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Despite EMR, Revenue Cycle Management Costs Were Still Substantial

Posted on April 26, 2018 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

While they may not say so out loud, most healthcare organizations bought EMRs largely because they believed they could use them to lower revenue cycle management expenses. If so, they may be somewhat disappointed. A new study has concluded that at least in one case, the presence of a certified EMR didn’t make much of a dent in these costs.

­To conduct the study, researchers conducted interviews with 27 health system administrators and 34 physicians at a large academic medical center. The interviews took place in 2016 and 2017. The research team used the feedback to create a process map charting the path of an insurance claim through the RCM process.

Using this data, the researchers calculated the cost of each major billing and insurance-related activity, as well as a total cost of processing a claim from end to end. The data included costs for five types of patient encounters, including primary care visits, discharge ED visits, general medicine inpatient stays, ambulatory surgical procedures and inpatient surgical procedures.

The team concluded that estimated processing times and total costs for billing and insurance-related activities were 13 minutes and $20.49 for a primary care visit, 32 minutes and $61.54 for a discharged ED visit, 73 minutes and $124.26 for a general inpatient stay, 75 minutes and $170.40 for an ambulatory surgical procedure and 100 minutes and $215.10 for an inpatient surgical procedure.

To put these numbers in perspective, the research team noted that billing costs represented an estimated 14.5% of professional revenue for primary care visits, 25.2% for emergency department visits, 8% for general medicine inpatient stays, 13.4% for ambulatory surgical procedures and 3.1% for inpatient surgical procedures.

There are more than a few unfortunate things to be seen in these numbers.

One is that primary care practices spent a very high percentage of revenue on RCM, which could be crushing given their typically low margins. Given that PCPs are already being squeezed by patients who can’t afford to meet their high deductibles, this is a recipe for financial disaster.

It’s also troubling to see that that the academic medical center in question was spending more than 25% of its ED revenue chasing insurance payments. I found myself wondering whether ED prices might drop to a reasonable level if it was easier for these departments to collect from insurers.

It’s scary to think that these numbers might’ve been higher before the academic medical center installed its EMR. As things stand, if the EMR is lowering RCM costs, it doesn’t seem to be having a major impact. But I’m just guessing here — what do you think?

Pilot Effort Improves EHR Documentation

Posted on February 9, 2018 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Though EHRs were intended to improve medical documentation, in many cases they seem to have made documentation quality worse. Despite their best intentions, bogged-down physicians may resort to practices — notably excessive copy-and-paste usage — that turn patient records into bloated, unfocused data masses that don’t help their peers much.

However, a pilot program conducted by a group of academic medical centers suggests using a set of best practice guidelines and templates for progress notes can improve note quality dramatically. The pilot involved intern physicians on inpatient internal medicine rotations at UCLA, the University of California San Francisco, the University of California San Diego and the University of Iowa.

According to a related story in HealthData Management, researchers rated the quality of the notes created by the participating interns using a competency questionnaire, a general impression score and the validated Physician Documentation Quality Instrument 9-item version (PDQI-9).

The researchers behind the study, which was published in the Journal of Hospital Medicine, found that the interns’ documentation quality improved substantially over the course of the pilot. “Significant improvements were seen in the general impression score, all domains of the PDQI-9, and multiple competency items, including documentation of only relevant data, discussion of a discharge plan, and being concise while adequately complete,” the authors reported. Even better, researchers said notes generated by the participating interns had about 25% fewer lines and were signed 1.3 hours earlier in the day on average.

One side note: despite the encouragement provided by the pilot, the extent to which interns used templates varied dramatically between institutions. For example, 92% of interns at UCSF used the templates, compared to 90% at UCLA, 79% at Iowa and only 21% at UCSD. Nonetheless, UCSD intern notes still seemed to improve during the study period, the research report concluded. (All four institutions were using an Epic EHR.)

It’s hard to tell how generalizable these results are. After all, it’s one thing to try and train interns in a certain manner, and another entirely to try and bring experienced clinicians into the fold. It’s just common sense that physicians in training are more likely to absorb guidance on how they should document care than active clinicians with existing habits in place. And unfortunately, to make a real dent in documentation improvement we’ll need to bring those experienced clinicians on board with schemes such as this.

Regardless, it’s certainly a good idea to look at ways to standardize documentation improvement. Let’s hope more research and experimentation in this area is underway.

Roche, GE Project Brings New Spin To Clinical Decision Support

Posted on January 10, 2018 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

The clinical decision support market is certainly crowded, and what’s more, CDS solutions vary in some important ways. On the other hand, one could be forgiven for feeling like they all look the same. Sorting out these technologies is not a job for the faint of heart.

That being said, it’s possible that the following partnership might offer something distinctive. Pharmaceutical giant Roche has signed a long-term partnership deal with GE Healthcare to jointly develop and market clinical decision support technology.

In a prepared statement, the two companies said they were developing a digital platform with a difference. The platform will use analytics to fuel workflow tools and apps and support clinical decisions. The platform will integrate a wide range of data, including patient records, medical best practices and recent research outcomes.

At least at the outset of their project, Roche and GE Healthcare are targeting oncology and critical care. With a pharmaceutical company and healthcare technology firm working together, providing tools for oncology specialists in particular makes a lot of sense.

The partners say that their product will give oncology care teams with multiple specialists a common data dashboard to review, which should help them collaborate on treatment decisions. Meanwhile, they plan to offer critical care physicians a dashboard integrating data from patient’ hospital monitoring equipment with their biomarker, genomic and sequencing data.

The idea of integrating new and possibly relevant information to the CDS platform is intriguing. It’s particularly interesting to imagine physicians leveraging genetic information to make real-time decisions. I think it’s safe to say that we’d all like it if CDS systems could bring the rudiments of precision medicine to thorny day-to-day clinical problems.

But the truth is, if my interactions with doctors mean anything, that few of them like CDS systems. Some have told me flat out that they end up overriding many CDS prompts, which arguably makes these very expensive systems almost irrelevant to hospital-based clinical practice. It’s hard to tell whether they would be willing to trust a new approach.

However, if GE and Roche can pull off what they’re pitching, it might just provide enough value it might convince them. Certainly, creating a more flexible dashboard which integrates data and office workflows is a large step in the right direction. And it’s probably fair to say that nothing like this exists in the market right now (as they claim).

Again, while there’s no guaranteed way to build out useful technology, bringing a pharma giant and a health IT giant might give both sides a leg up. I wonder how many users and patients they have involved in their design process. Let’s see if they can back up their promises.

To Avoid Readmissions, Hospitals Trying Post-Discharge Clinics

Posted on December 12, 2011 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

In recent years, hospitals have been under increasing pressure to keep their readmission rates low. The next bump in the road comes in October 2012, when Medicare will begin cutting back on reimbursement for facilities whose readmit rates are too high.

Hospitals are already hard at work at preventing readmissions due to preventable medical errors, which may not be reimbursed at all by Medicare at all. But it seems like they’re still far behind in the care coordination department.

In fact, research suggests that they’re facing an uphill battle, in part because patients often don’t get the kind of follow-up care they need.

In theory, fragile patients  should move smoothly from inpatient care to their PCP, ideally a medical home equipped to coordinate whatever follow-up care needs they have. Few primary care practices are up to speed yet, however.  In fact, some aren’t even sure when their patients are discharged.

How bad is the problem? According to one study quoted in The Hospitalist, only 42 percent of hospitalized Medicare patients had any contact with a primary care physician within 14 days of being discharged.

One solution to this problem might be a “post-discharge” or transitional care clinic offering primary care on or near a hospital’s campus, the article notes. This makes sense. After all, it’s more likely a patient will follow through and get follow-up care if it’s convenient to do so.

The idea behind these clinics isn’t to replace the patient’s existing PCP; instead, the clinic’s hospitalists, advance-practice nurses or PCPs are there to make sure patients absorbed their post-discharge instructions and are compliant with the meds prescribed during their stay.

Some hospitals have invested significant resources in building out transitional clinics, including Beth Israel Deaconess Medical Center, Seattle-based Harborview Medical Center and Tallahassee (Fla.) Memorial Hospital, which partnered with a local health plan to kick off the effort.

That being said, the idea is a new one and few other hospitals have taken the plunge as of yet. It will be interesting to see whether this approach actually works, and particularly, whether one model of transitional care stands out.

P.S.  I’d particularly like to know whether hospitals can accomplish some of these objectives by monitoring patients remotely after they’re discharged. After attending last week’s mHealth show, I’m betting remote monitoring would be cheaper than setting up a new clinic. Can’t wait to see whether hospitals try that route!

 

 

 

So many blank spots on the clinical data map!

Posted on November 21, 2010 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Emergency medical technicians evacuating an in...

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EMTs collect a lot of data on their trip to the emergency department — and usually, data treating ED physicians will want pretty badly when they see the patient. But in virtually every case, most of that critical info transfer takes place on paper or in a hurried conversation amidst much noise and distraction.

Community medical centers collect as much data on patients as private primary care practices do,  but how often are they connected with hospitals — even those that have done a big ambulatory EMR rollout?

And what about blood banks?   Independent clinical labs like LabCorp.?  School medical offices?  Is anyone paying attention to their data, or is it just being ignored?

Look, I don’t mean to be a dunce here. It’s not as though hospitals and medical practices are sitting around buffing their nails and waiting for something to happen, data-connection wise.

But it’s worth remembering, despite the labor involved in hooking up hospitals and primary care practices, that there are data leakage everywhere.  Until we look the flow of data more wholistically, whole workflows will be designed as though such relationships didn’t even exist — and that’s a Bad Thing.

I say, start with the EMT data, as it’s the closest to the point of care, but regardless of how you expand your clinical data source map, expand it. Otherwise, you’ll be left with a nasty information design problem and finding a workaround will be a nighmare.  Think about it.

(This editorial’s content draws on a speech given by Vivian Funkhouser of  Motorola at a trade show held last week by Everything Channel.)

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Can Priceline-style tactics transform medical practice?

Posted on July 14, 2010 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Yes, I realize the above is a pretty extravagant headline — the “real” Priceline isn’t involved here — but follow me, and tell me  if you think the question is on point.

Yesterday, I spoke to Alex Fair of FairCareMd.com, a New York-based company which lets patients and doctors directly negotiate a “fair deal” on services between themselves.  Physicians give (presumably big) discounts on services in exchange for getting cash on the barrelhead once the service is delivered.  The site is in beta but still worth a look;  seems the key pieces are in place.

Fair, a former scientist who’s been a serial entrepreneur for many years, once designed software helping doctors successfully beat claims denials, so he definitely knows the territory. And he’s obviously right that if they get cash up right away, doctors can easily beat the “retail” prices they’re sometimes forced to charge to cover health plan collection costs.

Fair’s (reasonable) assumption is that FairCareMD will be a lifesaver for patients with high deductibles or no insurance at all, as well as giving them a way to get procedures the insurance industry won’t cover.  Not only will patients have access to deeply-discounted fees, if the patient can’t find the deal he or she wants, they can push for a better price at a number they can live with. That is indeed along the lines of Priceline.com’s “name your own deal.” (I’m here to tell you that *that* mechanism works very well indeed.)

On the surface, the concept makes sense. And there’s precedent for it.  For example, a thriving market in cash-for-surgical-services, much along these lines, already exists in the bariatric surgery industry, as many health plans refuse to cover such procedures. Ah, the power of capitalism to work around other capitalists!

In his first month since launch Fair reports over 5,000 searches for care on his site, though only about 1 in 200 visitors requested a deal from a provider.  On average these deals have saved 47 percent off “list prices” so far. Fair’s surprised that so few consumers are making requests.  On the other hand, it’s only a few weeks after launch, and other sites have millions of such requests, so he’s in wait and see mode.

My guess is that a) people don’t see the value of shopping for prices just yet — so thoroughly has the health insurance industry hornswoggled them and that b) they’re likely to see more valuable in accessing such services if they pay a subscription fee. Just a human nature thing.

So hey, folks, what do you think? What will it take for consumers to feel comfortable paying doctors directly again?  Fair isn’t the only company banking on this notion  — in fact, there are several, including some with a national presence  — but my instincts suggest they haven’t won consumers over completely yet either.

An even bigger question:  Do you see the broad mass of consumers developing those sorts of relationships with hospitals anytime soon?  Now *that* would be a neat trick.

NOTE:   If you’re in the NYC region, or plan to be next week, you can meet Fair and other local social media/health entrepreneurs  at a Manahattan-based Health 2.0 meetup (details at  http://www.health20nyc.com/calendar/13913750/?eventId=13913750&action=detail#initialized).  Looks like it’s going to be a very nice group. I’ll be moderating a panel, so if you’re there please stop by and say hello!

Video: Accountable care organizations, the Steve Jobs way

Posted on July 10, 2010 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

This video, by healthcare consultant Anthony Cirillo, offers a neat suggestion — why not sic Steve Jobs on the accountable care organization model?  As Cirillo sees it, Jobs is one of few execs out there who really understands how to build complex things in a lean, functional way.

“When we develop products, we’re about putting as many features into them as possible, and hospitals, as many services as possible,” Cirillo says. “But Steve Jobs…wouldn’t just build an accountable care organization, he’d build your accountable care organization, where you would get just the amount of care you needed at the right time in the right place.”   More below:

Don’t be distracted by the guitars hanging on the wall in the background — they’re just symbolic of Cirillo’s other passions, singing and songwriting.  What he has to say on this subject is definitely worth a listen.

Passing the buck, or, why PCPs *are* the problem

Posted on July 9, 2010 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Look, let me say up front that I’m very sympathetic to primary care practices.  I mean, truly.  My family is lucky enough to have access to a small, intimate primary care practice, and I kid you not, I love those folks.

All that being said, I just had an experience which tells me that changing PCP business models are creating a very, very large problem.

What of my experience?  Well, in theory, it was no big deal.  I called in after hours to ask about a family medical problem which worried me, and asked for a bit of guidance.   I was just concerned enough about a family member’s health to see a bit of extra help.

The response I got was another matter. Rather than asking why I had called after regular practice hours, and what my concerns were, the clinician taking call said (more or less verbatim): “Well, I didn’t see (Jill) yesterday when you brought her in, so I have no idea what’s going on with her. Take her to the ED if you want, but I can’t help you.”  I was silent for a bit, shocked by her rudeness (she’s usually very helpful), then said “If that’s what you think” and hung up.

Because I know enough to avoid the ED whenever possible, I held off, and things turned out fine. But this encounter raised a few questions which trouble me deeply:

*  Let me get this straight: Are patients supposed to go to the ED first these days so as not to inconvenience their PCP?

*  If they do contact an on-call PCP, should they be afraid that their call will be “unsuitable” or not worth addressing?

*  Has the whole notion of taking call deteriorated so much that PCPs covering the night shift will only talk to patients they’ve seen recently?  If so, they’re nudging many, many patients to the ED who might otherwise just need a word or two.

For many years, the ED was the pressure point in the whole health system, with ED administrators secretly hoping to avoid uninsured GOMER (Get out of My Emergency Room) patients. (Yes, not very sensitive terminology.)

Now, the problem seems DCAHs (Don’t Call After Hours).  Greviously-stressed care practices just aren’t prepared to absorb the costs of after-hours care or even telephone advice, and it’s throwing the system out of balance in a new way.

As things stand, the exploding primary care clinician shortage just keeps getting worse and the need for patients to have medical homes is climbing. Pile these issues on top of the already overloaded primary care business — in which margins are so bad that practices are adding day spas, for heaven’s sake — and you’ve got real trouble.

Ultimately, I think all of these problems are going to be resolved, and I’m very clear that PCP practices want to help. In the mean time, someone’s going to have to do a better job of fielding the 5PM to 9AM gap in care.  Telemedicine, urgent care centers and retail clinics are making a dent, but they can only make a dent in the problem.   This is a very big deal, and it’s only going to get bigger.

Can hospitals be saved? Some fresh ideas

Posted on June 4, 2010 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

No matter what you do, there will always be people who consume more hospital resources than others, notably the chronically-ill poor with spotty access to ongoing care.  They’re sicker, over a longer time, and to boot have no way to pay their bills.  In that situation, everyone loses.

But is there a way to solve this problem without going broke?  Maybe.  Here at nextHospital we’ve been intrigued by news of a couple of proposals intended to help patients AND ensure hospital solvency:

*  Redeveloping commercial property around urban hospitals and leveraging it to bring a flow of traffic, personnel and physicians to the door. This would bring urgent care/retail clinics, primary care practices and other support mechanisms to the hospital’s doorstep. Ultimately, the idea is to tend to the of the sickest, most expensive patients first — the weakest link, if you will — freeing up more resources to improve care for everyone else.

*  Bringing together community healthcare organizations (including  hospitals) together into a self-sufficient economic unit which can afford to turn away managed care contracts — and offer affordable care. (See an overview by Dr. Jonathan James of Community MedPAC here:  http://www.box.net/shared/65h1c6sax0)

We don’t yet know enough about these models to predict whether they’ll work or not, and to our knowledge, neither has been fully implemented. However, there’s no question that there’s a big payoff, both financially and ethically, for those who can improve access to care while reducing financial strains to the system.

Are there other hospital care financing models which look like they can change the game?  If you’ve found any, we’d love to hear about it.

Theory #2: nextHospitals must provide primary care–*on site*

Posted on July 20, 2009 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Conventional wisdom breaks the healthcare system into two big silos.

There’s acute-care hospitals, which tend the acutely ill, and there’s primary care providers, which handle the sniffles,  hives, chronic disease management and anything else that isn’t likely to kill a patient within a few hours.  In between, there’s a big black hole where patients pretty much sit around feeling like hell and wondering just how much worse things are going to get.

This bifurcation is absolutely insane and has got to end.  It makes an assumption which is absolutely counterintuitive–in fact, which is simply crazy–which is that hospitals have no business treating anyone who isn’t at death’s door.  The nextHospital has to completely shatter this assumption by providing appropriate care, from throat cultures to the crash cart, for anyone who shows up at its door.  

Not only is the only sane, humane and appropriate way to treat the human beings who enter your doors, it’s the cheapest way to treat those who don’t need intensive services; after all, an all-night walk in clinic is almost 50 percent cheaper than ED care! Kinda sounds like a good idea, doesn’t it?

What makes hospitals’ failure to offer step down care even more foolsh is that all they’d have to do is invite Walgreens or CVS to bring in one of their TakeCare or MinuteClinics, which I’m pretty darned sure they’d be happy to do. No fuss, no muss, virtually no overhead. Everyone wins. Explain to me why this isn’t a good idea?

The current system assumes that if the healthcare system is falling apart, it’s all the fault  of nughty patients who come to an emergency department and somehow don’t know that they aren’t that sick after all.  Remember, the learned papers that castigate patients who show up in the ED and somehow fail to need lifesaving treatment aren’t any kinder to those who simply overestimated their acuity than those who use the ED as a primary care center.

Now, I’m not suggesting that primary care physicians shouldn’t exist, and that hospitals should take over their place in the community. But I am suggesting that hospitals accept their role as caring for people, not emergencies, and govern themselves accordingly.  It’s more efficient, it’s more effective, and it’s more appropriate.  Anything else just wastes time and money, while scaring away patients who need your help.