Value-Based Care

Insights

Marlowe Dazley

Predicting Denials to Improve the Healthcare Revenue Cycle and Maximize Operating Margins

Healthcare financial leaders are constantly brainstorming ways to increase operating margins through better revenue cycle performance. These efforts often lead revenue cycle leaders to denied claims—when a payer doesn’t reimburse a health system for a service rendered. Although denials are a common reason for lost revenue, experts deem nearly 90 percent avoidable.
Effective denials management starts with prevention. Organizations can use revenue cycle performance data, combined with artificial intelligence, to predict areas within each claim’s lifecycle that are likely to result in a denial. With denial insight, health systems can optimize revenue cycle processes to prevent denials and increase operating margins.

Health Catalyst Editors

Healthcare Price Transparency: Understanding the Cost-Pricing Relationship

Healthcare consumers are demanding the same level of price transparency for medical care they have in other transactions—particularly as healthcare moves away from a fee-for-service model and patients are responsible for larger portions of their medical bills. Meanwhile, as of January 2021, federal regulation requires health systems to make their service charges publicly available. The healthcare industry, however, hasn’t historically succeeded with consumer-grade price transparency. Organizations must now figure out how to bridge the gap between their costs and patient charges. Doing so requires comprehensive understanding of all the costs behind a service and consumer-friendly explanation of how these expenses translate into prices.

Health Catalyst Editors

Improving Sepsis Care: Three Paths to Better Outcomes

Sepsis affects at least 1.7 million U.S. adults per year, making it a pivotal improvement opportunity for healthcare organizations. The condition, however, has proven problematic for health systems. Common challenges including differentiating between sepsis and a patient’s acute illness and data access. In response, organizations must have comprehensive, timely data and advanced analytics capabilities to understand sepsis within their populations and monitor care programs. These tools can help organizations identify sepsis, intervene early, save lives, and sustain improvements over time.

Health Catalyst Editors

Deliver Data to Decision Makers: Two Important Strategies for Success

Surviving on thin operating margins underscores the need for all end users at a health system to make decisions based on comprehensive data sets. This data-centered approach to decision making allows team members to take the right course of action the first time and avoid making decisions based on fragmented data that exclude key pieces of information.
To promote data-driven decision making and a data-centric culture, healthcare organizations should increase data access and availability across the institution. With easy access to complete data, end users rely on the same data to make decisions, no matter where they work within the health system.
Two strategies can help organizations integrate and deliver data to end users when they need it:

Select infrastructure that fits most people’s needs.
Ask the right questions.

Farhana Nakhooda
Larry Lofgreen

2021 Asia-Pacific Healthcare Trends: Growing Digitization, Universal Health Coverage, and More

Along with the rest of the globe, 2021 healthcare trends across Asia-Pacific (APAC) countries will center on COVID-19 recovery and resuming the healthcare improvement journey. In the APAC region, however, a mix of developed and developing countries poses unique challenges, as healthcare access and basic infrastructure vary widely between urban and rural populations and economic levels. To shepherd healthcare out of the pandemic and enhance delivery overall in 2021, APAC nations will focus on increasing investment in digital health (including virtual care, machine learning, and EMR adoption), achieving universal health coverage, shifting more towards value, and improving payer-provider relationships.

Health Catalyst Editors

The Right Way to Build Predictive Models for the Most Vulnerable Patient Populations

Predictive artificial intelligence (AI) models can help health systems manage population health initiatives by identifying the organization’s most vulnerable patient populations. With these patients identified, organizations can perform outreach and interventions to maximize the quality of patient care and further enhance the AI model’s effectiveness.
The most successful models leverage a mix of technology, data, and human intervention. However, assembling the appropriate resources can be challenging. Barriers include multiple technology solutions that don’t share information, hundreds of possible, often disparate, data points, and the need to appropriately allocate resources and plan the correct interventions. When it comes to predictive AI for population health, simple models may harness the most predictive power, which allows for more informed risk stratification and identifies opportunities for patient engagement.

Tarah Neujahr Bryan

Expanding AI in Healthcare: Introducing the New Healthcare.AI™ by Health Catalyst

As healthcare leaders continue to face unprecedented decisions around revenue, cost, and quality, they turn to augmented intelligence (AI) to maximize their analytics. However, leaders struggle to implement AI into existing business intelligence workflows, demonstrate ROI, and move AI efforts beyond predictive models.
Health systems can overcome AI’s implementation challenges with the New Healthcare.AI™ offering by Health Catalyst. As a suite of AI products and expert services, Heatlhcare.AI integrates transparent, cutting-edge technology into existing workflows, allowing analysts to produce high-quality insights in minutes. The AI offering dramatically broadens the use and use cases of AI for any healthcare organization with a mix of self-service products and expert services:

Analytics integration.
Choosing/building predictive models.
Optimizing predictive models.
Retrospective comparisons.
Prescriptive optimization.

Kyle Salyers

Innovative Healthcare Partnerships: Making the Most of Merging Resources and Capabilities

Healthcare mergers and acquisitions performed solidly in 2020, despite the downturn in the U.S. economy and healthcare in general. Organizations responded to new challenges by partnering with each other to build core business strengths, address gaps in care delivery the pandemic exposed, and enhance their resources to navigate current and future crises.
Realizing the potential of emerging healthcare partnerships requires an open and scalable analytics infrastructure plus a cultural and contractual openness to allow innovation to flourish. Organizations that have adopted an open analytics platform have the data operating advantage to form partnerships, efficiently and smoothly bring best-of-breed solutions to market, and enable the innovative potential of collaborations.

Daniel Orenstein, JD
Stephen Grossbart, PhD

2021 Healthcare Trends: What Leaders Need to Know from COVID-19 to New Administration Policies

While much of the healthcare industry was eager to put 2020 behind it, the new year brings its own challenges, concerns, and promises. Trends in the three main categories of new Biden administration policy, care delivery, and healthcare technology will shape 2021, with key issues including the long-term effects of COVID-19, future emergency preparedness, and the outlook for the Affordable Care Act (ACA). Healthcare leaders can prepare for this pivotal year by understanding critical areas to watch within these categories and how events, activities, and political appointments will affect the healthcare ecosystem.

Health Catalyst Editors

Shifting to Value-Based Care: Four Strategies Emphasize Agility

As the healthcare payment shift from fee-for-service (FFS) to value-based reimbursement takes longer than expected, health systems must balance existing volume-based models with a growing emphasis on value. Organizations are in different phases of the journey from volume to value, and policies continue to evolve. In response, the industry’s best stance is to sustain FFS revenue while following guidelines and strategies to be increasingly ready for value.
Organizations can use four methods to remain agile as they navigate the limbo between volume and value:

Understand the first ten years of value-based care and prepare for what’s next.
Identify essential strategies for shifting from volume to value.
Leverage the Medicare Shared Savings Program.
Use population health management as a path to value.

Health Catalyst Editors

Three Analytics Strategies to Drive Patient-Centered Care

The cost of uncoordinated care that fails to prioritize patient needs is estimated to be over $27.2 billion. One of the primary reasons behind these wasted healthcare dollars is a failure to effectively leverage data to understand patient needs—a must-have to deliver patient-centered, value-based care (VBC).
Three analytics strategies enable health systems to focus on patients while also meeting the financial standards for VBC delivery:

Prioritize patient outreach by risk level.
Deploy data tools to combat COVID-19.
Promote data literacy.

Detailed information from comprehensive data sets allows health systems to understand patient needs at a granular level and then use that insight to drive care decisions. More informed care ensures health systems are also meeting the core elements of VBC—managing costs, delivering quality, and ensuring an excellent patient experience.

Darren O'Brien

2021 Changes to the Quality Payment Program: Must-Know Guidelines for ACOs

In 2021, CMS proposes the following four key changes to the Quality Payment Program (QPP) that will impact quality measurement for ACOs and ACO participants:

The discontinuation of the CMS Web Interface.
The introduction of the alternative payment model (APM) Performance Pathway (APP).
The discontinuation of the APM scoring card.
The addition of the APM entity as a submitter type for MIPS.

Each change will create new challenges for ACOs and ACO participants. Organizations can successfully navigate these shifts by partnering with a robust quality measures solution that creates a complete picture by combining comprehensive data and measures information in performance visualizations. An inclusive quality measures solution also creates a thorough workflow by combining the monitoring and improving processes, then submitting performance to payers.

Health Catalyst Editors

Healthcare Financial Transformation: Five Leading Strategies

Healthcare financial transformation—improving care delivery while lowering costs—has been an ongoing challenge for health systems in the era of value-based care and an even more prominent concern amid COVID-19. While better care and reduced expense to organizations and consumers might seem like opposing goals, by understanding the true cost of services and other drivers of expense, organizations can successfully manage costs while maintaining, and even improving, care delivery. To that end, health systems can use data- and analytics-driven tools and strategies to addresses financial challenges, including uncompensated care, prolonged accounts receivable days, discharged not final billed cases, inefficient resource use, and more.

Will Caldwell, MD, MBA

The Medicare Shared Savings Program: Four Tools for Better Profit Margins and High-Quality Care

Medicare patients make up the majority of health systems’ revenue; yet, organizations earn only a one percent profit while caring for this population. Despite historically low profit margins, Medicare can be lucrative for health systems, and through the Medicare Shared Savings Program, healthcare organizations can increase revenue with four tools:

The ability to aggregate and analyze data.
The ability to align financial incentives between payers and providers.
The ability to engage patients in behavior or lifestyle modifications.
The ability to garner support from clinicians and encourage them to lead the shift to VBC.

As the shift from fee-for-service to value-based care continues, health systems can leverage MSSP to deliver the highest level of care while also increasing profit margins.

Bob Alexander

Activity-Based Costing in Healthcare During COVID-19: Meeting Four Critical Needs

As health systems increasingly transition to a value-based care model, the financial strains and uncertainty of COVID-19 have placed more urgency on cost management. More than ever, organizations need a costing solution that helps them understand the true value of their services. With the right next-generation activity-based costing (ABC) tool, health systems can access the detailed data they need to lower the cost of care, automate costing activities, and reduce administrative costs while preparing for the mounting intricacy of the post-pandemic setting.
Activity-based costing meets healthcare’s complex COVID-19-era costing needs by addressing four big challenges:

Data management.
Scalability.
Ongoing maintenance.
Adoption.

Health Catalyst Editors

Population Health Management: A Path to Value

As value-based care (VBC) definitions and goals continue to shift, organizations struggle to create a roadmap for population health management (PHM) and to track associated costs and revenue. However, health systems can move forward with PHM amid the uncertainty by following the best practices of a path to value:

Begin with Medicare Advantage—a good growth opportunity with low barriers to entry.
Focus on ambulatory, not acute, care as it delivers more value.
Leverage registries based on utilization to identify the most impactable 3 to 10 percent of utilizers.
Simplify the physician burden by focusing on reasonable measures.

Bobbi Brown, MBA

Value-Based Purchasing 2020: A 10-Year Progress Report

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.

Duncan Gallagher

From Volume to Value: 10 Essential Strategies for Navigating the Healthcare Shift

As the transition of healthcare payment models from volume to value takes longer than expected, healthcare organizations must balance fee for service (FFS) with value-based care (VBC). The transition to VBC will accelerate, but as FFS persists and still generates adequate margins, organizations must also continue to be successful under volume-based reimbursement.
Ten tools can help health systems balance VBC with FFS:

A member perspective.
Cautious investment in hard delivery assets.
Accelerated investment in digital infrastructure.
Innovative digital engagement solutions.
Pricing concessions.
Aligned incentives.
Network management.
Payer-provider trust and collaboration.
Clinician and administrative alignment.
Physician leadership and accountability.

Health Catalyst Editors

Achieving Stakeholder Engagement: A Population Health Management Imperative

To succeed in population health management (PHM), organizations must overcome barriers including information silos and limited resources. Due to the systemwide nature of these challenges, widespread stakeholder engagement is an imperative in population-based improvement.
An effective PHM stakeholder engagement strategy incorporates the following:

Includes as many stakeholders as possible at the beginning of the journey.
Meets the unique analytics and reporting needs of the organization.
Enables users to measure, and therefore manage, PHM outcomes.
Provides the real-time analytics value-based care requires.

Britney Rosenau

Evolving CMS Quality Measures Move Towards More Patient-Centered Care, Less Burden for Clinicians

With today’s comprehensive Meaningful Measures initiative, CMS has refocused healthcare quality measures on improving patient needs and experiences, reducing regulatory burden on clinicians, and removing barriers to value-based payment. The evolved quality measures center on patient, clinician, and health system needs and strategic goals to truly impact improving care and lowering costs.
Meaningful Measures, according to CMS, must meet seven criteria:

Are patient-centered and meaningful to patients, clinicians, and providers.
Address high-impact measure areas that safeguard public health.
Are outcome-based where possible.
Minimize the level of burden for providers.
Create significant opportunity for improvement.
Address measure needs for population-based payment through alternative payment models.
Align across programs.

Adam Bell
Kristen McRae

Continuity of Care Documents: Today’s Top Solution for Healthcare Interoperability Demands

While healthcare waits for the expanded data interoperability that FHIR promises, the industry needs an immediate solution for accessing and using disparate data from across the continuum of care. With FHIR potentially several years away, continuity of care documents (CCDs) are the best option for acquiring the ambulatory clinical care data health systems need to close quality gaps today. Because organizations that rely only on claims data to drive quality improvement risk missing out on more that 80 percent of patient information, CCDs are the current must-have answer to interoperability for successful quality improvement.

Health Catalyst Editors

Healthcare’s Next Revolution: Finding Success in the Medicare Shared Savings Program

A series of revolutions has driven the development of the U.S. healthcare system, enabling dramatic improvements in all aspects of healthcare quality and outcomes over the past century. Although healthcare organizations have focused on moving towards value-based care for decades, the data shows that the shift is indeed taking place and fee-for-service models are declining.
New changes to the Medicare Shared Savings Program (MSSP) will help drive this change as revisions to MSSP require ACOs to take on more financial risk earlier. This article covers the following topics:

Important moments in history that led to today’s current challenges.
Why financial imperatives drive cultural change in our economic model.
Ways MSSP can help healthcare organizations achieve financial success.
How to utilize data to develop better healthcare delivery systems.

Health Catalyst Editors

ACOs and CINs: Past, Present, and Future

Accountable Care Organizations (ACOs) and clinically integrated networks (CINs) are two types of organizations working to address the problem of rising costs. As ACOs and CINs continue to evolve, organizations moving into value-based care (VBC) face an ever-changing landscape. This article looks at the evolution of the ACO and CIN models, what new tools ACOs employ today to promote success, and lessons learned from organizations that have succeeded in alternative payment models. It also explores what healthcare experts believe the future of alternative payment models will look like and competencies to develop to meet those changing demands.

Health Catalyst Editors

Five Action Items to Improve HCC Coding Accuracy and Risk Adjustment With Analytics

A hot topic in healthcare right now, especially in the medical coding world is the Hierarchical Condition Category (HCC) risk adjustment model and how accurate coding affects healthcare organizations’ reimbursement.
With almost one third of Medicare beneficiaries enrolled in Medicare Advantage plans, it’s more important than ever for healthcare organizations to pay attention to this model and make sure physicians are coding diagnoses appropriately to ensure fair compensation. This article walks through basics of the risk adjustment model, why coding accuracy is so important, and five action items for interdisciplinary work groups to take. They include:

Having an accurate problem list.
Ensuring patients are seen in each calendar year.
Improving decision support and EMR optimization.
Widespread education and communication.
Tracking performance and identifying opportunities.

Adam Bell
Carol Owen
Dan Soule
Eric Crawford

Pairing HIE Data with an Analytics Platform: Four Key Improvement Categories

Population health and value-based payment demand data from multiple sources and multiple organizations. Health systems must access information from across the continuum of care to accurately understand their patients’ healthcare needs beyond the acute-care setting (e.g., reports and results from primary care and specialists). While health system EHRs have a wealth of big-picture data about healthcare delivery (e.g., patient satisfaction, cost, and outcomes), HIEs add the clinical data (e.g., records and transactions) to round out the bigger picture of patient care, as well as the data sharing capabilities needed to disseminate the information.
By pairing HIE capability with an advanced analytics platform, a health system can leverage data to improve processes in four important outcomes improvement areas:

Workflow
Machine learning
Professional services
Data governance