Many changes are occurring in healthcare, with the next 10 years unlikely to look like the last 10. Numerous articles have been written by authors on the shift from volume to value. This briefing will focus on the above issues, simple and broad in concept, but integral to success in the new era of healthcare.
This content is sponsored by Accretive Health.
"Just as there was a schism between payers and providers for decades, there remains a divide between the various components of the healthcare experience," says Emad Rizk, MD. "The clinical and financial aspects of care remain disparate, and providers do not have a comprehensive view of their patients. Retrospective claims data and clinical outcomes can improve the prospective coordination of care. And, it is essential to manage risk."
The lack of an integrated clinical and financial database and the absence of a single patient identifier will create redundancies, increase costs and lead to sub-optimal identification of gaps in care. Without addressing gaps in care in a timely fashion, the inappropriate coordination of care will eventually lead to poor outcomes. Although it sounds simple, the merging of clinical and financial data is quite difficult, but definitely possible. It will require interoperability, and significant cooperation between payers and providers.
Dr. Rizk said, "It is easy to hide behind the difficulties of bringing the data sets together. But I know if the will is there, it will happen. I have seen it done in small geographies around the country. Most importantly, I used to believe that healthcare was different, unlike any other industry. But we have a lot to learn from other industries that have experienced similar inefficiencies and solved them."
Dr. Rizk is CEO of Chicago-based Accretive Health, a healthcare company that manages end-to-end revenue cycle management of hospital systems. Prior to his position with Accretive Health, he was the president of McKesson Health Solutions, a healthcare services and information technology company dedicated to helping customers deliver high-quality healthcare by reducing costs, streamlining processes, and improving the quality and safety of patient care. Dr. Rizk has a unique and in-depth understanding of the healthcare ecosystem on both a strategic and operational level. He understands the business models and interdependencies of payers, providers, government, and pharmaceutical/biotechnology organizations. He has developed and led strategies for change with Deloitte, McKesson, and now Accretive Health. Dr. Rizk has committed much of his career to closing the gap between the administrative and clinical sides of healthcare.
The Importance of Patient/Consumer Engagement
Patient/consumer engagement is the second dynamic that healthcare is lagging in. In most industries, the consumer is critical to success of any company.
Dr. Rizk states, "In healthcare, consumers are patients who are in a vulnerable state, and they do not understand the economics or the clinical jargon. They do not have any transparency: Is the bill right? Is my doctor's advice good? Does this hospital excel in this procedure/surgery/treatment? Patients are participants without any navigating power."
What makes this problem important is that patients will now have significant financial liability, and will be required to participate in their own care. The prevalence of high deductible plans, copays, tiers of networks, and disparate payments for different procedures and drugs will require patients to be well versed in their own care.
Dr. Rizk shares, "It is the provider and the health systems responsibility to create transparency of economics and clinical interventions. We have to be the advocates for the patients and their families, and bring all the information to the patient at the point of care. Health and wellness can only be successful when you have an engaged consumer empowered to navigate their own health".
The gap between receiving care and paying for it can narrow. When the right information is made available to patients — such as price estimates for certain services or understandable medical bills — they can make informed decisions about their care and payment plans. When communication after a patient's visit is not only about billing, but also the promotion of health and wellness, patients feel more engaged in maintaining their health. A majority of patients who rate their experiences negatively do so solely based on administrative tasks (i.e., waiting time, uncertainty of cost, billing, etc.).
Setting Patients Up for Success with Financial Literacy, Advocacy
"Although hospital finance teams may be well-versed in the ABCs of health insurance, navigating the world of co-pays, deductibles and out-of-network specialists is not so obvious to consumers — especially when they are ill," says Dr. Rizk.
"Health insurance is complicated. Few would dispute that statement, and several studies have documented gaps in health insurance literacy among consumers."
In a 2014 Kaiser Family Foundation survey, only 4 percent of respondents correctly answered all 10 questions on a quiz about health insurance terminology. Fewer than 75 percent of respondents could define a deductible or an annual out-of-pocket limit. More than half of respondents mistakenly believed all physicians are in-network if they provide care at an in-network hospital.
Dr. Rizk says the lack of clarity about in- and out-of-network status drives a substantial amount of unexpected medical bills and, as a result, patient dissatisfaction. In the past two years, 30 percent of privately insured Americans received a bill for which their health plan paid less than expected. In that same time period, 1 in 7 consumers were surprised to find a physician, lab or hospital that they believed to be in-network was actually out-of-network, according to a 2015 Consumer Reports national survey. He also points to local and national news stories of hospital patients hit with surprising and substantial medical bills post-discharge, which have come to be a regular occurrence and increased the sense of unease toward paying for care.
High-deductible plans are forcing patients to pay for more of their care out-of-pocket, which is driving patients to become more involved in care management decisions. "This means inquiries about price, or at least price estimates, are to be expected. Yet most hospitals remain ill-prepared to answer these questions," says Dr. Rizk.
In February, the Pioneer Institute released a study of price transparency at 54 hospitals in six different U.S. metropolitan areas. Of the hospitals included, only nine had systems in place to provide price information in a consumer-friendly way.
"Pricing is complex in healthcare, but patients deserve to know the cost of the services they're purchasing before they do so," says Dr. Rizk. "And when they do make those informed decisions, patients can become more committed to lifestyle choices that have a very real and direct effect on their personal finances."
In a push for price transparency, Dr. Rizk and his team at Accretive Health are working on technology to determine and communicate an accurate, educated estimate of what procedures will cost before the procedure is done. "We work closely with hospitals and health systems to help them effectively provide the information patients need to make decisions," he says.
"We want to make it easy for patients to be informed about healthcare finance," says Dr. Rizk. "If patients can check the prices of hotels, airfare and menu items on a mobile device, why should that ability not translate to their medical care? Accretive Health is seeking new tools to deliver information to the patient with apps no different than what they use on their smartphone."
Patient Engagement Through Active Health Management
"The traditional fee-for-service payment model did not financially incentivize patient engagement efforts, but this is no longer the case," says Dr. Rizk. Today, patient engagement is increasingly important to a hospital or health system's financial sustainability. Since accountable care contracts and narrow networks hold providers at risk for the utilization of care for an attributed population of patients across a defined period of time, providers face mounting pressure to keep patients in the network and affect behavioral change. Without complete and actionable data, providers have a difficult time doing so.
"If a patient is not incentivized to stay within a particular network, especially before the deductible is met, that can completely disrupt the balance of risk," says Dr. Rizk. He points to the results of Medicare Shared Savings Program ACOs around the country as an example. In summer 2015, only about 25 percent of MSSP ACOs earned a performance payment, while nearly half ended up costing Medicare more than expected. "I believe patient engagement and benefit design has to be part of the reason some ACOs see better results than others," says Dr. Rizk.
Healthcare providers not only have to work to keep patients in the proper network — they also have to instill healthy behavioral changes. Another way to describe patient engagement is "active health management," says Dr. Rizk. "This includes exercise and diet changes, scheduled wellness visits and preventive care, adherence to medications, scheduled follow-up appointments, and regular dialogue with the care team to ensure compliance with the care plan and the identification of any preventable complications."
"The largest opportunity is for hospitals to effectively manage care between interactions across the continuum of care and patient outreach," says Dr. Rizk. "Follow-up communication to a patient shouldn't entirely focus on billing. It can and should include follow-up on prescription refills, inquiries about the need for home care and confirmation of check-up appointments. Any and all of those communications will improve medication compliance, recovery and health maintenance."
Conclusion
Because healthcare involves health, illness, morbidity and mortality, it has a deep and emotional impact on people and their families.
That said, the industry has overcomplicated everything about the administrative and financial aspect of healthcare. It is time to simplify, collaborate (across physicians, hospitals, government, payers, pharmaceuticals/biotechnology, etc.), benchmark other industries, and begin to engage the most important customer of all: the patient.
Patient engagement is defined in many different ways, according to Dr. Rizk. "One component of engagement is empowering patients with the information they need — such as price estimates — to make the right decisions about their care. Another component is ensuring that post-service communication is not only about billing, but also the promotion of healthy behaviors."
It is essential for hospitals to find the right resources and partner that help manage revenue processes while making patient relationships stronger. Dr. Rizk says this is critical for hospitals to lower the cost curve and achieve improved patient outcomes, and it's possible with the proper mix of analytics, technology and personnel.
"The best healthcare professionals practice compassionate and comprehensive care," says Dr. Rizk. "This is their passion and purpose, so it is a serious disservice when a patient is treated with compassion only to face administrative and payment processes that feel disparate, impersonal and incomplete."