GE Healthcare Camden Group Insights Blog

A View into a World without the Affordable Care Act

Posted by Matthew Smith on Nov 11, 2016 7:45:10 AM

By James Smith, MBA, FACHE, Executive Vice President, and David DiLoreto, M.D., MBA, Senior Vice President, GE Healthcare Camden Group

Healthcare changes are on the way….AGAIN. Just as providers, health plans, and consumers thought they had begun to understand the “new” rules and had developed and activated the strategies required for success in an outcomes-based world; we find ourselves facing changes once again. With a new presidency launching in January, it appears certain that The Affordable Care Act (“ACA”) (also known as “Obamacare”) will be modified, repealed, and/or replaced.

With myriad questions floating around the television networks and on social media, it’s important to not get too far out over our skis before decisions are made. But we can address some of the larger questions Americans are asking. First, let’s assume the ACA is completely repealed--and ask and propose answers to 10 of the burning questions that are top of mind.

1. What are the big changes? 

A new administration may want the mandates, taxes, and regulations to go away, and individuals to be able to go to insurers and shop based on highly transparent information about providers, physicians, networks, and health plans on quality of care, service levels, and cost. Transparency, costs, and access will become the focus both for individual and group insurance premiums and healthcare provider charges. Balancing the budget will take precedence over access to insurance and healthcare services.

2. What goes away? 

The health insurance industry and providers would be released (immediately or within a short, prescribed time period) from numerous regulations, taxes, and rules connected with the ACA. The healthcare exchanges would be dismantled, or be continued as a non-subsidized option for States to administer at their discretion. Loss of minimum medical loss ratios (“MLR”) and rate oversight could lead to even larger premium increases as insurers would seek to return to profitability from the losses in their exchange business and stranded development costs.

3. What would be the most striking game changer of the economic impacts? 

According to a report with estimates from Kaiser Health Foundation, 20 million-plus people could lose their federal subsidies and tax credits that allowed them to purchase insurance, or lose eligibility as the rules change from ACA’s expansion of Medicaid eligibility. States would instead likely be provided block grants by the federal government, ending the federal-state funding partnership. The loss of the public subsidies for private insurance and reduction in Medicaid eligibility will likely increase bad debt, slow or stop cash flow, which will stretch reserves and change decision options for providers.  

4. What is NOT likely to change?

Payment reform within Medicare designed to reduce costs and promote quality (i.e. the shift from fee-for-service to fee-for-value) is not likely to change significantly. MACRA and other regulatory changes shifting the payment models have been largely bi-partisan supported, so are not likely to be significantly impacted. What would be uncertain is the continuation of initiatives sponsored by CMMI, the CMS Innovation Center, which was funded by the ACA. CMMI has launched bundled payments, and many other pilots such as CPC+ to foster faster movement to value-based care.

5. What does this do to providers? 

It could mean credit downgrades for many since recent capital investments in new service lines were made based upon volumes and service mix far different than what may occur. More high-deductible plans with low or underfunded HSAs and a return to more uninsured could lead to sicker patients, more intensive care, and hospitalizations and service line requirements and capacity needs different than planned for under ACA. The market may see a greater use of narrow networks or high-performing networks by health plans to reduce plan cost. Picture the payer mix (lower Medicaid and higher uninsured) and volumes (generally lower) you may have had in 2013, but with payers (including Medicare) putting dollars at risk for efficiency and quality.

6. Will we see more consolidation of providers and physicians? 

Yes, on both counts. The mere uncertainty of the environment if funding for the uninsured remains in flux could exacerbate a trend toward consolidation. Providers must seek every avenue of cost reductions and access to cash as they make new investment decisions in capital, equipment, buildings, service mix, management talent, and other resources. Just as today, efficiency will be the priority, but even more so. Layoffs to reduce staffing costs and strategic focus on services to increase market share and use of resources will be one of the few ways for providers to react.

7. Where would people go? 

As we have seen in the past, emergency departments will be the first site of care for many without insurance. Continued focus of providers on enabling access points to the most clinically appropriate and lowest cost site of care will continue to be a priority so consumers have viable alternatives to manage their healthcare needs with convenience.

8. What will insurers do? 

As insurers lose members, they too will react by attempting to grow market share and cut costs. Consequently, insurers would have to reallocate costs throughout their company—forcing layoffs, consolidations, and ultimately bankruptcy for those who cannot change fast enough. This cascade could accelerate consolidation with greater concentration of both health plans and providers as they respond to a necessity to grow even larger and to do it faster to absorb decreasing membership across a set of fixed costs. Remember too, that insurers will remain heavily regulated as the regulatory controls flow back to the state insurance and health departments. They may be able to return to state rules which allow experience rating and denial of coverage. The possibility of easing the sale of health plan products across state lines, a concept that candidate Trump proposed, could make managing health plan payment models and policies from the provider perspective even more complex than before--but it could provide more competition for health plans with sizable market share in certain states. Health plans may have a greater ability to increase premiums and to do these things with less oversight. Many have invested in new products, and there would no longer be controls over benefits, nor would there be limits on administrative costs and caps on profits which, in turn, could send premiums as well as out-of-pocket expenses even higher.

9. Sometimes campaign rhetoric is tempered by the political and economic realities of governing. Is there a middle ground that might be reached?

Speaker Paul Ryan released the GOP’s healthcare reform plan, “A Better Way,” in June 2016. The plan contains key initiatives that, if implemented, incrementally could increase the role of the private health insurance sector while reducing costs without wholescale withdrawal of coverage. For instance, expanding the use of consumer-directed healthcare options and removing the limits that ACA placed on HSAs, FSAs and HRAs provides more insurance options without eliminating coverage. Eliminating the taxes and fees on self-insured plans, eliminating excise taxes on medical device manufacturers as well repealing the “Cadillac” tax on high-cost plans would be consistent with campaign promises. Increasing support for portability, enabling purchasing across state lines, expanding opportunities for pooling, and advocating for meaningful medical liability reform are all contained within this plan.

10. What about Medicaid expansion? 

The most popular aspect of Obamacare was the expansion of health insurance coverage and, at least politically, it may prove hard to reverse. Over 98 million Americans are now covered by Medicaid at any point in each year. One in four dollars in the average state budget is spent on Medicaid coverage, and the total state and federal support for the program exceeds $545 billion. By 2025 the GAO projects that 108 million Americans will be covered by Medicaid, the federal share exceeding $600 billion and the combined state and federal spending in program approaching $1 trillion. Limited access to physicians and inconsistent quality remain significant obstacles to improving health outcomes for Medicaid beneficiaries. The GOP may look to expand block grants to states while relaxing the federal waiver process. This would create incentives for state governments to search for solutions to the cost and consequences of the recent expansion. Fueled by the shift toward more value-based reimbursement, considerable attention and increased scrutiny and changes in supplemental payments may be opportunities for cost reduction. As the largest payer of long-term services and support, and with continued increasing demand, states will also look to rebalance or reduce costs by shifting to home and community based services.

Changes are most definitely on their way, but as we’ve done in the past, we’ll adapt and adopt these new changes together. 2017 will be a year in which the legislative changes could be made, and in some cases Trump could use an Executive Order to defund certain provisions of the ACA. 2018 will likely be the soonest any substantive changes would be effective, given the fact that open enrollment is already underway and plans are in effect for 2017. We’ll continue to provide timely updates as we learn more in the coming weeks and months.

Jim Smith.jpgMr. Smith is an executive vice president with GE Healthcare Camden Group. He is a nationally recognized strategy and business healthcare consultant, author, and speaker. Mr. Smith has more than 30 years of experience as a leader of provider-owned, for-profit, and not-for-profit health plans, hospital, and health systems, as well as a large physician group. He has extensive experience in managed care and provider network development/operations, health system planning and development, medical group formation and operations, and direct contracting. He may be reached at



DiLoreto.pngDr. DiLoreto, senior vice president at GE Healthcare Camden Group, is a physician-executive who is highly experienced in executive management, strategy and operations of healthcare delivery systems, and managed care companies. He has deep management expertise in community-based and academic health systems, large group medical practices, hospitals, and managed care organizations. His areas of specialty include clinical transformation, population health, business process improvement, leadership development, medical informatics, quality improvement and patient safety, and data management and analytics. He may be reached at

Topics: ACA, Affordable Care Act, Obamacare, David DiLoreto, James Smith

Medicaid Reform: Are You Ready?

Posted by Matthew Smith on Nov 19, 2014 1:11:00 PM
By Gregory Shufelt, Adam Medlin, Patricia A. Hines
The Camden Group

The Camden Group, ACA, Affordable Care Act, Medicaid, Healthcare Reform, In an article for HFMA's HFM Magazine, our colleagues at The Camden Group urge health system leaders to view any steps they take to prepare for their state's Medicaid reform initiatives as integral to their organization's evolution toward value-based care and population health.

Hospitals and health systems should follow a four-step process to evaluate their state’s Medicaid initiatives and to develop new care models to better manage the Medicaid patient populations they serve:

  • Perform an initial assessment
  • Identify opportunities and risks
  • Develop a business plan
  • Implement the plan

More than 72 million Americans receive healthcare coverage from Medicaid, including children, nondisabled adults, pregnant women, individuals with disabilities, and seniors with both Medicare and Medicaid coverage (known as dual eligibles). This number is expected to grow to 93 million by 2024.a New reports are showing that even in states where Medicaid expansion under the Affordable Care Act (ACA) was rejected or put on hold, Medicaid enrollment is still expanding due to the “woodwork effect,” whereby people previously eligible for Medicaid are just now signing up, due in large part to the outreach and educational efforts associated with the ACA. Regardless of their state’s decision to expand Medicaid, healthcare leaders should prepare for potentially drastic changes in how states manage their Medicaid programs.

To read the full version of this article, please click the button, below:

Medicaid Reform, Affordable Care Act, ACA, Population Health

Topics: Medicare, ACA, Affordable Care Act

The Survey Results Are In: "Walmart as a Primary Care Provider"

Posted by Matthew Smith on Aug 29, 2014 1:04:00 PM

Survey, Health Directions, WalmartA big thanks goes out to the 89 respondents to our "Walmart as a Primary Care Provider" survey that we ran this past Monday. While clearly not scientific, it generated some great responses and elicited some meaningful comments on both the HD Insights Blog and within individual LinkedIn groups where it ran.

We will continue to leave the survey open for a few more weeks to gather more information. Here are the results as of 8/29/14. Survey Says...

Question 1: What is your initial reaction to Walmart entering the primary care provider market? (n=87)

34%: Somewhat Positive

22%: Somewhat Negative

18%: Indifferent

15%: Extremely Negative

  8%: Extremely Positive

Walmart Primary Care Survey

Question 2: Which of the following scenarios describes your STRONGEST thought on Walmart's primary care clinics? (n=88)

25%: I don't see any difference between Walmart and other commercial "minute clinics" (i.e CVS, Walgreens, etc.)

21%This may be fine for well visits, but I don't think this is a proper venue for chronic conditions.

20%: I'm in favor as long as this improves access to health care in rural communities

20%: I question the qualilty of care provided by Walmart

8%:  This will negatively impact local primary care providers.

3%:  (Please select this option if you cannot strongly identify with the previous six options.)

1%:  This is of absolutely no concern to me.

Walmart, Primary Care Survey

 Survey Comments

"The real issue will be quality of their care, and the market they will be attractive to. If they have low income folks using the stores, $40 may still be too high. Not sure I want to seek health care in a Walmart."

"I think it is a wonderful idea! It will help to get the patients closer to they're providers!"
"Our market has this service offered at a local grocery store. My worry is not only in regard to quality standards but also infection control. What happens during flu season? What safeguards are in place to protect the healthy patients who see this clinic?"

"I am in favor of increased access to healthcare in whatever form it is. I am however concerned about how to effectively manage populations especially chronic conditions. It seems that without a good foundation for care coordination we just have established an increased route that may reduce urgent care and ED visits but without an increase in care coordination and outcomes. What role will these areas play in population health?"

"It would be greatly beneficial if a variety of affordable diagnostic tests were also available. POS testing devices are available for this purpose. Many devices provide results within minutes."

"Access to initial screening tests and exams at low cost is a big plus; BUT the key would be referral to medical providers equipped to deal with the chronic conditions that the potential patient base is likely to present. - Former NYS Director of Regulatory Affairs (retired)"

Topics: Population Health, ACA, Survey Results, Primary Care, Obamacare, Accountable Care Act, Walmart, Primary Care Provider

Two-Question Survey: Walmart Launches Primary Care Clinics

Posted by Matthew Smith on Aug 25, 2014 12:31:00 PM

Walmart, Primary Care, Primary Care ProviderWalmart has a new take on retail clinics. These newly launched clinics will charge patients $40 for a visit—but only $4 for Walmart associates. Anybody, with or without insurance, can go into one of these clinics and be seen by a qualified health professional, without the usual paperwork. Although the mega-retailer has operated clinics in its stores for a few years now, the new ones are different in a couple of ways.

First, Walmart’s previous clinics were collaborations with local hospitals, which are described as having mixed success. It appears the Walmart is embarking in the primary care market alone at this time. In line with its usual branding, Walmart's touted the low prices available in its clinics: $40 to get a walk-in check-up, and even lower costs (possibly $4) for employees. "For our associates and dependents on the health plan, you can come and see a provider in the Wal-Mart Care Clinic for $4. Four dollars!" Jennifer LaPerre, a company official, said earlier this month. "That is setting a new retail price in the health care industry," she added.

Second, Walmart looks to be rolling out these clinics in states that have not expanded the number of residents dependent on Medicaid (such as South Carolina). Insurance is irrelevant to these clinics, which accept cash payments directly. 

And unlike most primary care providers, they will be open 12 hours a day on weekdays and at least eight hours a day on weekends, Forbes reports. 

What's your take? Please answer the following 2-question survey (make sure to scroll down for Question #2 and submit). Once you submit your answers, you will be directed to a link to see live polling results. If you choose to share comments on the blog, please be respectful and keep the conversation moving forward. Thank you for your feedback. We will publish the results at the end of the week.

Topics: Population Health, ACA, Survey, Primary Care, Obamacare, Accountable Care Act, Walmart, Primary Care Provider

Infographic: State of Emergency--Overcrowding in the ER

Posted by Matthew Smith on Aug 20, 2014 1:51:00 PM

Infographic, Health Directions, HD Insights Blog, When the ACA was enacted, ER visits were expected to decrease. Instead, the inverse is happening. What happens when an ER is faced with more patients than it can accommodate? Between 1995 and 2010, annual ER visits in the U.S. grew by 34%, while the number of hospitals with ERs declined by 11%. From long wait times to sky-high medical costs, overcrowding puts undue pressure on patients, providers and administrators when efficient, high-quality care matters most.

The Miken Institute School of Public Health at George Washington University created this infographic to show the impact of overcrowding on U.S. emergency rooms. The graphic looks at some of the major causes of congested ERs, examines the impact on care delivery and explores proposed solutions to the problem of overcrowding. 

The infographic highlights crucial areas for administrators, communicators, and physicians, nurses, and other ER staff:

  • The increase (national averages) in wait times for ER patients, broken down by urban/rural locations and other factors.

  • Boarding and ambulance diversion statistics.

  • Case urgency percentages.

  • Risks and costs of overcrowding, including uncompensated care figures.


George Washington University, ER, Emergency Room, Infographic


Brought to you by MHA@GW: MHA degree

Topics: Infographic, ACA, Affordable Care Act, Obamacare, ER, Emergency Room

Hospitals Seek To Help Consumers With Obamacare Premiums

Posted by Matthew Smith on Aug 15, 2014 12:02:00 PM
Article courtesy of Kaiser Health News.
Obamacare, Affordable Care Act, Finance

Low-income consumers struggling to pay their premiums may soon be able to get help from their local hospital or United Way. Some hospitals in New York, Florida and Wisconsin are exploring ways to help individuals and families pay their share of the costs of government-subsidized policies purchased though the health law’s marketplaces – at least partly to guarantee the hospitals get paid when the consumers seek care.

But the hospitals’ efforts have set up a conflict with insurers, who worry that premium assistance programs will skew their enrollee pools by expanding the number of sicker people who need more services.

“Entities acting in their [own] financial interest” could drive up costs for everyone and discourage healthier people from buying coverage, insurers wrote recently to the Obama administration.

Insurers are asking the federal government, which regulates the health insurance marketplaces, to restrict the practice.  

To date, regulators have sent mixed messages about whether they will permit such programs—even as providers across the country are moving to set them up.

“We saw the need in our community,” said Sarah Listug, spokeswoman for United Way of Dane County, a Wisconsin group that is using $2 million donated by a local hospital system to help more than 650 near-poverty-level policyholders pay their premiums. “We have had calls from all over the U.S. asking how to set up partnerships like this.”

The South Florida Hospital and Healthcare Association is seeking at least $5 million in donations from its 45 member hospitals toward premiums for first-time insurance buyers next year.

And members of the Healthcare Association of New York State, which represents 500 hospitals and nursing homes, are considering expanding existing consumer assistance programs to help people pay their premiums “to the extent that is legal and proper,” said Jeffrey Gold, senior vice president and special counsel.

Providers Have Financial Incentive

Hospitals or their foundations have long paid premiums for some patients— often those who fell behind after leaving their jobs and taking on the entire cost of coverage under a 1986 law known as COBRA.

But the issue of “third-party payments” has taken on new urgency because of a provision in the federal health law that could leave providers on the hook for unpaid bills.  Under the law, insurers must give subsidy-eligible enrollees who fall behind on payments a 90-day “grace period” before cancelling their policies. 

While insurers must cover bills for the first 30 days, they may hold off paying those bills for the next 60 -- and ultimately, deny payment if the patient doesn't catch up on premiums. That means doctors and hospitals face the prospect of not getting paid for their services, or having to seek payment directly from their patients.

That’s a big incentive for providers to help pay those premiums.

“It’s a situation where patients will be better off and the providers are better off as well if patients are able to maintain coverage,” said Mark Rukavina, a Massachusetts-based expert on medical debt who consults for the hospital industry. “But it does raise questions.”

Insurers argue that if federal regulators permit such programs, they should bar hospitals from selecting participants based on their health, or from directly paying the premiums.

"If third parties provide incentives to gain coverage only once someone is sick, that will -- as the administration has warned -- clearly lead to a less healthy risk pool and put upward pressure on premiums for everyone,” said Brendan Buck, a spokesman for the trade group, America’s Health Insurance Plans (AHIP).

But Gold of the New York hospital group thinks insurers’ concerns are overblown. He says insurers have already calculated into their rates that a certain percentage of policyholders will be sicker than average.

“If a couple of people who show up at hospitals or other providers have a premium lapse, I don’t understand why someone making them whole [by paying their premiums] would skew the risk pool,” he said.

Hospitals Try To Allay Fears

To avoid problems, hospitals are drafting selection criteria tied to income level -- and are paying consumers’ premiums for an entire year, rather than simply when they lapse.

In the Wisconsin program, for example, eligible residents must live in Dane County, earn between 100 percent and 150 percent of the federal poverty level – about $11,490 to $17,235 for an individual— and enroll in a subsidized silver plan.

The program, called HealthConnect, pays the difference between the subsidy and the cost of the plan for the entire year, which could be as little as $20 to $50 a month for individuals, although it runs higher for families. Money for the program comes from the University of Wisconsin-Madison health system.

In South Florida, meanwhile, “we’re not talking about making premium payments for those who enrolled, then fell behind, but only [for] first-time buyers,” said Linda Quick of hospital group, which has not yet finalized its plans.  

The association plans to enlist several local United Way chapters to help find and enroll eligible residents.

Still, Quick acknowledges that getting the program off the ground may be difficult because of the cost to hospitals.

“I have a couple of systems where we’re talking about half a million dollars” in contributions, she said.

And the enrollees who are helped may never need hospital care, in which case those facilities would see no return on their investment.

Regulators Send Mixed Messages

To date, the administration has said insurers must accept payments toward premiums and other costs from government programs such as the Ryan White HIV/AIDS Program, which helps provide medical services and defrays costs for people living with HIV/AIDS.

But it has been less clear about the role hospitals and other health care providers might play.

Last October, a letter from the administration to Rep. Jim McDermott, D-Wash., indicated that hospitals and drugmakers could help subsidized policyholders pay their premiums.

But that was quickly followed by a Nov. 4 online FAQ discouraging such “third party payments” by hospitals and others because they could “skew the risk pool.”

After protests by patient groups, another advisory said insurers could also accept premium payments from not-for-profit foundations which set financial eligibility criteria and do not consider enrollees’ health status.

An interim final rule in March left out any mention of payments by charitable foundations, although it reiterated concern about payments made directly by hospitals.

Both the insurance industry and hospital groups are seeking clarification.

AHIP, the insurers’ trade lobby, has asked the government not to allow hospital-affiliated foundations to run aid programs. The funds “must be donated to a legally independent foundation that is separate from the organization with a potential financial interest,” AHIP said.

The hospital industry, meanwhile, wants insurers to be required to accept premium payments made by health systems as well as by their foundations.

“Any effort to limit the ability of hospitals or hospital-affiliated foundations to help individuals in need to obtain access to health insurance coverage is bad public policy,” wrote Rich Umbdenstock, president and CEO of the American Hospital Association. 

Topics: ACA, Affordable Care Act, Obamacare

Translating Five Accountable Care Goals Into IT Action

Posted by Matthew Smith on Jun 9, 2014 11:19:00 AM
By Daniel J. Marino, President/CEO, Health Directions

Health IT, HIT, Accountable CareThe push for accountable care has created a new vocabulary for healthcare leaders: clinical integration, longitudinal records, ambulatory networks, patient registries, care protocols, and more. Many hospital CIOs are uncertain how to piece it all together, and they are having trouble pinning down the IT requirements for making accountable care a reality.

The solution is to break the problem down into functional objectives and concrete steps. Following is a quick guide to translating the goals of accountable care into specific action items for CIOs.

Goal #1: Coordinate Patient Care Across Multiple Settings

Coordination is the watchword of accountable care, but from an IT perspective it's often easier said than done. To create the infrastructure for coordinated care, hospital CIOs should focus on three steps.

First, select a platform for exchange that ensures interoperability. True system interoperability takes disparate medical data maintained in different formats and transforms it into integrated multidisciplinary patient care information. Many large healthcare organizations are faced with the challenge of connecting 100 to 400 different information systems, including both internal systems and those of community partners. The key is exchanging patient information in a continuity of care record (CCR) or continuity of care document (CCD) format, aggregating the data from major clinical systems and semantically organizing it into viable medical information for providers.

Second, establish an agnostic application strategy. Individual clinical systems need to interface with other applications, but “integrated” enterprise solutions also pose a challenge. An integrated hospital/ambulatory solution has many benefits and will make implementation easier, but some vendors discourage connecting outside the integrated platform. This will undermine coordination of care and true interoperability. CIOs need to select an integrated solution that allows full connectivity-or specify within the vendor agreement that outside interfaces will be allowed and supported.

Third, connect to or build a health information exchange (HIE). Several options are available. The critical question for IT executives is: what is your hospital's strategy? Does the hospital intend to lead its own ACO, develop clinical integration, and drive decisions about data collection and sharing? If so, you probably need to develop your own HIE. If, on the other hand, your hospital plans to take part in a community accountable care strategy, consider connecting to your state or regional HIE.

Goal #2: Improve Quality & Outcomes

The opportunity is clear-using electronic medical record (EMR) technology to push evidence-based care and quality improvement. The challenge is that there is no cookie-cutter approach. Again, three action items are key.

First, focus on “tailoring” structured data. Where will hemoglobin A1c labs for diabetic patients appear within the EMR? How will consult notes map into the system? While many EMR systems are pre-loaded with structured data, “out of the box” data sets rarely work well. CIOs need to make sure structured data are individualized to the organization's clinical goals.

Second, build a patient longitudinal record. To manage quality, physicians need a composite patient record within the ambulatory EMR. Customization is essential. Work with physician leaders to make sure patient information is mapped to the right place within the EMR. (This will often be determined by physician workflows.) Also, work with clinicians to standardize terminology for tests, lab values, diagnoses, etc. This is critical to ensuring the system has useful semantic data.

Third, implement clinical decision support systems (CDSS). Technology can drive better care through automated alerts and reminders. Once more, however, avoid prepackaged solutions. CDSS functions need to support the specific clinical quality and improvement goals of your organization.

Goal #3: Reduce Costs & Utilization

The government has already decided how much money it will save thanks to accountable care. Whether hospitals will maintain profitability depends on their ability to manage costs. The job of the CIO right now is to build the IT infrastructure for identifying “cost of care,” quality-of-care thresholds, and revenue metrics. The important thing to realize is that traditional business information systems are not up to this task.

Guidance on Strategies, Systems, Priorities, and Pitfalls for Hospital CIOs

Instead, put resources into creating or enhancing a data warehouse system. The goal is to be able to integrate system-wide cost, utilization, and revenue data and stage it for reporting. Hospital IT also needs to acquire or develop advanced analytics capabilities. Look for a system versatile enough to tie clinical outcomes to revenue cycle claims data.

Functionally, the goal of a data warehouse/analytics system is to identify opportunities to reduce waste, reduce spending, and improve operational efficiency.

Goal #4: Integrate Patients Into Communication

There are a growing number of personal health record (PHR) systems on the market. Most hospitals are looking at ways to use these systems to provide patients with access to their health data. But under accountable care, patient integration is about more than just information access. IT executives need to focus on using PHR systems to build patient engagement and support chronic care.

One priority is technical. Make sure PHR data feeds into key information systems, including the hospital registration system, the acute care EMR, and the ambulatory EMR. The second priority is strategic. CIOs need to guide PHR design based on high-level decisions about what information will be captured and exchanged and how it will be used. The overall driver is strategy. For example, if a hospital is launching its accountable care effort with a clinical integration project for asthma management, the IT department should configure the PHR to allow patients to log their medication use, record lung function measures, and receive seasonal asthma reminders.

Goal #5: Create Managed Clinical Value

Right now, accountable care is being driven by the promise of higher government payments. Before long, however, leading accountable care organizations will work proactively to identify enhanced clinical value and get paid for it.

Here, the most precious commodity is patient medical information. What many hospital leaders struggle with is that an EMR system is not enough. EMR is a tool for capturing and retrieving patient information at the point of service. For CIOs, the core action item is to build a model of system integration that allows for the capture of clinical data within a data repository.

A clinical data repository (also called a patient disease registry) is a database that stores and coordinates clinical information for an entire population of patients. It allows an organization to report off clinical data, which is needed for calculating actual clinical quality outcomes and comparing them against industry benchmarks. By tracking clinical quality outcomes and accurately measuring the cost of care, hospitals will be in a position to identify savings-which will then lead to evidence-based reimbursement opportunities. A clinical data repository also creates an infrastructure for joint clinical decision making about population care. This is essential for achieving clinical improvement across the enterprise to meet performance goals and therefore payment goals.

Hospital Strategy is Key

The common theme that runs through all these action items is the importance of an integrated IT strategy. The key to designing an effective IT infrastructure is to focus on your hospital's clinical and business goals. In almost every case, strategic goals determine how to configure technology to support accountable care.

ACO, Accountable Care, Clinical Integration, Population Health

Topics: Accountable Care, CIO, HIT, Health IT, ACA

Visualizing Health Policy: Public Opinion At The End of the First Affordable Care Act Open Enrollment Period

Posted by Matthew Smith on May 21, 2014 10:56:00 AM

ACA, Affordable Care Act, This Visualizing Health Policy infographic takes a look at public opinion of the Affordable Care Act at the end of the first enrollment period, including the persistent deep partisan divisions, the sources of people’s impressions, and the favorable views towards many of the ACA’s least well-known provisions. Further, more people want Congress to improve the ACA than to repeal it.


Affordable Care Act, ACA, Kaiser Family Foundation

Source: Kaiser Family Foundation analysis. Original data and detailed source information are available here .

Topics: ACA, Affordable Care Act, Kaiser Family Foundation

Population Health Management Market to Reach $40.6 Billion by 2018

Posted by Matthew Smith on May 1, 2014 7:58:00 AM

population healthA new report published by MarketsandMarkets studies the global population health management market over the forecast period of 2013 to 2018. Population health management solutions are increasingly being adopted by healthcare providers, payers, employer groups, and government bodies across the globe, particularly in the U.S. This report studies the global market over the forecast period of 2013 to 2018. This market is estimated to grow at a CAGR of 26% to reach $40.6 billion by 2018 from $12.8 billion in 2013.

The adoption of population health management solutions enables the healthcare industry to reduce costs while improving the quality of healthcare. The solutions also provide positive returns on investment. Furthermore, legislative reforms of the Affordable Care Act (ACA) in the U.S., federal funding, rise in aging population, and incentives by the government for the adoption of PHM programs have stimulated the adoption of population health management solutions in the healthcare industry. 

Population Health Barriers

However, in spite of the numerous benefits of population health management certain barriers exist including:

  • huge investments
  • lack of skilled analysts
  • fragmented end-user market
  • security of patient data are restraining the growth of this market

The North American market commands the largest share of the global PHM in 2013. Europe represents the second largest market, but is growing at a lower rate, while the Asian market is relatively new to population health management; however, the increasing health IT adoption, proficiency of IT skills, and outsourcing trend will drive the growth of this market.

Top Population Health Players

The global Population Health Management Market is a highly fragmented market with some major players such as:

  • Phytel Inc.
  • McKesson Corporation
  • Verisk Health Inc.
  • Health Catalyst, LLC
  • Allscripts, Inc.
  • i2i Systems Inc.
  • Wellcentive, Inc.
  • Conifer Health Solutions, LLC
  • Explorys, Inc.
  • Healthagen, LLC

End-User Market

The end-user market is divided into providers, payers, employer groups, and government bodies. The providers market accounted for the largest share of 65% of the global market. This market was valued at $8.3 billion in 2013 and is expected to grow at a CAGR of 26% from 2013 to 2018, to reach $26.4 billion by 2018. However, the employer groups segment is expected to have the highest CAGR of 27.2% from 2013 to 2018. Based on geography, the market is divided into North America, Europe, Asia, and Rest of the World (RoW: Pacific countries, Africa, Middle East, and Latin America).

Clinical Integration, Health Directions, Population Health

Topics: Accountable Care, Population Health, ACA, Affordable Care Act

Study Shows Growth of Primary Care Provider Pay Tied to Quality

Posted by Matthew Smith on Jul 5, 2013 10:34:00 AM

Physician CompensationWhile a new survey indicates that a small percentage of both primary care and specialist pay is tied to quality and patient metrics, it could be growing in the future.

For the first time in over 35 years of surveying physicians, the Medical Group Management Association (MGMA) included questions on quality and patient satisfaction metrics on its latest annual compensation survey, according to MGMA director of data solutions, Todd B. Evenson.

"Obviously, under the ACA and other value-based reimbursement that we see in the future, we'll see [quality metrics] as increasingly important components of physician compensation models," said Evanson. "So we felt that it was very important to begin that process to highlight how compensation plans are being changed based upon those changes to reimbursement models."

The "Physician Compensation and Production Survey: 2013 Report Based on 2012 Data," which surveyed over 60,000 physicians and nonphysician providers, found that primary-care physicians reported 3 percent of total compensation tied to quality metrics, while specialists reported 2 percent of compensation.

While this number is relatively small, MGMA president and CEO, Susan L. Turney, MD, said in a statement, "It's encouraging to see physician practices invested in patient-centered care and continuing to seek ways to better incorporate quality and experience into compensation methodologies."

Mary Barber, vice president of physician recruitment and retention firm, Cejka Search, agrees.

"We do see signals that these components [patient satisfaction and quality measures] will be growing in significance and proportion to total compensation. Primary-care physicians will be positioned as the care quarterback for their patients from an outpatient basis. And, in fact, physicians are positioned to lead and their compensation will reflect that reality," said Barber in an e-mail to Physicians Practice.

In the Physician Retention Survey 2011, the American Medical Group Association and Cejka Search asked physicians "what minimum percentage of incentive compensation is required to drive desired changes in practice outcomes for [quality measures]." Fifty-one percent of respondents felt that 3 percent or 5 percent of incentive compensation was sufficient to drive quality measures in their practices.

Evenson noted that while practices are already moving in the direction of patient-centered care and reimbursement contingent on quality measures, e.g. PQRS and e-prescribing programs, very often they are limited by the amount of funds available for that purpose. However, through the expansion of government initiatives like the EHR Incentive Programs, physicians are being paid for meeting quality measures like meaningful use, which, he said, could help them expand their own quality programs.

So while these metrics directly affect physician compensation, it will be a practice-wide effort, added Evenson, driving stronger relationships between physicians and staff.

"The administrative and support staff team will have a larger role ultimately in delivering that satisfying experience for the patient," he said. "As a result, it will be critically important for the physician and the administrator to develop a stronger relationship to be successful at that."

The MGMA survey also reported that the growth of physician compensation was relatively flat during the period 2011-2012, with a modest 5.6 percent increase for select primary-care specialties. Annual median compensation in 2012 was reported for selected specialties.

• Family Practice (without OB/GYN) — $207,117

• Pediatric/Adolescent Medicine ― $216,069

• Internal Medicine ― $224,110

• Obstetrics/Gynecology ― $301,737

• Cardiology Invasive ― $532,269

Topics: ACA, Primary Care, Physicians, Specialists, Accountable Care Act

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