Session # 205 Implementing Sustainable Revenue-Cycle Workflows: CayHealth ACO and Intermountain Healthcare

Transcription

1 Session # 205 Implementing Sustainable Revenue-Cycle Workflows: CayHealth ACO and Intermountain Healthcare DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2 Conflict of Interest Disclosure Dale Sanders and Todd Craghead Travel expenses provided by: Craneware, Inc HIMSS

3 Overview The concept of the accountable care organization (ACO) has been one of the hottest topics in healthcare Many see ACO as the best path to efficient quality care for the U.S. healthcare system This is the story of two organizations seeking the goal of high-quality, high-efficiency, low-cost care CayHealth: a national health system implementing a new ACO-style model for a small nation Intermountain Healthcare: a U.S. health system renowned for its track record of reducing costs while delivering exceptional quality Both offer useful insights and models for healthcare leaders seeking to find their way in the world of ACO 3

4 Learning Objectives Identify the five key components that executives should focus on when working to improve their organization s revenue cycle and operational efficiency while delivering quality care Summarize how to successfully drive revenue cycle performance using proven best practices Recognize how sustainable revenue cycle management can greatly improve overall patient care at a lower cost Discuss how the underlying economic model of healthcare is changing from Fee-for-Service to Fee-for-Quality Explain the major impact that this shift will have on traditional revenue cycle processes

5 Dale Sanders Chief Information Officer, National Health Services Authority, Cayman Islands Senior Vice President, Healthcare Quality Catalyst Senior Research Fellow, The Advisory Board 15 years in healthcare 12 years in US Air Force; space & defense; and manufacturing IT 5

6 Overview Doing things differently in the Cayman Islands CayHealth & CarePay Problems and flaws in the US healthcare reimbursement and revenue cycle model 6

7 Healthcare Billing at a Restaurant You wait 45 minutes for a table, even though you had a reservation. You tell the waiter that you re hungry but there s no menu. The waiter returns with a meal that he thinks is appropriate for you but he doesn t know how much it costs. You have no idea what the food is or what it costs, but you agree to eat it. You leave without knowing your bill. The restaurant sends the bill to your bank, not you. Your bank tells the restaurant, Your waiter ordered the wrong thing for you. We re not paying for it. 90 days later, the restaurant calls to tell you that your account is being turned over to collections. 7

8 Changing the Economic Mindset Revenue to our hospitals and clinics is an Expense to The Ministry of Health and employers We can t talk about revenue in the same context as in the past. It s time for a change in mindset. 8

9 The Cayman Islands Three islands 50,000 people Territory of the UK Tax free since 1794 Wreck of the Ten Sails 128 different races and nationalities $1.7T in financial assets under management #5 in the world 9

10 Cayman Islands Healthcare Ministry of Health Environment, Youth, Sports & Culture Health Services Authority HSA Two hospitals, 150 beds Six clinics Public Health System National Insurance Company CINICO Fee-For-Service, CPT driven Moving to ICD driven reimbursement 80% capitation inpatient & outpatient Balances the tension between cost and service 10

11 Financial Performance $10.0 Annual Net Revenue (million) $5.0 $- 2005/ audited 2006/ audited 2007/ audited 2008/ audited 2009/ unaudited 2010/11 - forecast $(5.0) $(10.0) $(15.0) $(20.0)

12 Factoids HSA US 103 FTEs (Full Time Equivalent) employees at HSA are involved in billing and reimbursement 31% of healthcare costs are in administrative overhead associated with billing and claims processing That s about $50,000,000 per year in Cayman 12

13 Cayman s CarePay Project Partnership between HSA and CINICO Real time, point of care eligibility verification and claim adjudication Goal: Model a retail credit/debit card transaction The patient will know their coverage and out-ofpocket expenses at the point of care No Mystery Billing, days later Claims denials reduced or eliminated completely Elimination of medical record coding from the revenue cycle 13

14 CarePay: Point of Care Financial Adjudication & Transaction 14

15 CayHealth Capitated payments for inpatient and outpatient treatment Including chronic condition management ICD-based billing, not CPT Reimbursement tied to quality of care Evidence of evidence based medicine

16 CayHealth + CarePay An Electronic Medical Record that integrates Patient specific data Patients Like This population management data Cost of care data At the point of care, in the physician s workflow

17 The Building Blocks: Multiple Vendors IMO Patient Problem & Diagnosis Terminology BMJ Clinical Practice Guidelines Craneware Charge Master IMO Patient Procedure Terminology BMJ Evidence Based Medicine Metrics Cerner Chronic Condition Management Cerner PowerChart Clinical Encounter

18 A New User Interface for EMRs

19 Summary The US insurance and claims processing environment is the single greatest threat to sustainable healthcare quality and affordability If we ignore patient accountability for their own choices, that is Insurance companies profit from the gross inefficiencies We refuse to accept the status quo of the US for the Cayman Islands The Cayman CarePay concept can be applied in the US 19

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21 Todd Craghead Vice President of Revenue Cycle Organization, Intermountain Healthcare Accountable for approximately 1500 FTEs 22 years in healthcare Leadership finance positions with healthcare systems and managed care organizations Helped to lead Ernst & Young healthcare consulting practice 21

22 Another Perspective For some organizations, cessation from the union is not an option Achieving profitable, efficient, high-quality care within the US system presents some different challenges Many of the same critical success factor still apply: Taking a system-wide approach Focusing on understanding and managing costs and revenue performance every step of the process Creating a culture of revenue integrity

23 23 Non-profit hospitals 150 Medical group clinics 625 Employed physicians Health Plan Division (SelectHealth) $5.2B Gross patient revenues ($3.0B Net) Provider of choice and last resort in Utah Mission to provide excellent care regardless of ability to pay

24 Our Vision Our vision is to be a model healthcare system by continually learning and providing extraordinary care in all its dimensions: Clinical Excellence Service Excellence Physician Engagement Operational Effectiveness Employee Engagement Community Stewardship 24 24

25 A systems approach to healthcare not only improves quality, it reduces cost. 25

26 Revenue Cycle Summary Vision Be the Best FOR the Nation Revenue Cycle Organization Standardize engineering out unnecessary variability in process, systems, and tools Centralize achieving efficiency from scale Organize creating areas of focused expertise, centers of excellence that include checks and balances needed in a large scale organization

27 Processes and Enabling Technologies that Sustain the Revenue Cycle

28 Focus on Pre-Service and Point of Service Collections Scheduled Services -Pre-Service -Point of Service Emergency Department Quality Review Measurements & Accountability

29 Web-based Calculator FINANCIAL ASSISTANCE INITIATIVES Voucher program Excluded services & services requiring approval process Centralized processing of applications Online application Patient Risk Automated estimation of patient liability

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32 Automated Patient Liability Estimation Service Line-Specific Estimations Technology leverages historical charging practices by provider to Patient Benefits evaluated Real-Time Payer Benefit Searches Technology reviews benefits data in order to provide the most up to date and accurate information. Remit Analysis Estimates are compared to payer remittance in order to validate the accuracy of the data, and improve service line crosswalks. Payer Webbots EDI / Clearinghouses Contract adjustments applied based on member benefits Practice patterns used to determine total charges Benefit searches further enhance and improve the accuracy of estimation of patient liability. 835/837 remits also used to verify patient liability Accuracy Analyses Enhances Estimate Algorithms

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34 Revenue Integrity enhanced by leveraging Charging Technology Automating the charge master management processes using Craneware tools empowers Intermountain to manage by exception and improve accuracy and efficiency Integrated workflows connect our health system's varied revenue management processes Greater visibility using technology allows us to achieve bestpractice operating processes across the enterprise

35 VP Clinical Operations and operational directors have goals tied to Charging Practices Monthly, one-on-one meetings with Clinical Operations and Revenue Cycle leaders make certain that there is a cohesive partnership Clinical leadership meetings have agenda items related to charge practices

36 The strategy that has never failed Intermountain Sustaining the lowest appropriate cost for the people we serve

37 Questions and Discussion Cell/Text: Work: