Bobbi Brown, MBA

Healthcare organizations today have access to so much data from across their systems that they may struggle to know where to focus quality improvement efforts. An analytic framework and a stepwise process ensures organizations have broad data access and can identify the most significant opportunities for impact. With a strategic, data-informed approach to clinical quality improvement, health systems can consume fewer resources, discover cost savings, and improve ROI and the quality of care. 
Three steps comprise an effective quality improvement process:

1. Adopt a healthcare-specific, open, scalable data platform.
2. Identify improvement priorities using the 80-20 rule.
3. Gain consensus from clinical teams on specific projects and goals.

With the healthcare industry move towards value-based payment (VBP), financial executives must navigate a shift away from volume and embrace quality care as a key driver of financial health—particularly as accountable care, quality measures, shared savings, and bundled payments gain traction. To meet this ongoing quality-cost challenge, health systems must understand their progress in clinical quality measures and costs of delivering care, as clinical quality is an increasingly significant predictor of financial outcomes. While the traditional fee-for-service environment emphasized volume, today’s VBP paradigm puts quality ahead of older metrics.

1. Health equity.
2. Patient safety.
3. Staffing.
4. Care delivery.
5. COVID-19 recovery.
6. Payment and payers.

As healthcare financial leaders plan for 2021, they can expect COVID-19 to shape their strategies. Pandemic response and recovery will continue to dominate the industry, inform new perspectives on existing issues (e.g., the shift to value-based care and health equity), and shape priorities. Meanwhile, the Biden administration will start to puts its stamp on U.S. healthcare, further making 2021 a pivotal year for the industry.

Healthcare finance teams can best navigate 2021 by monitoring and preparing to take action in five prominent areas:
1. Election impact.
2. Price transparency.
3. Financial forecasting.
4. Value-based care.
5. Health equity.

The long-term success of healthcare performance improvement relies on a sustainable infrastructure and strategic execution. Otherwise, improvement initiatives risk becoming one-off projects that don’t support ongoing advances in critical areas, such as critical areas, clinical outcomes, patient experience, and organizational cost.

Healthcare organizations can follow six steps for a sustainable, impactful performance improvement program:

1. Integrate performance improvement into strategic objectives.
2. Use analytics to unlock data and identify areas of opportunity.
3. Prioritize programs using a combination of analytics and an adoption system.
4. Define the performance improvement program’s permanent teams.
5. Use a best-practice system to define program outcomes and interventions.
6. Estimate the ROI.

The long-term success of healthcare performance improvement relies on a sustainable infrastructure and strategic execution. Otherwise, improvement initiatives risk becoming one-off projects that don’t support ongoing advances in critical areas, such as critical areas, clinical outcomes, patient experience, and organizational cost.

Healthcare organizations can follow six steps for a sustainable, impactful performance improvement program:

1. Integrate performance improvement into strategic objectives.
2. Use analytics to unlock data and identify areas of opportunity.
3. Prioritize programs using a combination of analytics and an adoption system.
4. Define the performance improvement program’s permanent teams.
5. Use a best-practice system to define program outcomes and interventions.
6. Estimate the ROI.

As the healthcare industry recovers from COVID-19, providers are re-evaluating the financial arrangements that motivate them to improve their processes while benefiting payers and patients.

With the pandemic driving lower provider volumes and straining hospital resources, the industry has a renewed urgency for policies that drive better outcomes while lowering cost and improving revenue. Moving forward, healthcare must reset its payer-provider performance standards to the post COVID-19 environment.

Renewed approaches to the following models will consider the impact of remote care, how to reimburse telehealth services, and the need for consistent payments to providers:

1. Pay for performance.
2. Bundled payments.
3. ACOs.

During the emergency phase of the COVID-19 pandemic, almost half of all U.S. healthcare consumers postponed routine and non-emergent care, leaving organization with significant revenue loss across all care settings. In response to the widespread financial strain on the healthcare industry, Congress has allocated $100 billion in relief funding for hospitals and other healthcare providers. But while providers clearly need the financial relief, using it (including navigating terms and conditions and eligibility) has been less straightforward. Better understanding of these relief programs and compliance requirements will help organizations confidently optimize this assistance.

During the emergency phase of the COVID-19 pandemic, almost half of all U.S. healthcare consumers postponed routine and non-emergent care, leaving organization with significant revenue loss across all care settings.
In response to the widespread financial strain on the healthcare industry, Congress has allocated $100 billion in relief funding for hospitals and other healthcare providers.
But while providers clearly need the financial relief, using it (including navigating terms and conditions and eligibility) has been less straightforward. Better understanding of these relief programs and compliance requirements will help organizations confidently optimize this assistance.

The year 2020 marks a decade since the passage of the Affordable Care Act in 2010 and healthcare’s first transitional steps from volume to value.
The 10-year progress report is mixed. On one hand, CMS’s emphasis on quality and cost is driving an upward trend for patients and providers, with substantial improvement in readmissions; on the other hand, organizations still need to simplify and consolidate value-based programs for more widespread positive impact.
As the industry enters into another decade of value, it’s time for health systems to consider the impacts of these programs so far and make sure they have the processes and tools in place to succeed in an increasingly value-driven industry.

Healthcare payers today must develop new business models to address the industry’s mounting challenges around cost, access, and quality. The best emerging models are simple and aligned, accommodate all stakeholders’ needs, and center on the patients/members.

Five key payer opportunities provide a framework for new models that will support the healthcare transformation goals of lower cost, better quality, and increased access:

1. Understand the impact of the Affordable Care Act.
2. Be ready for potential shifts due to regulatory impacts.
3. Understand how social determinants of health impact members.
4. Focus on provider relations.
5. Prepare for future trends.

As a performance-based incentive program, DSRIP (the Delivery System Reform Incentive Payment) is designed to help participating states reform Medicaid. To date, 13 states have implemented DSRIP and received a Section 1115 waiver from CMS to transform their Medicaid programs and align them with value-based reimbursement. These states have agreed to budget neutrality, transparency, statewide quality metrics, and frequent reporting of outcomes.

While each state’s program structure and objectives are unique, under DSRIP, participating states share three key goals:

1. Reducing the total medical spend.
2. Improving patient outcomes.
3. Establishing a direct link between provider performance and payment.

Since accountable care took the healthcare industry by a storm in 2010, health systems have had to move from their predictable revenue streams based on volume to a model that includes quality measures.
While the switch will ultimately improve both quality and cost outcomes, health systems now need the capability of tracking and analyzing the data from both clinical and financial systems.
A late-binding enterprise data warehouse provides the flexible architecture that makes it possible to liberate both kinds of data to link it together to provide a full picture of trends and opportunities.

Health systems that meet the 2018 Hospital Value-Based Purchasing Program measures stand to benefit from CMS’s $1.9 billion incentive pool. Under the 2018 regulations, CMS continues to emphasize quality. To reduce the risk of penalty and vie for bonuses, it’s increasingly critical that organizations leverage data to build skills and processes that meet more demanding reimbursement measures.

To thrive under value-based payment, healthcare systems must understand CMS’s four quality domains, and their associated measures, for 2018:

1. Clinical Care
2. Patient- and Caregiver-Centered Experience of Care/Care Coordination
3. Efficiency and Cost Reduction
4. Safety

I am one of the brave souls who takes the time to read the report issued each spring by the Medicare Payment Advisory Commission (Medpac).
The report shows the numbers of Medicare beneficiaries and claims are growing; healthcare organizations are increasingly losing money on Medicare; payment increases certainly will not keep pace with declining margins; and Medicare policies will continue to incentivize quality and push providers to assume more risk.
But the report also reveals that some healthcare organizations—referred to as “relatively efficient”—are making money from Medicare with an average 2 percent margin. How do you become one of these organizations? And how do you target and counter Medicare trends that impact your business?

When expenses exceed revenue, business has a financial problem. In healthcare, the focus has been on revenue for so long, we’ve lost sight of runaway costs brought about by high labor and technology expenses, inefficient use of resources, and supply waste. Recognizing the cost problem is a big first step toward solving it.

Five expense-controlling strategies can play a significant role in returning healthcare systems to a stronger financial position:

1. Refocus on labor management.
2. Manage employed physicians.
3.Change the patient encounter environment.
4. Augment standard approaches with technology.
5. Manage patient access and flow through the healthcare system.

With new, value-based payment structures, shrinking margins, and decreasing reimbursements, this insight offers some new ways to think about expense inefficiency and how to get costs under control.

Besides improving your information systems and educating your staff on the ins and outs of managing revenue, there are many more opportunities for improvement. Here are five suggestions to help health systems improve their revenue cycle management:

1. Trend and benchmark your healthcare data.
2. Use DOS to Mine Your Healthcare Data.
3. Constantly ask frontline staff for suggestions.
4. Monitor all payer contracts.
5. Maintain convenient and caring touch points with patients.

The shift from fee-for-service to value-based reimbursements has good and bad consequences for healthcare. While the shift will ultimately help health systems provide higher quality lower cost care, the transition may be financially disastrous for some. In addition, the shifting revenue mix from commercial payers to Medicare and Medicaid is creating its own set of challenges.
There are, however, three keys to surviving the transition:

1) Effectively manage shared savings programs to maximize reimbursement.
2) Improve operating costs.
3) Increase patient volumes.

With an analytics foundation, health systems will be able to meet and survive today’s healthcare challenges.