Get the E-newsletter
In an ideal world, people with volatile chronic conditions could identify specialists whose patients are more likely to avoid emergency department (ED) visits, inpatient admissions, and the debilitating health crises that prompt them.
A handful of gastroenterology practices are paving the way for that to happen. In response to the value movement in health care, leading gastroenterologists in Chicago and Pittsburgh are adapting the patient-centered medical home model to treat patients with inflammatory bowel disease (IBD)—and the benefits to the patients have surprised even the physicians.
Their care models are somewhat different, but here’s what they have in common: Each has reduced ED visits and hospitalizations for patients with IBD by more than 50 percent.
Most gastroenterology practices are not set up to provide the patient engagement and integrated care that are essential to the medical home model. But as the implications of this new approach to chronic care management become clear, patients with IBD and other chronic conditions can be expected to seek out the providers who can keep them healthy.
The same goes for health plans and employers. For example, Blue Cross and Blue Shield of Illinois is so happy with the medical home care delivery model for IBD care used by Illinois Gastroenterology Group (IGG), Chicago’s largest gastroenterology practice, that it has expanded the concept to three other practices around the state. The health plan contracted with SonarMD, which provides technology that supports IGG’s patient engagement strategy, so that the other practices can deliver the same proactive care for high-cost patients.
“We’ve replicated our original approach with IGG and hope to replicate the same results for our members,” Donna Levigne, divisional senior vice president of healthcare delivery for Blue Cross and Blue Shield of Illinois, says in emailed comments.
Miguel Regueiro, MD, a gastroenterologist and co-director of the Total Care-IBD specialty medical home at UPMC, foresees a day when integrated, high-touch care for patients diagnosed with IBD becomes standard. Providers thus need to get prepared.
“If they are not doing something like this in the future, the payer is going to demand it,” he says. “Trying to figure this out in their own region is going to be important.”
IBD is an umbrella term for two autoimmune digestive disorders—Crohn’s disease and ulcerative colitis—that affect about 1.6 million Americans. Although the conditions can go into remission for long periods, both have painful and serious symptoms that can wreak havoc on patients’ lives. More than half of people with Crohn’s disease will require surgery to address damage to their colon. Some patients with ulcerative colitis, the more common condition, must have their colon removed.
Because of surgeries and hospitalizations—and, in some cases, the use of expensive biologics—patients with IBD have high healthcare costs. Annual direct costs are estimated at $12,000 to $20,000 per patient.
In recent years, specialists have come to recognize that patients with IBD often have mental health and psychosocial comorbidities that exacerbate symptoms and complicate treatment. In a white paper published by the American Gastroenterology Association earlier this year, Regueiro and coauthors write that “whole person care”—medical care plus psychosocial, environmental, and behavioral interventions—may “result in achieving highest health value.”a
Some health plans are stepping up to support the new approach to care. Through its “intensive medical home” contract, Blue Cross and Blue and Shield of Illinois pays IGG a per member, per month fee to support the labor-intensive care delivery model. After a successful pilot, the insurer started encouraging gastroenterology practices across the state to follow the example.
“This specialty intensive medical home model—which is aimed at improving patient care while reducing avoidable complications and associated treatment costs—has enormous potential for making the healthcare system work in a sustainable way,” Levigne says.
Meanwhile, in Pittsburgh, UPMC Health Plan uses the term specialty medical home to describe the Total Care-IBD program developed by Regueiro and his colleagues. Total Care-IBD is in the third year of a pilot in which the gastroenterology care team serves as the principal provider for patients with IBD, responsible for coordinating and managing all their healthcare needs, including behavioral health and psychosocial support.
UPMC Health Plan is supporting the work with funding for additional staff. With the pilot ending next year, the plan and associated providers are working on the details of a novel alternative payment model.
The idea of adapting the patient-centered medical home approach to IBD care began when IGG’s Lawrence Kosinski, MD, MBA, analyzed Blue Cross and Blue Shield of Illinois claims data on the Crohn’s disease patients in his practice to understand why the care of those patients is so expensive. He found that ED visits and hospitalizations were the big cost drivers—and that, in the majority of cases, patients had not visited their gastroenterologist in the month before excruciating pain or severe dehydration from diarrhea required emergency treatment.
“We’ve uncovered something that I myself didn’t have any idea we would encounter: Patients with chronic disease flirt with the edge all the time,” he says.
Patients may get so used to feeling ill that they don’t recognize when their status is deteriorating until they are in a crisis. In response, Kosinski and his colleagues developed a whole new way of interacting with patients who have Crohn’s and ulcerative colitis. Nurse care managers—aided by a smartphone app that asks patients to answer a few questions about their health status on the first day of each month—constantly monitor patients. At the first sign of deterioration, patients are urged to visit the gastroenterologist’s office to head off a serious problem.
“People who have serious chronic diseases like IBD need a little hovering,” Kosinski says. “You need to be there for them not only when they perceive they need intervention, but when we perceive they need intervention.”
In the first two years of IGG’s intensive medical home contract, inpatient costs for patients with Crohn’s and ulcerative colitis dropped by about 60 percent. Overall costs for these patients are about 10 percent lower than they were before implementation of the new care delivery model, Kosinski says, and significantly lower than the costs for patients in a control group.
When Regueiro and his colleagues were developing their specialty medical home for high-utilizer IBD patients, they hoped to decrease both ED visits and hospitalizations for those patients by 2 percent from the previous year. In fact, ED visits fell by 52 percent and hospitalizations by 53 percent during the first year of the pilot, Regueiro says.
He co-directs the specialty medical home with psychiatrist Eva Szigethy, MD, PhD, an expert in behavioral health services for patients with chronic illnesses. They supervise a large care team—nurse practitioners, nurse coordinators, social workers, and dietitians—that provides a wide range of services not typically offered by gastroenterology practices. Many Total Care-IBD patients also work with UPMC Health Plan health coaches on lifestyle modifications.b
Based on the pilot’s early results, Regueiro is “cautiously optimistic” that the specialty medical home care model will point the way to a better standard of care for patients with IBD. He believes integrated psychosocial support, including easy-to-access telepsychiatry, is one key to success. Other vital elements are team-based care, enhanced access for outpatient visits, and care coordination.
“Whether it will be called a medical home going forward, I don’t know,” he says. “But as the disease becomes more complex, with the need to provide psychosocial care and help with pain management, specialty centers are going to get more referrals and a new care model will evolve.”
Lola Butcher writes
about healthcare business and policy topics for several HFMA publications.
Interviewed for this article: Lawrence
Kosinski, MD, MBA, partner,
Illinois Gastroenterology Group, Chicago; Donna Levigne, divisional senior vice
president-healthcare delivery, Blue Cross and Blue Shield of Illinois; Miguel
Regueiro, MD, co-director, Total Care-IBD, University of Pittsburgh Medical
a. Szigethy, E.M. Allen, J.I., Reiss, M., et
al., “White Paper AGA: The Impact of
Mental and Psychosocial Factors on the Care of Patients With Inflammatory Bowel
Clinical Gastroenterology and Hepatology,
b. Regueiro, M., Click, B., Holder, D., et al., “Constructing
an Inflammatory Bowel Disease Patient-Centered Medical Home,”
Clinical Gastroenterology and Hepatology,
6 Patient Revenue Cycle Metrics You Should Be Tracking (and How to Improve Your Results)
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
10 Ways to Reduce Patient Statement Volume (and Reduce Costs)
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
Reduce Patient Balances Sent to Collection Agencies: Approaching New Problems with New Approaches
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
The Future of Online Patient Billing Portals
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Payment Portals Can Improve Self-Pay Collections and Support Meaningful Use
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Large Health System Drives 10% UP (Patient Payments) and 10% DOWN (Billing-related Costs)
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
ICD-10: Managing Performance
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Clarity Drives Collections
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Orlando Health Gains Insight into Denials, Reduces A/R Days with RelayAnalytics Acuity
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
Revenue Cycle Payment Clarity
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Streamlining the Patient Billing Process
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Wallace Thomson Hospital Automates to Maximize Limited Resources
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
7 Steps for Building and Funding Sustainability Projects
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Key Capital Considerations for Mergers and Acquisitions
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
Key Capital Considerations for Mergers and Acquisitions
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
Trend Watch: Providers adapt as value-based care moves from hype to reality
Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.
Yuma Regional Medical Center case study
Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities.
Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.
Reforming with a New 50-Bed Acute Care Facility
Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.
5-Minute Briefing on Revenue Integrity Through HIM WhitePaper Hospitals FS
As the critical link between patient care and reimbursement, health information enables more complete and accurate revenue capture. This 5-Minute White Paper Briefing shares how to achieve cost-effective revenue integrity by your optimizing HIM systems.
5-Minute Briefing on Accelerating Cash Flow Through HIM WhitePaper Hospitals FS
Speedier cash flow starts with better CDI and coding. This 5-Minute White Paper Briefing explains how providers can improve vital measures of technical and business performance to accelerate cash flow.
5-Minute Briefing on Reducing the Cost of RCM WhitePaper Hospitals FS
Qualified coders are getting harder to come by, and even the most seasoned professional can struggle with the complexity of ICD-10. This 5-Minute White Paper Briefing explains how partnerships can help improve coding and other key RCM operations potentially at a cost savings.
Providers Focus Too Much On Revenue Cycle Management
The point of managing your revenue cycle isn’t just to improve revenue and cash flow. It’s to do those things effectively by consistently following best practices— while spending as little time, money, and energy on them as possible.
Lucille Packard Children’s Hospital Stanford Case Study
How Lucile Packard Children’s Hospital Stanford increased payments received within 45 days by 20% and reduced paper submission claims by 70% by using ZirMed solutions.
Using Predictive Modeling To Detect Meaningful Correlations Across Claims Denials Data
The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.
ZOLL and Emergency Mobile Health Care Case Study
Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.
Maximizing Medicare Reimbursements White Paper
Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.
Denials Deconstructed: Getting Your Claims Paid
Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.
Automation and Operational Improvement Drive Sustainable Results
Physician practices must improve organizational efficiency to compete in this era of reduced reimbursement and escalating administrative costs.
Revenue Cycle Management Resolves Migration Implementation Issues
Many healthcare organizations are pursuing next-generation health information systems solutions. Learn more about Navigant's work with University of Michigan Health System.
Partnering For Success – Provider Achieves Strength in Stability
The proper implementation of healthcare information technology systems is crucial to an organization’s financial health.
Building a Clinically-Integrated Network
As value-based payment models evolve, providers are challenged to maintain superior clinical outcomes while controlling costs.
Winning in the Post-Acute Marketplace
Read more about factors contributing to the changes in the post-acute marketplace and what it means for manufacturers, physicians, clinicians, patients, and post-acute facilities as they anticipate the transition to the second curve.
Building A Common Vision with Employed Physicians
HSG helped the physicians and executives of St. Claire Regional in Morehead, Kentucky, define their shared vision for how the group would evolve over the next decade. As well as, develop the strategic and operational priorities which refocused and accelerated the group’s evolution.
Practice Performance Improvement
The client was a nine-hospital health system with 14 clinics serving communities in a multi-state market with very limited access to care, poor economic conditions, high unemployment, and a heavy Medicare/Medicaid/uninsured payer mix. In most of these communities, the system was the sole source of care.
Though the clinics were of substantial size (they employed 98 physicians) and comprised of multiple specialists, the physicians functioned as individuals and the practices lacked any real group culture.
Clinical Integration Without Spending a Fortune
Clinical integration can be expensive, but it doesn’t have to be, as this four-step road map for developing a CIN proves. Does it have to cost millions to initiate a clinical integration strategy?
Contrary to popular belief, we have clients who have generated substantial shared savings and a significant ROI over time, without massive investments. Yes, some financial capital is required for resources the CIN providers can’t bring to the table themselves. But the size of that investment can be miniscule relative to the value it produces: improved outcomes and documentation for payers.
Adding Value to Physician Compensation
Today’s concerns about physician compensation are the result of the changing healthcare environment. The transition to value is slow, but finally becoming a reality. Proactive hospitals want to ensure that provider incentives are properly aligned with ever-increasing value-based demands.
This report focuses on the three big questions HSG receives about adding value to physician compensation; Why are organizations redesigning their provider compensation plans? What elements and parameters must be part of successful compensation plans? How are organizations implementing compensation changes?
Effective Revenue Cycle Management in Your Network
Revenue Cycle Management has become an even more complex issue with declining reimbursements, implementation of Electronic Health Records, evolving local carrier determinations (LCD), and payer credentialing [The emphasis on healthcare fraud, abuse and compliance has increased the importance of accuracy of data reporting and claims filing).
The efficiency of a medical practice’s billing operations has critical impact on the financial performance. In many cases, patient billings are the primary revenue source that pays staff salaries, provider compensation and overhead operating cost. Inefficiencies or inaccurate billing will contribute to operating losses.
Succeeding in Value-Based Care
This publication identifies and outlines the necessary characteristics of a fully-functioning clinically integrated network (CIN). What it doesn’t do is detail how hospitals and providers can participate in the value-based care environment during the development process.
One common misconception is that the CIN can’t do anything significant until it has obtained the FTC’s “clinically integrated” stamp of approval. While the network must satisfy the FTC’s definition of clinical integration before single signature contracting for FFS rates and contracts can legally start, hospitals and providers can enjoy three key benefits during the development process.
Therapy: Benefits at All Levels of Care
Nearly half of all Medicare beneficiaries treated in the hospital will need post-acute care services after discharge. For these patients, a stay in an inpatient rehabilitation facility, skilled nursing facility or other post-acute care setting comes between hospital and home.
Does Your Budgeting Process Lack Accountability?
With the proper process, tools, and feedback mechanisms in place, budgeting can be a valuable exercise for organizations while helping hold organizational leaders accountable. Having a proper monthly variance review process is one of the most critical factors in creating a more efficient and accurate budget. Monthly variance reporting puts parameters around what is to be expected during the upcoming budget entry process.
Cost Accounting: the Key to Cost Management and Profitability
Managing the cost of patient care is the top strategic priority of most hospital CFOs today. As healthcare shifts to more data-driven decision making, having clear visibility into key volume, cost and profitability measures across clinical service lines is becoming increasingly important for both long-range and tactical planning activities. In turn, the cost accounting function in healthcare provider organizations is becoming an increasingly important and strategic function. This whitepaper includes five strategies for efficient and accurate cost accounting and service line analytics and keys to overcoming the associated challenges.