With uncertainty surrounding the ACA and the new administration, payers and providers alike are facing many challenges. Payers are bracing themselves for the 20 million people who could become uninsured, 20 percent of providers remain unfamiliar with the requirements set in place by MACRA and 35 percent of providers are still not getting paid via alternative payment models. These challenges, in addition to any potential roadblocks from new policies, mean that the industry needs to have a strong understanding of where they stand in their journey to value and the potential risk they can feasibly take on. To understand this, healthcare organizations need a strategic partner that can provide best-in-class analytics and guidance on how to make the most of their analytics investment. MedeAnalytics’ consulting team helps clients across the nation better leverage their data and turn cost-saving opportunities into realities.
In this week’s blog post, we explored the current client landscape with Karen Mitchell, Group Vice President of Consulting Services. This Q&A highlights how MedeAnalytics’ consulting services are helping clients overcome their challenges to remain successful in the competitive healthcare landscape, along with her predictions and hopes for the industry throughout 2017.
1. What are some of the common challenges that healthcare organizations come to you with, especially with the uncertainty around the ACA?
Due to rising costs, the continued transition to value-based care and new CMS regulations, financial risks are greater today than they ever have been. Provider organizations are looking for insight into how they can accurately and appropriately bill to decrease denials, improve payment accuracy and ultimately increase revenue and cut costs. Our consulting services can help organizations better identify ways to manage their financial risk so they don’t inadvertently miss revenue opportunities or receive less reimbursement than contracts stipulate.
Payers are facing similar issues due to variations in the cost of services from hospital to hospital. For example, knee and hip replacements are very common operations in the U.S. with about 1 million done each year. In most cases, health plans are not incentivizing members to go to hospitals with lower costs and higher quality outcomes, putting millions of dollars on the line in potential losses from high-cost, lower-performance hospitals. We can help payers identify high-performing hospitals and collaborate on strategies that encourage members to use these top providers, all of which can generate major savings for all.
2. What role do consulting services play after the analytics implementation process?
Our consulting team offers post-implementation services aimed at driving adoption, identifying value and engaging and educating employees on our solutions. We offer an in-depth assessment, in which we comb through the organizations’ data and identify 15-25 areas where they can change processes or establish initiatives and save money. In most cases, these savings come from procedural, administrative or healthcare costs. Here are two examples of how we help providers and payers.
For providers, one common cost saving area is around health plan authorizations. Most hospitals have the information and technology available to engage with health plans effectively, but they don’t let the data do the talking. For example, when a patient gets admitted to the ER, hospitals will take the patients’ insurance information and contact the insurance company to obtain authorization. Unfortunately, this sometimes doesn’t happen in a timely manner, leading to a service write-off. One of our assessments looks at why hospitals are being denied and makes recommendations for communication improvement opportunities with health plans. This ensures that everyone is aligned and services rendered are being reimbursed in a timely manner. These changes reduce write-offs, administrative re-work time and bill-to-payment cycle time.
For health plans, optimizing drug utilization can generate immediate cost savings. Through a pharmacy claim analysis, our consulting team can identify physicians or medical groups that are over utilizing drugs or are using the most expensive drug available. For example, at Covenant Health, we identified a patient who was taking an expensive medication four times a day. Working with the Covenant team, we identified a similar medicine that could instead be taken twice a day at a lower cost.
3. Where do you expect the industry to go in the next year and what are your hopes for healthcare organizations in 2017?
Demographic shifts in our population will have a major impact on the healthcare industry in the next few years. By 2050, the global population of people aged 60 and older is expected to rise to 2 billion, up from 900 million in 2015, creating a greater demand and need for providers. The increase in the aging population coupled with the shortage we are already facing, will produce obstacles for the healthcare industry since aging populations tend to have numerous chronic conditions that require added care. To better service the changing demographics of the population, the industry needs to improve the efficiency of the healthcare system and identify treatment alternatives, which include increased utilization of nurse practitioners or more online communication.
In addition to serving the everchanging population, we will continue to see more payer and provider organizations come together to form integrated health systems. For those organizations who aren’t adopting this model, they will need to improve their partnerships, communication and data sharing to maintain a competitive edge with more integrated players. If we continue to encourage these types of relationships and eliminate the animosity that has existed for so long between payers and providers, the industry will rapidly move towards more cost-effective practices and value-based care.
Regardless of the state of the ACA, the healthcare industry will face many challenges and changes in the coming years. With the millions of people who could become uninsured without the ACA, the continued transition to value-based care and MACRA, healthcare organizations must quickly address the future head on with user-friendly analytics as they will play a crucial role as the payer and provider collaboration continues– whether it is in the form of full integration or simply just more open channels.