Advanced payment models incentivize Accountable Care Organizations (ACOs) to deliver high-quality care and close gaps in care for members, thereby earning shared savings and increasing profits. However, in order to succeed and identify gaps in care, ACOs must be able to rely on solid data and analytics to avoid losing income that could be invested back into patient care. Utilizing its analytics platform and a quality measures solution has allowed Hospital Sisters Health System to close care gaps, improve ACO quality measures performance, and enhance reporting accuracy and effectiveness.
On average, claim denials cost each healthcare provider $5 million every year. This loss of revenue resulting from claim denials is a concern for healthcare providers. Billings Clinic sought to determine the cause of claim denials and realized that it needed an analytics solution that could integrate data from multiple sources. The health system leveraged its data platform and analytics applications to pinpoint the sources of the denials, allowing the organization to implement prevention plans and procedures for recovering the denials. Billings Clinic achieved significant results, including:
Responsible for coding approximately 380,000 episodes annually, clinical coders at Guy’s and St Thomas’ NHS Foundation Trust review documentation across several systems. The overwhelming amount of data, burdensome manual review processes, and limited coding resources made reviewing all data unfeasible. To address its coding challenges, Guy’s and St Thomas’ leveraged its data platform to combine and standardise data across disparate source systems. The organization now has access to data and technology that can be used to augment coders’ work, automating data gathering to better identify patients whose diagnostic coding could be improved.
Texas Children’s Hospital had dramatically improved patient access, yet it recognized that it could advance access further by improving space utilization and proactively reallocating underutilized exam rooms. The organization developed a space visualization analytics application, and conducted a comprehensive space assessment, identifying opportunities to improve utilization of current space to increase clinic offerings—resulting in improved access for patients and families by utilizing space efficiently.
The amount of time a patient may have to wait for a scheduled appointment at Texas Children’s Hospital varied greatly as a result of a lack of standardized processes. After taking a deeper look at its scheduling process with the help of analytics, it was able to develop an improvement strategy aimed at improving access to care—enhancing patient care and boosting revenue.
Memorial Hospital at Gulfport (Memorial) knew that decreasing clinic no-show rates was an opportunity to increase revenue, eliminate delays in care, and improve care coordination for its patients. With a robust data platform, Memorial leveraged its data and analytics to better understand the reasons behind its high no-show rates. With actionable data, the organization implemented measures to effectively improve its no-show rates and increase revenue.
Community Health Network identified that inconsistent oversight of durable medical equipment (DME), and process variation, were a likely source of waste and lost revenue. The health network sought a systemwide, data-driven process for the purchasing, dispensing, and billing of DME. A data platform and analytics applications were utilized to understand organizational performance, identify opportunities for improvement, and evaluate the impact of these changes on patient, financial, and organizational outcomes.
MultiCare Health System’s Pulse Heart Institute (Pulse Heart) recognized that better care coordination was required for patients receiving cardiac, thoracic, and vascular care. The organization wanted to further improve quality outcomes, provider engagement and recruitment, and its own economic health. To meet these objectives, Pulse Heart focuses on clinician engagement and organizational alignment, ensuring widespread access to meaningful, actionable data and analytics to inform decisions and drive improvement.
Albany Med’s clinical documentation improvement specialists provide high-quality care to complex, acute-care patients; however, Albany Med was experiencing lower reimbursement rates due to gaps in clinical documentation. The organization created a seamless process for clinical documentation with the use of an analytics application as driven by clinical leadership.
Unwarranted variation in clinical care is costly, representing as much as $30 million of actionable savings opportunity for a typical organization. Allina Health launched its Clinical Value Program—a systemwide effort to measure and improve clinical value. The program quantifies the value of clinical change work to improve outcomes while reducing costs and increasing revenue for reinvestment in care.
Financial challenges rank as the number one issue hospitals face. As a result, these organizations are constantly looking for strategies to improve outcomes, manage costs, and boost revenue. Learn how Thibodaux Regional Medical Center sustained and improved its discharged not final billed (DNFB) efforts.
CMS denies nearly 26 percent of all claims, of which up to 40 percent are never resubmitted. The bane of many healthcare systems is the inability to identify and correct the root causes of these denials, which can end up costing a single system tens of millions of dollars. Yet almost two-thirds of denials are recoverable and 90 percent are preventable.1 Despite previous initiatives, The University of Kansas Health System’s denial rate (25 percent) was higher than best practice (five percent), and leadership realized that, to provide its patients with world-class financial and clinical outcomes, it would need to engage differently with its clinical partners.
To effectively reduce revenue cycle and implement effective change, The University of Kansas Health System needed to proactively identify issues that occurred early in the revenue cycle process. To rethink its denials process, it simultaneously increased organizational commitment, refined its improvement task force structure, developed new data capabilities to inform the work, and built collaborative partnerships between clinicians and the finance team.
As a result of its renewed efforts, process re-design, stakeholder engagement, and improved analytics, The University of Kansas Health System achieved impressive savings in just eight months.
$3 million in recurring benefit, the direct result of denials reduction.
$4 million annualized recurring benefit.
Successfully partnered with clinical leadership to transition ongoing denial reduction efforts to operational leaders.
Research shows that despite an increase in the number of improvements in clinical, cost, and operational outcomes, there is a lack of sustained improvements. Some of the key challenges can be access to the data and analytics, and adherence to data-driven clinical standards, things the Allina Health Spine Clinical Service Line (CSL) clinical leadership team experienced.
By providing widespread access to the data and analytics, the Spine CSL at Allina Health has been able to continue its reduction in LOS and further improve its reduction in complications, all while increasing cost savings and achieving pay-for-performance incentives.
$1 million in pay-for-performance incentives received.
More than $2 million in supply chain savings, a result of data-driven clinical standardization.
31 percent of expected complications avoided.
22 percent relative reduction in surgical site infections.
Today’s healthcare industry, in which a lack of insight into clinical variation has contributed to increased expenses, has significant opportunities to use data and analytics to improve outcomes and reduce costs. As part of its ongoing commitment to improve clinical value, Allina Health has employed a systemwide process to identify, measure, and improve clinical value. The health system has been able to quantify the value of clinical change work to improve outcomes, while reducing costs and increasing revenue for reinvestment in care.
Allina Health achieved the following meaningful results with this collaborative, data-driven opportunity analysis process:
Identified nearly $33 million in potential cost savings for the first three quarters of 2017.
Achieved over $10 million of confirmed savings during the first three quarters of the year.
Elevated discussions of cost concerns, leading to the development of standard processes, and significantly reducing unwarranted clinical variation.
Substantial evidence indicates a correlation between a patient’s experience in a healthcare setting and adherence to medical advice, appropriate use of healthcare services, and clinical outcomes. Many organizations evaluate patient experience using Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey scores.
Mission Health’s patient experience survey scores in the emergency department (ED) were significantly lower than desired. Extended wait times negatively impact patient experience and perceptions of quality of care.
To improve the wait-time experience, Mission changed to a quick registration process, implemented patient notifications via text messaging, and began notifying patients of anticipated delays due to volume surges, thus better managing expectations. Text messaging also improved patient privacy, as did remodeling the waiting room to create a private registration area.
In just over a year, Mission’s ED achieved the highest patient experience ratings it had ever received:
Threefold improvement in patient ranking of:
Overall quality of care.
29 percent relative reduction in time from discharge order to patient discharge.
At MultiCare Health System, the processes for denial management were not as effective as they could be, negatively impacting net patient revenue and financial performance through millions of dollars in adjustments. While only two-thirds of denials are recoverable, nearly 90 percent are preventable. MultiCare looked at improving denial management as an opportunity to improve appropriate revenue capture for services provided. Through targeted improvement efforts that included standardized workflows and increased data visibility, the health system is improving the root cause of denials.
$14.99M reduction in denials and avoidable write-offs.
How Allina and Minnesota Perinatal Physicians Lowered Stress and Raised Satisfaction for High Risk Maternal Patients
Assuring patient satisfaction can be challenging, particularly when providing care to pregnant women with high-risk pregnancy conditions. As one of the foremost perinatal practices in the country, Minnesota Perinatal Physicians (MPP) acted swiftly to end a significant delay in scheduling ultrasound appointments, and reduced wait times for other visits.
With an aim to improve patient care and experience, the maternal fetal medicine (MFM) specialists at MPP, employees of Allina Health, leveraged Allina’s “Improving Clinical Value” Program—an initiative that has elevated the patient care experience for numerous other patient populations while simultaneously lowering the per capita cost of care for each one.
$210,000 in increased revenue because of improved access, projected to be $280,000 within 12 months.
20.8 percent relative improvement in no-show rate.
20 percent increase in available ultrasound appointments and an 18.2 percent increase in utilization.
Data-Driven Clinical Documentation Improvement Program Increases Revenue and Improves Accuracy of Risk Adjusted Quality Metrics
Allina Health, an integrated delivery system throughout Minnesota and western Wisconsin, has long understood the value of clinical documentation improvement (CDI), and its growing importance in recent years. With the implementation of ICD-10, the specificity needed for accurate coding has increased, and reimbursement shifts have occurred as well, creating sizeable payment disparity for some clinical conditions. Leaders at Allina wanted to understand where their CDI program would have the greatest return on investment. However, data from the EHR was not sufficient to inform their strategy. CDI specialists still lacked the ability to perform a comprehensive assessment of the accuracy of clinical documentation, and were unable to confidently target improvement efforts in areas that would generate the greatest return on investment. To take a more data-driven approach, team members leveraged the Health Catalyst Analytics Platform, including their Late-Binding™ Data Warehouse and broad suite of analytics applications to develop a CDI analytics application. With the application, the team identified opportunities and thoroughly vetted them, before collaborating with physicians and service line leaders to educate providers on documentation improvements.
They achieved the following results:
12.1 percent improvement in CV surgical cardiology CC/MCC capture rate.
6.3 percent increase in medical cardiology CC/MCC capture rate.
Increased accuracy in publically reported risk adjusted quality metrics
Revenue capture improvement across the system – resulting in millions of dollars of additional reimbursements.
Since 2004, the US healthcare system has annually ranked last relative to 10 other developed nations in quality, access, efficiency, equity, and health outcomes. In an effort to improve the quality of care and patient outcomes in the U.S., the Center for Medicare and Medicaid (CMS) launched a series of quality incentive programs designed to generate a shift from volume to value-based reimbursement. The health insurance industry soon followed their lead, and started writing contracts with hospitals in which a percentage of payment was based on performance on selected quality metrics.
Faced with the challenge of reporting on numerous incentive programs with differing expectations, Mission Health leveraged their enterprise data warehouse to aggregate the data needed to track the quality measures. With millions of dollars on the line with one particular payer, Mission developed an analytics application to monitor performance on the metrics in that contract. The application was used to analyze whether performance feedback and workflow changes would lead to improved performance on the metrics, thus ensuring that they would maximize reimbursement, while improving care for patients.
Achieved 100 percent of all at risk dollars.
100 percent of the ambulatory metric targets were exceeded, some by as much as 19 percent.
All five hospitals exceeded targets for 80 percent or more of their inpatient metrics.
Health spending in the United States is greater than the gross domestic product of most nations, and the costs for cardiovascular disease (CVD) and stroke care alone total $193.1 billion. CVD accounts for approximately one out of every three deaths in the U.S. and contributes to the shorter life expectancy of Americans. Thirty-five percent of CVD related deaths occur before the age of 75 years, and 19 percent before the age of 65.
Allina Health is a large integrated healthcare delivery network operating in Minnesota and western Wisconsin that includes three large cardiac centers. Due to the prevalence and mortality rate of CVD, leaders at Allina Health recognized that they needed to focus on cardiovascular health in order to truly impact the population health and patient outcomes of the communities they serve.
By leveraging real-time data from its enterprise data warehouse (EDW), Allina Health effectively identified and addressed clinical practice variation and operational issues affecting cardiovascular care and costs. In doing so, the health system realized more than $75 million in performance enhancement savings and revenue increase over a four-year period by focusing on supply chain, lab test and blood utilization, clinical practice changes and clinical documentation improvement.
One in three pregnant women give birth via cesarean section in the United States, which is more than double the rate the World Health Organization (WHO) recommends. And instead of decreasing, the overall C-section rate in Washington State increased 73 percent from 1996 to 2009. C-section rates are just one area of maternal care where our practice in the U.S. lags behind the science and knowledge of best practice. MultiCare Health System believes that all of its female patients should experience the same high-quality care across its integrated delivery system. The health of the next generation depends on it.
MultiCare recognized that it had to standardize care across its system to meet quality standards, improve its patients’ experiences and outcomes, and maintain its market share. The health system launched a Women’s Collaborative, the sole purpose of which was to improve clinical care and patient outcomes for women’s services systemwide.
By working with clinicians to implement standards of care, and using analytics to measure performance, the Women’s Collaborative achieved the following:
NTSV (low-risk, rst-time mother) C-section rate 9 percent less than the national average and already below the 2022 national goal of 23.9 percent
Six-point increase in market share for inpatient OB/GYN services
Improvements in care delivery:
63 percent reduction in episiotomy rate
11 percent reduction in SSI rate for C-sections
14 percent reduction in 3rd or 4th degree perineal laceration rate
Non medically indicated induction rate consistently less than a quarter of one percent
6.7 percent reduction in the percentage of abdominal hysterectomies
Texas Children’s Hospital has dedicated itself not only to successfully improving diabetes mellitus (DM) outcomes, but also to developing a framework for measuring the ROI of its performance improvement efforts. Texas Children’s tackled its DM initiative with a combination of technology investments and new organizational models, including an enterprise data warehouse (EDW) and analytics platform, a clinical care process team model for improving the quality and cost of care, and a diabetic care unit (DCU) staffed by a highly specialized, highly trained group of providers. Health system leaders also worked with the business school at Rice University to develop a model for measuring ROI that focused on easily quantifiable drivers. The results of this effort include substantially improved quality of care for DM patients, an increase in net revenue by a projected $232,000 annually, and an estimated ROI of 53 percent.
Improving clinical outcomes is good for patients and good for health systems. In fact, Allina Health’s focus on data-driven outcomes improvement realized a total financial improvement of $125 million in a single year.
Allina embraced the mandate of achieving the Triple Aim: improving the quality and cost of care, as well as the patient experience. To achieve this goal, Allina’s leaders recognized that they would need to realign their strategies, organizational structures, and management practices. Confident that data would help the health system improve the quality of patient care and reduce costs, they implemented a data-driven performance improvement strategy.
The results are astounding. This strategy has achieved financial improvements for the health system of $100+ million per year, four years running, while also advancing Allina Health’s Triple Aim goals of improved clinical outcomes and a better patient experience through dozens of improvement initiatives.
How to Avoid PQRS Penalties and Earn Potential Incentives with Accurate Submission of Quality Measures
CMS has recently transitioned its Physician Quality Reporting System (PQRS) program from a pay-for-reporting program to a program that will now apply a negative payment adjustment to providers who do not satisfactorily report data on quality measures. Memorial Hospital faced a significant problem when its PQRS reporting process was hampered by its transition to a new EHR system. They needed a solution. Learn how Memorial successfully used their enterprise data warehouse to submit the necessary data to a certified registry, avoiding a four percent Medicare reimbursement adjustment, and providing them with the potential to earn an incentive payment. They also now have several patient registries that can be used for quality improvement initiatives in clinical care, patient safety, and care coordination.
Studies have shown that elective deliveries before 39 weeks increase the risk of newborn respiratory distress as well as increase the rates of C-sections where there is a higher rate of postpartum anemia and longer lengths of stay for both mothers and babies. Payers are partnering with healthcare organizations to lower elective delivery rates. Learn how this healthcare organization reduced their elective deliveries by 75 percent in just six months and received a six-figure payer partner bonus.