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The Key to Transitioning from Fee-for-Service to Value-Based Reimbursement

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.

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The Formula for Optimizing the Value-Based Healthcare Equation

Two variables are required in the value-based healthcare equation if it is to add up to a profitable contract. One variable, optimizing the care for the patient population, is commonly included and is a focus for most healthcare systems involved in managing population health. However, a second variable, getting the right dollars in order to care for that population, is often overlooked. And yet this variable is easier to attain. It’s a matter of appropriately assessing the risk of the population by addressing inaccurate diagnoses coding. Here, we offer four methods for solving this variable: identifying high-risk gaps over time, persistent diagnosis tracking, identifying code adequacy, and identifying likely diagnoses.

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Value-Based Purchasing / Risk-Based Contracting - Additional Content

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The Key to Transitioning from Fee-for-Service to Value-Based Reimbursement

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.

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The Top Three Healthcare Financial Trends in 2017: Payment Transitions, Disruption, and New Skills

Influential healthcare financial trends in 2017 emerged in three areas:

  1. Transitions in payment.
  2. Disruption from familiar players and newcomers.
  3. Emerging data skillsets.
Uncertainty has been a common theme for 2017. Organizations continue waiting for clarity on the future of the Affordable Care Act (ACA), while working to implement value-based care. Changes from established healthcare organizations as well as the arrival of prominent newcomers (e.g., Amazon) add to the unsettled outlook, as do emerging data skillsets. Amid the uncertainty, however, healthcare is clearly continuing on the path to patient-centered care. Organizations best positioned for 2018 will understand their performance in 2017’s top three healthcare financial trends as they evaluate their preparedness for the coming year.

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Chilmark Report Studies the 2017 Healthcare Analytics Market Trends and Vendors

Chilmark’s 2017 Healthcare Analytics Market Trends Report is a trove of insights to the analytics solutions driving the management of population health and the transition to new reimbursement models. The report reviews the analytics market forces at work, such as:

  • The need to optimize revenue under diverse payment models.
  • The increasing importance of analytics in general, and a platform in specific, that can aggregate all data.
  • Continuing confusion about how to react to MIPS and APMs.
  • The growing importance of providing a comprehensive set of open and standard APIs.
  • The need for better tools to create analytics-ready data stores.
The report is also a succinct guide to the 17 leading analytics vendors (which represent EHR, HIE, payer, and independent categories) with the most promising products, technology, and services offerings in the market.

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From Surviving to Arriving: A Road Map for Transitioning to Value-Based Reimbursement

When it comes to transitioning to value-based reimbursement, health systems consistently ask two questions:

  1. Why should I invest in reducing utilization when 90+ percent of my business is still fee-for-service (FFS)?
  2. Where do I start?
This value-based reimbursement road map can help systems transition from barely surviving to successfully arriving (while respecting both shared-risk and FFS worlds): Stop #1: Surviving— If you don’t get paid for the risk you take on, then you can’t survive long term. Stop #2: Sustaining—Numerous clinical interventions occur in hospitals that systems can focus on to help improve the bottom line. Stop #3: Succeeding—Build out competencies on a smaller population with aligned incentives so you can negotiate deeper alignment with key payers. Stop #4: Arriving— The ultimate destination, where the lines between traditional healthcare delivery and public health are blurred. Although healthcare is far from arriving at the value-based reimbursement destination, it can use this road map’s pragmatic strategies for heading down the right road.

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Against the Odds: How this Small Community Hospital Used Six Strategies to Succeed in Value-Based Care

The constant thread weaving through every healthcare organizational strategy should be adherence to the Triple Aim. But with uncertainty generated by the changes at the federal level, healthcare organizations may be tempted to put their value-based care plans on hold. This article explains why that’s not necessary and lists six strategies for thriving under a fee-for-value model: 1.) Use Leadership and Team Structure to Support Improvement 2.) Drive Down Costs 3.) Reduce Unnecessary Waste 4.) Encourage the Learning Organization 5.) Prioritize Patient Education 6.) Track Data and Outcomes This blog cites one small medical center with odds stacked against it, and how it is managing to not only weather the changes, but also distinguish itself by staying true to the values of the Triple Aim.

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The Formula for Optimizing the Value-Based Healthcare Equation

Two variables are required in the value-based healthcare equation if it is to add up to a profitable contract. One variable, optimizing the care for the patient population, is commonly included and is a focus for most healthcare systems involved in managing population health. However, a second variable, getting the right dollars in order to care for that population, is often overlooked. And yet this variable is easier to attain. It’s a matter of appropriately assessing the risk of the population by addressing inaccurate diagnoses coding. Here, we offer four methods for solving this variable: identifying high-risk gaps over time, persistent diagnosis tracking, identifying code adequacy, and identifying likely diagnoses.

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Why Adding External Data to Your EDW Is Critical to Driving Outcomes Improvement

Many healthcare organizations are entering, or are planning to enter, into some type of at-risk contract, be it a bundled payment program, a Medicare Advantage plan, or an ACO. In order to manage these contracts most effectively, integrating external and internal claims data in to the EDW is critical. Aggregating data in to an EDW from internal, disparate, clinical, administrative, and financial systems is the first critical step to identify opportunities for quality improvement. However, external data from organizations such as CMS and commercial payers, along with benchmarking and consumer and demographic data, also has the potential to improve the quality of care, increase patient satisfaction, and lower costs. In the new world of at-risk contracts, integrating external and internal data enables leaders to successfully oversee, manage, and strategically plan for future at-risk arrangements.

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Advanced Care Management: Healing the Whole Patient

In the new world of value-based care, success is defined as consistently delivering excellent, value-based care, and improving patient outcomes, long-term. Making the vision of value-based care a reality will require a cross-functional team, focused on healing the entire patient according to the principles of advanced care management. Recognizing the needs of the whole patient, instead of only focusing on the specific condition, especially in a shared-risk arrangement, can have a profound effect on everyone, most importantly the patient. To achieve success the entire team, including physicians, nurses, social workers, psychiatrists, and social workers,   must work together and coordinate their efforts. Building a genuine and trusting relationship between the patient and care team is the cornerstone of ACM programs. Helping a patient feel better can inspire them to be an active part of their treatment plan. A successful ACM strategy can inspire the care team to drive long-term, tangible change, leading to improving outcomes for the organization and the patient.

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2015 Sustainable Growth Rate Repeal: The Future is Here

The bill repealing SGR and replacing it with a more reliable payment schedule will alleviate physicians having to wonder whether their Medicare reimbursement rate will be slashed each year. However, it has also accelerated the need for providers to adopt value-based reimbursement (VBR). While the transformation won’t happen overnight healthcare organizations can, and should, begin preparing now. The following steps will make the transition easier: 1. Get educated and involved; 2. Understand the new law; and 3. Most importantly, providers should consider ways to take advantage of the upcoming 5 percent bonus. Providers that are already participating in VBR arrangements should consider how to increase the volume of their VBR business. Those that have not yet embraced VBR practices need to start immediately. Having a solid roadmap by the end of 2015 will ensure for a successful transition to a value-based system.

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Value-based Healthcare and Effective Analytics Outlined in New Gartner Report

The need for healthcare analytics has expanded greatly over the last few years, especially with the rise of value-based healthcare. CIOs are finding they must adapt quickly to keep up with the transition. A report from Gartner entitled “Transitioning to Value-Based Healthcare: Building Blocks for Effective Analytics” recommends that organizations view analytics as a program, not a project, and defines the Logical Data Warehouse (LDW) as the most important concept a CIO must understand.

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Value-Based Purchasing: Why Your Timeline Just Got Shorter

CMS has announced a new, more aggressive timeline for implementing Medicare fee-for-service (FFS) payments to value-based reimbursement. While this transition is needed gaps in several areas of the VBP models are causing angst among provider organizations. Healthcare organizations can begin to improve quality and lower costs today as CMS works to address the challenges associated with these models. An EDW is key in enabling organizations perform the sophisticated analysis and tracking to meet the requirements set by CMS successfully.

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Value-based Purchasing: Start with These Patients

Almost 90 percent of healthcare spending is associated with traditional pay-for-service contracts. But value-based purchasing encourages effective and proactive healthcare delivery. The Cayman Islands Health Services Authority started their value-based purchasing program, even agreeing to a 3 percent reduction in payments for selected diagnoses and procedures. The list of patients the system start with includes: Inpatient procedures (knee replacements, hip replaces, hip and knee replacement revisions, and hip and knee arthroscopy), Outpatient procedures (cataract removal, perinatal care, hysterectomy, and maternity), Chronic conditions (asthma, diabetes, end stage renal), and Acute conditions (upper respiratory infection). The US healthcare system should set a goal to have 80 percent of healthcare dollars going to value-based contracts by 2019.

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How to Prepare for Value-based Purchasing in 4 Steps

I spent many years of my career as a healthcare finance executive in the state of California, where I had the opportunity to participate in several groundbreaking pay-for-performance (P4P) initiatives. However today, things have grown much more complex and intimidating. Health systems have to report on Medicare quality measures that determine important incentives and penalties. Add to this the host of private payers who have established their own value-based programs, all of which require different metrics. In this post, I discuss 4 lessons learned for success in VBP: 1) assessing your performance 2) education programs, 3) your analytics strategy, and identifying areas for clinical quality and cost improvement.

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