In this special Speaker Series, Becker's Healthcare caught up with Patricia Goede, PhD, vice president of clinical informatics at XIFIN.
Dr. Goede will speak on a panel during the Becker's Hospital Review 4th Annual Health IT + Revenue Cycle Conference titled "Prior authorization and Financial Sustainability of Genomic Testing in Precision Medicine" at 9:00 a.m. Thursday, Sept. 20. Learn more about the event and register to attend in Chicago.
Question: In the past 12 months, how have you adapted to new patient experience expectations in the age of consumerism?
Patricia Goede: In today's world, reimbursement is tied to value-based care, and patients are the key to measuring what value means for any healthcare system. The Agency for Healthcare Research and Quality defines the patient experience as an integral component of healthcare quality that encompasses the range of interactions patients have with their physicians and is the foundation of patient-centered care. The practical aspect of patient experience is how patients engage in their healthcare as consumers, from price comparison for tests and procedures, to active involvement as a participant in their care. The trend toward patients as consumers is gaining traction through technology and access to information. Tools that patients utilize to 'shop' and 'engage' require new ways of providing access, such as [patient] portals, while meeting the challenges of privacy and security.
XIFIN solutions are [developing tools] specifically to manage financial, clinical and diagnostics for physicians, providers and laboratories in the healthcare system. However, the trend of incorporating the patient into the clinical workflow and decision-making process is an area of focus and functionality that we have also been providing for our customers. We recognize that patient experience is not limited to how to interpret a billing statement, but may also include how the amount on the billing statement links to the diagnostic report that is read by the care team to arrive at a diagnosis. In the same manner, physicians, providers and laboratories are now focusing on how to engage patients in their care using portals that are tailored to meet the specific needs of XIFIN customers and their clients. Patients as consumers are demanding accountability, transparency and access with the evolution of patient portals and other electronic tools. We're also expecting that the maturing population of millennials will request a cost estimate and comparison before undergoing treatment. Here at XIFIN, we continually strive to provide quality solutions for our clients to facilitate all aspects of communication with patients throughout each individual patient's journey and to help maintain patient loyalty and retention.
Q: What do you see as the most vulnerable part of a hospital's business?
PG: I see the most vulnerable part of a hospital's business being how to manage reimbursement changes from two Medicare [related] legislative mandates: Protecting Access to Medicare Act and the Medicare Access and CHIP Reauthorization Act. These are the two most significant pieces of legislation hospitals are facing as they move to pay for performance and shared risk.
PAMA legislation is based on reported data from private health plans and designed to save Medicare Part B payments $400 million in 2018. Cost cutting alignment will continue through the Clinical Lab Fee Schedule for the highest-volume diagnostic tests, a move that will have a significant impact on margins. Another example of PAMA's impact is the requirement that ordering physicians consult on and document advanced imaging orders through a qualified Clinical Decision Support Mechanism that relies on a set of defined Appropriate Use Criteria. Where the CLFS impacts hospital labs, the Medicare Physician Fee Schedule will drive reimbursement through requirements for documentation that physicians use clinical decision support when ordering any advanced imaging study that will impact radiology and oncology reimbursement.
MACRA legislation is designed to move to, or eliminate, fee-for-service [payment models] and usher in value-based reimbursement through quality reporting by combining three programs: Meaningful Use, Physician Quality Reporting System and the never-ending problem of the Sustainable Growth Rate 'Doc Fix' into a single quality program. MACRA is designed to reduce Medicare Part B spend by establishing reporting requirements around quality that are directly tied to value and patient safety through two tracks: Merit-based Incentive Payment System and Alternative Payment Models. Both tracks have reporting requirements that are designed to encourage quality reporting through process and clinical improvement measures with payment schedules that include incentives and penalties, which are derived from a score that is based on how well the health system, laboratory or physician reports their data. While incentives can start anywhere from 4 percent, penalties also are assessed by the same measure.
What complicates matters is CMS' 2018 MPFS and the Quality Payment Program Final Rules to revise PAMA and MACRA. The 2018 Final Rule, passed on November 2, 2017, aligns the CDS consultation requirements of PAMA with the quality reporting initiatives in MACRA. The 2018 Final Rule aligns PAMA and MACRA [by] requiring clinical documentation that demonstrates consultation of AUC and cost display for determining payment for extraordinarily high cost cases — [known as] cost outliers — on laboratory and radiology orders. Clinical documentation will be required for every Medicare Part B member on the claim that utilizes a standardized unique identifier or Decision Support Number beginning in January 2020. If a claim does not contain clinical documentation, it will not be paid. At XIFIN, we focus on providing solutions to hospitals and labs that help them plan ahead to mitigate risks and adopt a way of thinking that protects reimbursements and optimizes the revenue cycle through documentation.
Q: How do you promote innovation within your organization?
PG: I feel that innovation begins with engaged employees. Our CEO, Lâle White, takes innovation to the next level by setting a standard of combining innovative leadership with strategy to enable continued improvement across all stakeholders. Her philosophy has always been as a steward of important values that links strategy to independent thinking to transcend conformity, giving employees a sense of purpose and value to the organizational mission. Here at XIFIN we don't just talk about innovation, we engage in the rigorous exercise of collaboration to capture ideas and bold thinking, and [we] encourage open communication across all functional units and departments. In today's environment, business models change and diversity in business is constantly evolving. Innovation is the key to a diverse and long-term sustainable business model.