quality and decrease costs by tying reimbursements to performance outcomes rather than fee-for-service payments. A survey of healthcare CEOs found that most believe value-based models should dominate over fee-for-service and can increase revenues and profit margins. However, some CEOs are concerned it may decrease revenues or margins. Measuring patient satisfaction, health outcomes, and costs will be important for value-based reimbursement. Integrating and analyzing data on populations, processes, and responses can help create high-value healthcare delivery systems.
mHealth Israel_US Health Insurance Overview- An Insider's PerspectiveLevi Shapiro
Presentation about the US Health Insurance Sector by Lori Rund, VP, Product Management and Market Intelligence at Health Alliance Plan, a managed care organization owned by the Henry Ford Health System, with 650,000 lives. Lori is responsible for the identification, concept building, researching and business case developments for new products, services and markets. She develops and leads comprehensive market intelligence functions to help the organization better understand industry trends and identify business opportunities.
Prior to joining Health Alliance Plan, Lori was Director of Product Development and Market Intelligence at Health Alliance Medical Plans in Illinois and Director of Market Research and Strategy at Carle Clinic Association, also in Illinois.
Todd Berner: Assessment of Payer ACOs: Industry's RoleTodd Berner MD
This document summarizes key points about payers' accountable care organizations (ACOs) and the industry's role in partnering with ACOs. It finds that ACOs with commercial contracts tend to be larger and more advanced. They have more experience with pay-for-performance initiatives and other reforms. The document also discusses various strategies for ACOs to better manage costs, such as considering drug acquisition costs, utilization management, and developing care coordination programs. It notes opportunities for specialty pharmaceutical companies to partner with ACOs in areas like managing high-cost conditions and supporting patient care.
Using Advanced Analytics for Value-based Healthcare DeliveryMichael Joseph
Promoting Value-based Healthcare Delivery
The fundamental principles of the Affordable Care Act recognize that the volume-based, fee-for-service payment model is unsustainable and that a value-based healthcare delivery system is essential. With the emergence of Accountable Care Organizations (ACOs), providers are incentivized to implement payment reforms and participate in shared savings programs that seek to balance quality of care, access to care and cost of care.
Our healthcare analytics payment model uses predictive analytics to assist ACOs in patient attribution, budget development, bench-marking and performance monitoring to maximize incentives through shared savings and quality improvements.
The document provides an overview of health insurance in India. It defines health insurance and describes what a typical health insurance policy covers, including room and boarding expenses, nursing costs, surgeon fees, and medical treatment costs. It notes that over 80% of Indians lack health insurance coverage. The major types of health insurance policies in India include hospitalization plans, pre-existing disease plans, senior citizen plans, maternity plans, daily cash plans, and critical illness plans. The document also outlines several government-run health insurance schemes in India like RSBY, Ayushman Bharat, and state-specific programs. It concludes with a discussion of public and private agencies involved in providing health insurance in India.
MACRA consolidated several existing Medicare quality programs and introduced new payment models. It established two tracks for physician payment and quality programs starting in 2017 - MIPS and Advanced APMs. MIPS consolidated existing programs into four categories and allows physicians to gradually increase their participation over multiple years. Advanced APMs provide incentives for participation in alternative payment models and include models like Accountable Care Organizations. MACRA aims to reform Medicare payments to physicians and transition to value-based models.
Healthcare Consumerism and Cost: Dispelling the Myth of Price TransparencyHealth Catalyst
This document discusses healthcare consumerism and the myth of price transparency. It notes that while consumers want simple, clear, and actionable price information, finding such information is challenging. Regulations now require hospitals to provide pricing information, but hospitals often struggle to understand their own costs. The document outlines factors that have historically impacted hospitals and discusses how advanced cost accounting can help hospitals better understand their true costs and align prices with costs to improve transparency. It concludes by asking attendees if they would like to enter a drawing or learn more about Health Catalyst's products and services.
PYA Principal Carol Carden and Senior Manager Angie Caldwell presented “Hot Topics in Physician Compensation” at the Kentucky Society of CPAs (KY CPA) Health Care Conference, May 18, 2016. The presentation explored the latest developments in physician compensation structure, as well as considerations related to stacking compensation elements, the role and impact of quality incentives, the latest in affiliation models, and population health initiatives.
The many ways in which healthcare reform affects the healthcare industry are still playing out. Undoubtedly, a question for physicians and the hospitals that employ many of them is “how will physician compensation be affected?”
PYA Principal Carol Carden recently spoke at the 2013 AICPA Healthcare Industry Conference, where she addressed this question with her presentation, “Current Reform Initiatives and Their Impact on Physician Compensation.”
PYA Speaks the New Language of HealthcarePYA, P.C.
PYA Principal David McMillan addressed the 2013 Florida Institute of Certified Public Accountants Health Care Industry Conference and offered a consultant-turned-linguist perspective on “Learning the New Language of Healthcare.”
Mastering MACRA: A Beginner’s Guide to New Reimbursement ModelsCureMD
MACRA is 2 years of work, signed into law in April 2015
Extends the Children’s Health Insurance Program (CHIP) for two more years
Requires Medicare to move away from SSN based Medicare ID numbers
Includes new funding for development and testing of performance measures
Enables new programs and requirements for data sharing
Establishes new federal advisory groups.
(Click the download button for a high-resolution view)
Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse...PYA, P.C.
PYA Senior Manager Chris Beckham co-presented “Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse Scrutiny” with Ross Burris of Polsinelli at the American Health Lawyer Association’s (AHLA) Physicians and Hospitals Law Institute, February 8-10, 2016.
4. walsteijn.edifecs enabling value based healthcare 2015 04 09 v3Matthijs van Hagen
1) The document discusses the shift in healthcare from fee-for-service to fee-for-value and value-based care. It outlines challenges around information exchange, process automation, and community collaboration that are key to scaling partnerships under value-based models.
2) Edifecs is introduced as a partnership platform that can address these challenges through integrated data, automated workflows, and shared intelligence across organizations.
3) The platform is depicted as enabling various components of value-based care including population health monitoring, intervention programs, and payment calculations.
The Vicissitudes of Valuing Value--Legal and Valuation Issues Associated with...PYA, P.C.
PYA Principal Carol Carden co-presented “The Vicissitudes of Valuing Value--Legal and Valuation Issues Associated with Value-Based Payment Models” at the 2017 American Health Lawyers Association Physician and Hospitals Law Institute, February 1-3, 2017, in Orlando, Florida.
The presentation addressed:
Emerging alternative payment models (APMs)
The application of fraud and abuse laws and IRS rules to provider network payments
Existing market data and regulatory guidance
Considerations in determining fair market value and commercial reasonableness
The document discusses the goals and requirements for Accountable Care Organizations (ACOs) under the Medicare Shared Savings Program. It outlines that ACOs aim to improve patient care, health outcomes, and lower costs. It also describes the organizational structure, participants, governance, and focus on managing patient care across settings that ACOs require. Finally, it discusses challenges such as accepting risk and care coordination, as well as factors for success like clinical integration and use of health IT.
This case study describes how a national multi-site healthcare provider was able to increase EBITDA by $3.38 million, free cash flow by $8 million, and exit value by $31.3 million through active management and minor tweaks to their benefits strategy over 5 years. This included aggregating multiple plans into a single plan, implementing new data and analytics tools, and ongoing minor changes to incentivize smart member decisions and remove unnecessary costs and waste while maintaining low employee premium increases and decreasing payroll contributions.
The document provides an overview of accountable care organizations (ACOs) including:
1) ACOs aim to tie provider reimbursements to quality and reduce total cost of care for assigned patients.
2) Key stakeholders include providers, payers (primarily Medicare), and patients (primarily Medicare beneficiaries).
3) The concept of ACOs originated in 2006 but builds on prior models. Successful implementation remains challenging.
4) The Patient Protection and Affordable Care Act supports the development of ACOs and other innovative models.
Medicaid: An Edge of Your Seat View of Medicaid Risk Adjustment by Bonnie BurkeAltegra Health
This document provides an overview of WellPoint's Medicaid business and the challenges of risk adjustment across different states. WellPoint serves over 4 million Medicaid members across 19 states, with 14 states using different risk adjustment methodologies. State Medicaid programs face significant budget pressures that are increasing the focus on risk adjustment to help fund medical costs. Risk adjustment in Medicaid is a zero-sum game where health plans compete through accurate reporting to obtain higher risk scores and payments relative to their membership risks.
HMOs and PPOs in USA (Healthcare Management Functions)Abdu Naf'an
The document provides an overview of HMOs and PPOs in the US healthcare system. It defines HMOs as organizations that combine health insurance and healthcare delivery, requiring members to use providers in the HMO network. PPOs allow members to use out-of-network providers but with higher costs. The document then discusses key differences between the two models such as network size, cost structures, claims processes and more. It analyzes trends in HMOs and PPOs and concludes there is no single better option, as preferences depend on individual health needs and priorities around affordability versus flexibility of choice.
Accountable Care Organizations: Overview and the Role of Information TechnologyDave Shiple
This document provides an overview of Accountable Care Organizations (ACOs) and the role of information technology in ACOs. It describes the key features and goals of the Medicare Shared Savings Program for ACOs, including quality reporting requirements and the role of health information technology (HIT) in enabling care coordination, population health management, and sharing of cost savings. The document also presents potential delivery models, governance structures, and an IT reference model for ACOs.
The Need to Embrace Profit Cycle Management in Healthcare - WhitepaperGE Healthcare - IT
Executive Overview
Healthcare organizations have been operating under a fee-for-service
model for many years. As such, financial leaders have become well
versed in implementing revenue cycle management systems and
processes that primarily focus on the money that comes into an
organization. Today, a new need is emerging. Healthcare reform
and other system changes are moving the industry toward hybrid
payment models such as bundled payments, shared savings, and
capitation. To thrive in this new environment, financial leaders need
to move toward profit cycle management – an emerging model
that matches the revenues from new payment models with an
improved understanding of the true costs to deliver patient care.
The result: Positive financial performance – even in the face of
declining payments – that can be reinvested in the mission to
provide better care.
The foundation of any business or household is profit, defined as
revenue net of expenses (and applicable as such even to not-for-profit
organizations). Regardless of whether you are start-up, a Fortune 500
company, or a family of four, you need to ensure that you are bringing
in more money than you are spending. In many businesses, the
formula to determine your “profitability” is fairly straightforward.
In healthcare, however, the situation is significantly more complex,
as existing and new payment models make it difficult to determine
exactly how much revenue is going to come in the door. On the cost
side, the move to accountable care and value-based payment has
shifted the management of risk and cost onto the providers and
delivery networks, yet most providers lack the tools that would
provide a detailed understanding of the costs required to deliver
quality care, especially when that care is delivered in multiple
locations. A new model of software tools is required – representing
the next generation of revenue cycle management tools and an
emerging class of healthcare cost accounting tools. The end goal?
A solution for profit cycle management that will help organizations
generate a positive financial performance and can be reinvested
in the mission to provide better care.
This change will not happen overnight. Rather, it will be an evolution
over the next five years, as integrated delivery networks update
their revenue cycle solutions to accommodate the new payment
models, and as they deploy new activity-based costing solutions.
Medicare Access and Chip Reauthorization Act (MACRA) is the law that changes how Providers are to be reimbursed. One of the key characteristics is that it rewards Providers based on value and not volume.
The Evolution of Predictive Analytics in Maaged CareAltegra Health
This document discusses predictive analytics in managed care. It begins with an overview of predictive analytics terms and concepts. It then describes the company's approach, which uses a multi-disciplinary team and multiple data sources to develop predictive models. Examples of models discussed include those predicting dual eligibility, likelihood of recertification, and risk scores. Accuracy results are provided for some models showing high prediction rates.
Making the shift to value-based care is not easy. However, a growing number of healthcare organizations are finding success leveraging Lean process improvement and health IT to reduce waste, lower costs, and improve quality.
In fact, leading health systems like Bon Secours, Prevea Health, and North Mississippi Medical Center are using these principles to improve care management processes and achieve better patient outcomes.
We have assembled these strategies into a new whitepaper. You will learn:
- How key concepts of Lean thinking can be applied to healthcare
- Why high-performing practices are using Lean to enable care team members to provide better care
- The financial advantages of a team-based, population health management approach in a value-based reimbursement system
Testing for design validation & structural health monitoring for offshore str...Pieter Jan Jordaens
The OWI-lab offers monitoring hardware and analysis
services for offshore testing and structural health
monitoring.
OWI-lab’s data-acquisition systems and dedicated sensors
allow identifying those parameters that are crucial:
• to minimize construction and installation costs
• to extend the lifetime of offshore structures
• to reduce operation and maintenance costs
Structural health monitoring uses sensors and data collection techniques to monitor structures for damage or changes over time. This improves safety, reliability and reduces costs. The document discusses using P3HT, a conductive polymer, for sensors as it displays electro-chemical sensing abilities. SHM involves identifying critical damage types, data acquisition from sensors, signal processing, and statistical modeling to correlate responses to damage types.
Healthcare Consumerism and Cost: Dispelling the Myth of Price TransparencyHealth Catalyst
This document discusses healthcare consumerism and the myth of price transparency. It notes that while consumers want simple, clear, and actionable price information, finding such information is challenging. Regulations now require hospitals to provide pricing information, but hospitals often struggle to understand their own costs. The document outlines factors that have historically impacted hospitals and discusses how advanced cost accounting can help hospitals better understand their true costs and align prices with costs to improve transparency. It concludes by asking attendees if they would like to enter a drawing or learn more about Health Catalyst's products and services.
PYA Principal Carol Carden and Senior Manager Angie Caldwell presented “Hot Topics in Physician Compensation” at the Kentucky Society of CPAs (KY CPA) Health Care Conference, May 18, 2016. The presentation explored the latest developments in physician compensation structure, as well as considerations related to stacking compensation elements, the role and impact of quality incentives, the latest in affiliation models, and population health initiatives.
The many ways in which healthcare reform affects the healthcare industry are still playing out. Undoubtedly, a question for physicians and the hospitals that employ many of them is “how will physician compensation be affected?”
PYA Principal Carol Carden recently spoke at the 2013 AICPA Healthcare Industry Conference, where she addressed this question with her presentation, “Current Reform Initiatives and Their Impact on Physician Compensation.”
PYA Speaks the New Language of HealthcarePYA, P.C.
PYA Principal David McMillan addressed the 2013 Florida Institute of Certified Public Accountants Health Care Industry Conference and offered a consultant-turned-linguist perspective on “Learning the New Language of Healthcare.”
Mastering MACRA: A Beginner’s Guide to New Reimbursement ModelsCureMD
MACRA is 2 years of work, signed into law in April 2015
Extends the Children’s Health Insurance Program (CHIP) for two more years
Requires Medicare to move away from SSN based Medicare ID numbers
Includes new funding for development and testing of performance measures
Enables new programs and requirements for data sharing
Establishes new federal advisory groups.
(Click the download button for a high-resolution view)
Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse...PYA, P.C.
PYA Senior Manager Chris Beckham co-presented “Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse Scrutiny” with Ross Burris of Polsinelli at the American Health Lawyer Association’s (AHLA) Physicians and Hospitals Law Institute, February 8-10, 2016.
4. walsteijn.edifecs enabling value based healthcare 2015 04 09 v3Matthijs van Hagen
1) The document discusses the shift in healthcare from fee-for-service to fee-for-value and value-based care. It outlines challenges around information exchange, process automation, and community collaboration that are key to scaling partnerships under value-based models.
2) Edifecs is introduced as a partnership platform that can address these challenges through integrated data, automated workflows, and shared intelligence across organizations.
3) The platform is depicted as enabling various components of value-based care including population health monitoring, intervention programs, and payment calculations.
The Vicissitudes of Valuing Value--Legal and Valuation Issues Associated with...PYA, P.C.
PYA Principal Carol Carden co-presented “The Vicissitudes of Valuing Value--Legal and Valuation Issues Associated with Value-Based Payment Models” at the 2017 American Health Lawyers Association Physician and Hospitals Law Institute, February 1-3, 2017, in Orlando, Florida.
The presentation addressed:
Emerging alternative payment models (APMs)
The application of fraud and abuse laws and IRS rules to provider network payments
Existing market data and regulatory guidance
Considerations in determining fair market value and commercial reasonableness
The document discusses the goals and requirements for Accountable Care Organizations (ACOs) under the Medicare Shared Savings Program. It outlines that ACOs aim to improve patient care, health outcomes, and lower costs. It also describes the organizational structure, participants, governance, and focus on managing patient care across settings that ACOs require. Finally, it discusses challenges such as accepting risk and care coordination, as well as factors for success like clinical integration and use of health IT.
This case study describes how a national multi-site healthcare provider was able to increase EBITDA by $3.38 million, free cash flow by $8 million, and exit value by $31.3 million through active management and minor tweaks to their benefits strategy over 5 years. This included aggregating multiple plans into a single plan, implementing new data and analytics tools, and ongoing minor changes to incentivize smart member decisions and remove unnecessary costs and waste while maintaining low employee premium increases and decreasing payroll contributions.
The document provides an overview of accountable care organizations (ACOs) including:
1) ACOs aim to tie provider reimbursements to quality and reduce total cost of care for assigned patients.
2) Key stakeholders include providers, payers (primarily Medicare), and patients (primarily Medicare beneficiaries).
3) The concept of ACOs originated in 2006 but builds on prior models. Successful implementation remains challenging.
4) The Patient Protection and Affordable Care Act supports the development of ACOs and other innovative models.
Medicaid: An Edge of Your Seat View of Medicaid Risk Adjustment by Bonnie BurkeAltegra Health
This document provides an overview of WellPoint's Medicaid business and the challenges of risk adjustment across different states. WellPoint serves over 4 million Medicaid members across 19 states, with 14 states using different risk adjustment methodologies. State Medicaid programs face significant budget pressures that are increasing the focus on risk adjustment to help fund medical costs. Risk adjustment in Medicaid is a zero-sum game where health plans compete through accurate reporting to obtain higher risk scores and payments relative to their membership risks.
HMOs and PPOs in USA (Healthcare Management Functions)Abdu Naf'an
The document provides an overview of HMOs and PPOs in the US healthcare system. It defines HMOs as organizations that combine health insurance and healthcare delivery, requiring members to use providers in the HMO network. PPOs allow members to use out-of-network providers but with higher costs. The document then discusses key differences between the two models such as network size, cost structures, claims processes and more. It analyzes trends in HMOs and PPOs and concludes there is no single better option, as preferences depend on individual health needs and priorities around affordability versus flexibility of choice.
Accountable Care Organizations: Overview and the Role of Information TechnologyDave Shiple
This document provides an overview of Accountable Care Organizations (ACOs) and the role of information technology in ACOs. It describes the key features and goals of the Medicare Shared Savings Program for ACOs, including quality reporting requirements and the role of health information technology (HIT) in enabling care coordination, population health management, and sharing of cost savings. The document also presents potential delivery models, governance structures, and an IT reference model for ACOs.
The Need to Embrace Profit Cycle Management in Healthcare - WhitepaperGE Healthcare - IT
Executive Overview
Healthcare organizations have been operating under a fee-for-service
model for many years. As such, financial leaders have become well
versed in implementing revenue cycle management systems and
processes that primarily focus on the money that comes into an
organization. Today, a new need is emerging. Healthcare reform
and other system changes are moving the industry toward hybrid
payment models such as bundled payments, shared savings, and
capitation. To thrive in this new environment, financial leaders need
to move toward profit cycle management – an emerging model
that matches the revenues from new payment models with an
improved understanding of the true costs to deliver patient care.
The result: Positive financial performance – even in the face of
declining payments – that can be reinvested in the mission to
provide better care.
The foundation of any business or household is profit, defined as
revenue net of expenses (and applicable as such even to not-for-profit
organizations). Regardless of whether you are start-up, a Fortune 500
company, or a family of four, you need to ensure that you are bringing
in more money than you are spending. In many businesses, the
formula to determine your “profitability” is fairly straightforward.
In healthcare, however, the situation is significantly more complex,
as existing and new payment models make it difficult to determine
exactly how much revenue is going to come in the door. On the cost
side, the move to accountable care and value-based payment has
shifted the management of risk and cost onto the providers and
delivery networks, yet most providers lack the tools that would
provide a detailed understanding of the costs required to deliver
quality care, especially when that care is delivered in multiple
locations. A new model of software tools is required – representing
the next generation of revenue cycle management tools and an
emerging class of healthcare cost accounting tools. The end goal?
A solution for profit cycle management that will help organizations
generate a positive financial performance and can be reinvested
in the mission to provide better care.
This change will not happen overnight. Rather, it will be an evolution
over the next five years, as integrated delivery networks update
their revenue cycle solutions to accommodate the new payment
models, and as they deploy new activity-based costing solutions.
Medicare Access and Chip Reauthorization Act (MACRA) is the law that changes how Providers are to be reimbursed. One of the key characteristics is that it rewards Providers based on value and not volume.
The Evolution of Predictive Analytics in Maaged CareAltegra Health
This document discusses predictive analytics in managed care. It begins with an overview of predictive analytics terms and concepts. It then describes the company's approach, which uses a multi-disciplinary team and multiple data sources to develop predictive models. Examples of models discussed include those predicting dual eligibility, likelihood of recertification, and risk scores. Accuracy results are provided for some models showing high prediction rates.
Making the shift to value-based care is not easy. However, a growing number of healthcare organizations are finding success leveraging Lean process improvement and health IT to reduce waste, lower costs, and improve quality.
In fact, leading health systems like Bon Secours, Prevea Health, and North Mississippi Medical Center are using these principles to improve care management processes and achieve better patient outcomes.
We have assembled these strategies into a new whitepaper. You will learn:
- How key concepts of Lean thinking can be applied to healthcare
- Why high-performing practices are using Lean to enable care team members to provide better care
- The financial advantages of a team-based, population health management approach in a value-based reimbursement system
Testing for design validation & structural health monitoring for offshore str...Pieter Jan Jordaens
The OWI-lab offers monitoring hardware and analysis
services for offshore testing and structural health
monitoring.
OWI-lab’s data-acquisition systems and dedicated sensors
allow identifying those parameters that are crucial:
• to minimize construction and installation costs
• to extend the lifetime of offshore structures
• to reduce operation and maintenance costs
Structural health monitoring uses sensors and data collection techniques to monitor structures for damage or changes over time. This improves safety, reliability and reduces costs. The document discusses using P3HT, a conductive polymer, for sensors as it displays electro-chemical sensing abilities. SHM involves identifying critical damage types, data acquisition from sensors, signal processing, and statistical modeling to correlate responses to damage types.
Structural health monitoring (SHM) involves implementing a strategy to detect and characterize damage in engineering structures. It uses sensors to measure responses and detect changes that could indicate damage. The data is processed to extract features and develop statistical models to distinguish between damaged and undamaged structures. SHM is important as it improves safety, allows for timely maintenance, and helps develop better future designs by providing real-world performance data. While sensors cannot directly measure damage, SHM uses the sensor data to provide damage information through feature extraction and analysis.
The document summarizes Merit Enckell's thesis presentation on lessons learned from structural health monitoring of bridges using advanced sensor technology. Some key points:
- The thesis evaluated structural health monitoring systems using fiber optic sensors that were installed on several bridges, including the Götaälv Bridge and New Årsta Railway Bridge.
- Monitoring of the New Årsta Railway Bridge revealed cracking in the deck and allowed study of long-term effects like shrinkage and creep.
- Fiber optic sensors were found to be well-suited for casting in concrete to monitor local behavior.
- Lessons from the projects informed recommendations for sensor installation, data collection, and interpretation to improve future structural health monitoring system
Non Invasive Health Monitoring with mHealthBart Collet
mHealth Trends and examples of non invasive mobile health devices, organisations and services.
Made as preparation for MoMoAMS #14 about mHealth, Jan 25th 2010, Amsterdam
Smart Sensors for Infrastructure and Structural Health MonitoringJeffrey Funk
These slides use concepts from my (Jeff Funk) course entitled analyzing hi-tech opportunities to show how smart sensors are becoming more economically feasible and more widely used in infrastructure. This is enabling greater monitoring and self-healing of structures. Twenty years ago, it was improvements in MEMS, piezo-electric ceramics, and ultrasonic sensors that was enabling structural health monitoring. More recently, it has been improvements in fiber optic sensors, wireless sensors and RFID tags that are enabling this monitoring. Today, it is the falling cost of these components and their combination with more recently available ones such as ionomers (a type of polymer), carbon nano-tubes, and energy harvesters. Improvements in these sensors have enabled the absolute cost of sensors and their percentage of costs in for example bridges to fall over the last 20 years to fall. These trends are expected to continue and become applicable to a broader number of structures including buildings and vehicles.
An Accountable Care Organization (ACO) is a provider-led organization that manages the full continuum of care for a defined patient population to improve quality and reduce costs. The US healthcare system lacks coordination and incentives for value over volume, motivating ACO development. ACOs differ from 1990s integrated delivery systems by focusing on managing performance risk rather than insurance risk through tools like bundled payments, quality tracking, and health IT. Critical functions include attributing patients, budgeting, performance measurement, and managing payment models to distribute shared savings incentives.
DeMarco and Associates and Pendulum HealthCare Corporation provide services to help organizations develop accountable care organizations (ACOs). They assist with infrastructure development, care coordination, and data analytics. Pendulum also designs, develops, and manages ACOs. An ACO aims to deliver coordinated, efficient care to a defined patient population through provider collaboration and accountability for costs and quality outcomes. Requirements include agreements between primary care physicians, specialists, and hospitals to be responsible for a minimum number of Medicare beneficiaries.
Presentation delivered by Bryan Starnes, Chief Financial Officer, Affinity Living Group at the marcus evanc Long-Term Care & Senior Living Central CXO Summit, October 2016, in Chicago.
The Foundations of Success in Population Health ManagementHealth Catalyst
From hospital systems to large employers, organizations are increasingly taking on financial risk for the health of populations. Drivers of this trend include the update to the MSSP model, the recent CMS Primary Cares Initiative announcement, the increasing prevalence of the Medicare Advantage model, innovative partnerships in the self-insured employer space, and the proliferation of Medicaid ACOs. Yet while market pressures push organizations toward population risk, they don't necessarily help them succeed: most organizations are struggling to attain or sustain the dual imperatives of high-quality care and cost containment. A primary reason? Short-sighted and tactical approaches that don't provide the flexible data infrastructure and tools to adapt to emerging trends in population health—or to support short-term contractual requirements while building toward long-term success.
View this launch webinar to learn about Health Catalyst’s Population Health Foundations solution, a data and analytics-first starter set aimed at optimizing performance in value-based risk arrangements and providing the data ecosystem that will flex and adapt to complex needs of risk-bearing organizations. Solution services ensure that the strategic value of data is maximized to improve performance in risk contracts—and provide side-by-side subject matter expert partnership for establishing short- and long-term goals for population health management (PHM).
Built on Health Catalyst’s foundational technology and supported by the nationwide experience and perspective of its experts, the Population Health Foundations solution helps organizations leverage multiple data sources to understand their patient populations and create meaningful views of financial and clinical quality performance. As a starter set that organizations can build on based on their needs, the solution is designed to compensate for the known limitations of “black box” population health applications that fail to reveal the “why” of analytic insights and exacerbate the challenges of transforming quality, cost, and care. The Population Health Foundations solution delivers the essential analytic tools needed for success under value-based risk arrangements.
In these slides you can expect to:
- Review recent changes to the field of value-based care, and reactions and insights from the market
- Discover how the Population Health Foundations solution can act as a comprehensive, data-first analytics solution to support your population stratification and monitoring needs
- Understand how this solution functions as a foundational starter set for value-based care success, enabling clients to leverage all their data and other relevant population health tools
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Despite general frustration related to legislative involvement, history has proven that regulatory changes precede attitudinal changes and the MSSP (combined with accurate, timely data) may be just the piece of legislation to help make value-based care a reality. By viewing this webinar you will learn:
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- Why financial imperatives drive cultural change in our economic model.
- Ways that the MSSP can help your organization achieve financial success.
- Ideas for how to utilize data to develop better healthcare delivery systems.
Dr. Will Caldwell is a strong proponent of the use of data analytics to promote good health and save lives. His area of expertise rests in technology-enabled health care delivery models and value-based care platforms. We hope that you will view this webinar and learn from his 17-years of work as a data-informed clinician.
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ACSG DIRECT TO EMPLOYER WHITE PAPER MARCH 15
1. A Proven Commercial Population Health Management System for Medical Providers
Direct-to-Employer
Gain Sharing Model
2. There has never been a better time in this nation’s history for Medical Providers to take control of the healthcare system
than now. Healthcare Reform has produced a number of challenges to the way that Medical Providers get paid and the
number one question is how you adapt while still remaining profitable. One of the key opportunities available today is to
maximize reimbursements with self-funded employers in your community without any down side risk. These systems are
available as a proprietary strategy of your organization, not just another financial reimbursement contract with Medicare,
Medicaid, or a commercial insurance carrier.
Goals and objectives must lead toward the management of positive outcomes and value while diminishing healthcare
expenses. Sustainability is contingent on managing the risks of population segments that are predicted to increase
healthcare expenditures if left unattended. These items must be accomplished while embracing a patient centric
approach.
Medical providers can now have access to a proven population management
system that has been in place for over 12 years with extraordinary results
applied to over 1 million members under management. ACSG/Key Family
has established a comprehensive system of patented and proven processes
that can track quality and cost of care with proven and targeted interventions.
Through the American Health Data Institute’s (AHDI) population management
process hundreds of health plans have seen their healthcare trend reduced
year over year and in many instances total aggregate costs have been reduced
substantially.
EMPLOYERS ARE CHALLENGED
With the advent of ACA there are increased uncertainties and escalating costs for employers that offer a group health
plan. Key market forces indicate that:
• Employers are looking to establish direct
relationships with medical providers to improve
quality and reduce costs
• Rate increases in group health plans are higher
than they have been in 5 years
• Employers are becoming more frustrated with the
lack of information when rate increases are being
presented
• Refugees from the fully-insured marketplace are
looking at self-funding alternatives
• Employees are becoming increasingly less
satisfied with their benefit plans
• 57% of health plans are self-funded today, an
increase of nearly 30% in the past ten years
• There is very little risk management in the
marketplace to manage and understand the key
elements affecting healthcare plans
A Proven Commercial Population Health Management System for Medical Providers
We know that given
the right tools Medical
Providers can have
the greatest impact on
controlling costs and
increasing quality, even
more than any insurance
company or HMO.
Direct-to-Employer Gain Sharing Model
3. A PROVEN POPULATION HEALTH MODEL
Accountable Care Solutions Group (ACSG/Key Family) has developed a “turn-key” and customizable infrastructure
that medical providers can deploy within their communities to access self-funded employer purchasers on a direct basis
with a value proposition of quality and cost savings that no other system can attest. With more than 30 years of health
plan management experience and over 3,300 corporate clients covering over 1 million members, ACSG/Key Family has
developed a system that medical providers can “private label” to attract employers into their medical provider delivery
system. The infrastructure supports all of the components for managing and administering self-funded plans with
preferential stop loss and pricing advantages.
A PROVEN ANALYTICAL FRAMEWORK
The American Health Data Institute (AHDI) utilizes sophisticated data warehousing techniques and analytical tools. The
data in the AHDI warehouse includes over three million lives, all but two states are represented related to geographic and
regional data and there are over 20 terabytes of computer storage, capacity and memory. To provide a perspective on the
volume of data, a warehouse, which can store eighteen terabytes, could hold the entire printed collection of the Library
of Congress. The back end database engine is a Microsoft SQL Server 2000/2008. The data in the AHDI warehouse
is transformed into powerful, actionable intelligence utilizing very sophisticated software to analyze the variance, cost
drivers, cost trends and other significant clinical and financial factors influencing healthcare costs. Using the AHDI
intelligent data to manage chronic diseases will drive the favorable variances necessary to optimize a gain
sharing distribution.
Identify
the sickest
of the sick
Set up a
regimen of
care for the
chronically ill
Monitor
compliance with
sophisticated
data analytics
FFS
reimbursement
and gain share
Coach patients
into quality
narrow network
providers
Increase service
and completion
rates for the
chronically ill
4. PROVEN RESULTS
Thousands of employer groups are realizing improved plan performance and lower healthcare expense as the result
of our patented and proven care systems for population health management. Medical Provider groups that desire to
sponsor a program to get direct access to the self-funded marketplace can access this proven system, and by actively
participating, can “turbo-charge” the results we are already achieving.
ACSG/KEY FAMILY SMALL MID-SIZE GROUP
HEALTHCARE COSTS (10-150 EES)
CostsPerEmployeePerYearEmployee HRA and
Biometric Data
Physician Group, Narrow
Network
and Non-Network Claims
Data
Membership and Eligibility
Data
ETGs and ERG
Episode Treatment and
Episode Risk Groups
Gaps in Care
Regimens of Care/
Care Standards for the
Chronically Ill
Reporting
EZViewTM
and Health
Risk Management (HRM)
Reports
$9,000
$8,500
$8,000
$7,500
$7,000
$6,500
$6,000
$5,500
Small to Mid-Size Fully Insured Employer Groups
Source: United Benefit Advisor Survey 2008, 2009, 2010, 2011
Healthcare Trend at 8% per year
Key Healthy PartnersTM
$7,236
$6,224
$7,536
$5,785
$6,722
$8,110
$5,908
$7,260
$8,688
$6,228
$7,841
2008 2009 2010 2011
5. LEVERAGING RESULTS TO MAXIMIZE GAIN SHARING
The gain sharing system encompasses the following key elements:
1. BENEFIT BUDGET
• Employers and healthcare providers determine health benefit budgets
• Healthcare providers arrange for discounted healthcare services
• Employers and healthcare providers share in the savings to the healthcare budget through financial
performance rewards
2. ENGINEERING AND COORDINATION OF CARE
• Medical director engineers the coordination of patient care pathways through top performing medical
providers
3. BEST OF BREED PHYSICIANS AND HOSPITALS RECRUITED
• Best of breed medical providers are identified by the medical director and are heavily incentivized by the gain
sharing due to favorable variances to the employers’ healthcare budget
• High quality, cost effective medical providers
4. DEVELOP A CULTURE OF WELLNESS
• Member Health Incentive Programs
• Member Healthcare Coaching—Ongoing healthcare education
PROVIDER GAIN
SHARE DISTRIBUTION
YEAR MEMBERS
HEALTH
BUDGET ACTUAL
FAVORABLE
VARIANCE
MEDICAL PROVIDERS
(50% OF FAVORABLE VARIANCE)
1 1278 $7,326,774 $5,822,568 $1,504,206 $752,103
2 1354 $8,476,040 $6,524,926 $1,951,114 $975,557
3 1368 $9,337,640 $6,792,120 $2,585,520 $1,292,760
Based upon actual claims results
TotalMedicalCosts
COMPANY 1
TEXTILE MANUFACTURER
Healthcare Index 1.22
$6M
$5M
$4M
$3M
$2M
$1M
2004 2005 2006 2007 2008 2009
32% SAVINGS
COMPANY 2
TRUCKING COMPANY
Healthcare Index 1.21
$6M
$5M
$4M
$3M
$2M
$1M
2004 2005 2006 2007 2008 2009
17% SAVINGS
COMPANY 3
CITY GOVERNMENT
Healthcare Index 1.25
$8M
$7M
$6M
$5M
$4M
$3M
$2M
$1M
2007 2008 2009
12% SAVINGS
Trend Company
6. WHAT IS THE VALUE PROPOSITION
FOR MEDICAL PROVIDERS?
• Diversify payer mix by disintermediation of third party payers in order to drive additional margin
• No need to establish your own insurance company
• National and regional PPO network wrap
• Actuarial pricing of medical provider network reimbursement contracts
• No insurance risk to assume
• Four to six months start-up
• Minimal cost requirements, e.g., infrastructure already in place
• Proven sales and marketing distribution process
• Proven population management system
• Optimal revenues through gain sharing, reducing outmigration, increasing top line revenues, and addition of
new administrative revenues
• Complete transparency
WHO IS A GOOD CANDIDATE FOR THIS PROGRAM?
• A provider organization structured as a loosely affiliated network, IPA, PHO, or a clinically integrated group
(e.g., clinical integration is not required).
• Geographic markets with a service area comprising 100,000 or more individuals
• Market segment that can generate 2,500 members or more over an 18 month period
%ofCost
% of Service
140%
120%
100%
80%
60%
40%
20%
0%
S/P Medicare Medicaid Commercial
8% 40% 20% 32%
REIMBURSEMENT
RATE GAIN SHARING
CONTRIBUTE TO MARGIN
HOSPITAL PAYER MIX DISTRIBUTION
Direct-to-Employer Mix
Direct-to-Employer
Under 100% Cost
Special Payments
Provider Tax
% Cost
7. ACSG/KEY FAMILY - POINTS OF DIFFERENTIATION:
STOP LOSS REINSURANCE
• Managing General Underwriter (MGU)—Highly rated stop-loss partners with “favored-nation” relationships
and pricing
NETWORK DEVELOPMENT AND PPO WRAP NETWORKS
• 20 + years’ experience
• Access to over 70 wrap PPO networks
• Network agnostic—we do not own or manage provider networks - we are a vested partner with the medical
provider community
TPA ADMINISTRATIVE SERVICES
• National administrator for multiple insurance product carriers, including:
◦◦ Consumers Mutual Insurance Company of Michigan (CMI-CMS CO-OP), Assurant (Fortis, John Alden
Time Life), Companion Life, Fidelity Security Life, HM Insurance Group, ING and TransAmerica
• Administrative Systems—Claims, Customer Service, Fulfillment, Compliance, Data Reporting
• Core Competency in complex health care administration
• Over 30 years of self-funded and insured medical plan management experience
• Integrated Healthcare Risk Management (HRM) solutions
• A proven track record of reducing claims costs
• Exceed all industry benchmarks for financial, procedural and processing accuracy
• Administrator and population health data warehouse for several fortune 1000 companies
POPULATION HEALTH MANAGEMENT
• Patented Population Health Management process in place for over 12 years
• Data Warehouse containing 20 terabytes of claims, biometric, Rx, health risk assessment and encounter data
• Real-time access to data analytics:
◦◦ Population risk stratification and predictive analysis
◦◦ Gaps in care analysis
◦◦ Clinically based physician profiling
• Integrated Chronic Disease Nurse Coaching
• Over 40 payers extract data to our warehouse, including insurance carriers and
Third Party Administrators (TPA)
8. MARKETING AND SALES
• Private-label programs with branding opportunities
• Access to major national and regional agency relationships
• Proven sales and marketing distribution system
GAIN SHARING MODELS
• Methods for calculating employer favorable variance
• Calculations for defining distribution model based upon key metrics
• Practice improvement data
• Completely transparent
ACSG/KEY FAMILY PROVIDES THE FOLLOWING
SERVICES IN DEPLOYMENT OF THE PROGRAM
• Facilitate Gain Sharing Arrangement
• Planning, Negotiation
• Network Development and Wrap Networks
• Administrative Systems—Claims, Customer Service, Fulfillment, Compliance, Data Reporting
• Employer Group Education
• Integration of Claims Data and Certain Medical Records
◦◦ Population Health Management, Wellness Programs, Nurse Coaching
• Educate and Communicate with Medical Providers
• Administration of Plan Designs
• Sales, Marketing/Branding, and Distribution
• Financial Distribution of Gain Share Disbursements Reporting
FOR MORE INFORMATION ON NEXT STEPS, PLEASE CONTACT:
Bret Petrick, CLU, ChFC, CSFS
Distribution Partner
408.358.0084 | bretACSG@outlook.com
Jack Hill
Partner
630.878.7539 | jack.hill@accountablecaresg.com
www.accountablecaresg.com