Thursday, August 8, 2013

Simple solutions can help fill gaps in health care

by Dan Gunderson, Minnesota Public Radio

FERGUS FALLS, Minn. — Martha Hitzeman is legally blind, and at 87, needs medication for pain and to prevent strokes.
But sometimes she forgets to take her pills.
"She was starting to miss doses, sometimes maybe four or five doses in 10 days," said her daughter, Marie Fuchs. "So I knew she wasn't getting the medication she needed."
Fuchs, who manages her mother's medication, enrolled Hitzeman last August in MedSmart, a pilot project run by PioneerCare a long-term-care facility in Fergus Falls.
Her mother now has a small device on her kitchen table that holds two weeks' worth of medication. The automated dispenser beeps twice a day -- and keeps beeping until Hitzeman tips it over and the pills are dispensed.
"When I hear it ringing, I do what I need to do and take my time getting out here 'cause it will ring till I get here," Hitzeman said. "It's really a wonderful convenience."
By ensuring that elderly people take medications, the simple device could allow them to stay healthy and out of the hospital or nursing home. After a year, it has proved so successful that other communities plan to start using the program.
MedSmart was created in response to a state Minnesota Department of Human Services request for ideas that could help elderly patients stay at home. It is funded in part by a $117,000 DHS matching grant.
The device is connected to a phone line, and if it isn't tipped over within an hour, Marie Fuchs will receive an automated text message.
"I was able to take a week's vacation last fall and not worry about her taking her meds every day," Fuchs said. "It gives her the independence and gives me the peace of mind that she's getting what she needs."
The MedSmart program costs patients $39 a month. Data collected during the project found the device reduced medication errors for most participants.
In Fergus Falls, there are 73 people using the MedSmart program, 40 of whom are monitored each day. On a recent week, 39 took their medication as directed 100 percent of the time.
The device won't help everyone. For some, it won't provide the level of help they need. However, the project is filling a need in the community, said Todd Johnson, a pharmacist at Lake Region Healthcare in Fergus Falls.
"I know there's a case or two where family members have said, 'you pretty much allowed my family member to maintain independent living, when they weren't able to do that before,' " he said. "Non compliance, especially with chronic disease medications, or just not taking them properly or running out of them is a major cause of re-admissions, clinic visits."
"...How valuable is that medication if they're not taking it?"
- Karen Wulfekuhle, PioneerCare
There are a number of devices on the market that dispense medication, but what makes the Fergus Falls project unique is that it's not just about technology, said Karen Wulfekuhle, director of home and community services for PioneerCare. It provides a local team of health professionals who decide on the best solution for individual patients, she said.
Wulfekuhle is trying to convince insurance providers to pay for the medication reminder. She said it's not unusual for insurance to pay hundreds of dollars a month for drugs a patient needs.
"The argument is, how valuable is that medication if they're not taking it? A $39 a month charge for a machine that helps support their health - [it] makes sense to cover that expense if in turn it's going to keep them out of the hospital," she said.
Since 2003, DHS officials have awarded 400 grants to organizations that help fix health care gaps for the elderly according, Jean Woods, director of the department's aging and adult services division.
The grants cover a variety of community based projects. An earlier grant helped establish an electronic monitoring program for seniors in Fergus Falls. Another grant trained Somali volunteers in the Twin Cities to check on elders and perform basic home chores. In Aitkin County, a grant funds a volunteer program to add safety equipment to the homes of senior citizens to reduce falls.
"Minnesota has been very intent and very purposeful about wanting to make sure people, wherever they live in the state, can stay home and be served through home and community-based services," Wood said.
DHS officials awarded $2.3 million in grants during the 2012 fiscal year. The funding is appropriated each year by the legislature. The department tracks grant projects for five years. More than 90 percent become self sustaining, Wood said.

Medication Management: Integrating the Pharmacist as the Champion

Jon Easter, BSPharm, RPh
Published Online: Thursday, August 8, 2013

Pharmacists should solidify their place within the patient-centered medical home. Here is an early model that achieves better health outcomes through comprehensive medical management and a team-based approach.

I have worked in the pharmaceutical industry for more than 20 years. At my core, I am a pharmacist by training, and have long had a passion for exploring ways to integrate pharmacy practice into care teams with a goal of improving outcomes and lowering the total cost of care.

For me, this quest began in the mid-1990s working in state government affairs for GlaxoSmithKline (GSK) in the Pacific Northwest on pharmaceutical care initiatives with local pharmacy associations and schools of pharmacy. As I moved into the US Public Policy group at GSK, my role transitioned to educating policy makers on the results and benefits of the Asheville Project ( and eventually, to support a collaboration with the American Pharmacists Association Foundation to replicate the Asheville model through the Diabetes Ten City Challenge.

We haven’t been alone at GSK. Many leaders in the profession have worked tirelessly to elevate pharmacy practice as part of care coordination models. But challenges to date around payment for services, scope of practice, and a lack of technology needed to implement effective comprehensive medication management solutions have slowed the progress. However, to use an old cliché, there is light at the end of the tunnel. Today, the movement toward a value-based health care system in the United States represents an incredible opportunity for pharmacists, and most of all, for patients.

The United States health care delivery system is currently designed to focus on episodic care and acute illness. Most health care reform experts have articulated the need to improve the health care delivery infrastructure to enable better proactive management of chronic diseases and prevention services. However, implementing a better health care delivery system is interdependent on achieving payment reforms that align incentives to clinical outcome improvements, as well as connecting the care delivery infrastructure with health information technology, which facilitates the sharing of information and provides the needed quality data mining necessary for payment.

Improving the health care delivery system is a key, interdependent component of overall health care reform. One way to do this—coordinating the delivery of health care through a Patient Centered Medical Home (PCMH)—is gaining popularity among public and private payers as well as policy makers. The medical home model is gaining momentum because of its value proposition for the patient, physician, and payer by improving outcomes while lowering costs.

The medical home model is gaining strong political support as well. The 2010 Patient Protection and Affordable Care Act (ACA) contains several provisions relating to the PCMH. Most notable is the creation of the Center for Medicare and Medicaid Innovation (CMMI), which is piloting broad payment and delivery system reforms across the country. CMMI has launched 2 large demonstration programs, the Multi-Payer Advanced Primary Care Practice ( and the State Innovation Models Initiative (, both of which have a significant PCMH component.

In addition to the federal activity, most states understand the value of the medical home and several are currently implementing pilot programs. According to a recent Health Affairs (http://archive, 25 states have enhanced provider payment systems to encourage implementation of the PCMH within their Medicaid program.

Unfortunately, of all the great care coordination work being done across the country, very few of these initiatives have included clinical pharmacists on the care team. Appropriate use of medications is a key element of a coordinated care delivery system, and in my opinion, pharmacists are the best suited to lead the effort to optimize therapy and help patients achieve their clinical goals.

Demonstrated Success with PCMH

Nowhere is the value proposition of the patient-centered medical home model more clear than at Community Care of North Carolina (CCNC), an organization with which GSK is proud to have a long history of collaboration.

CCNC ( began in 1998 in order to improve health care quality and save costs. The program now provides care to more than 1 million Medicaid recipients in North Carolina and has grown to encompass 14 networks, 4500 primary care physicians, and 1000 medical homes. According to a 2011 Milliman analysis, CCNC saved the state of North Carolina almost $1 billion between 2007 and 2010, primarily through lower emergency department and hospitalization utilization. The Healthcare Leaders Council awarded CCNC its Wellness Frontiers Award in April 2013 for implementing evidence-based care management programs that prevent disease and encourage wellness.

CCNC relies on patient-centered medical homes, population health management, case management services, and community-based networks to deliver care. The program provides each Medicaid recipient a case manager to serve as their coach to make sure they understand doctors’ orders and get to their appointments on time. CCNC has further developed their care coordination networks by adding several disease management initiatives, including asthma, diabetes, and congestive heart failure, as well as a chronic obstructive pulmonary disease pilot program.

Pharmacists began to work with CCNC on its medical home program in 2007 after it was noticed that there were patients with diverse medications who were prone to polypharmacy-related problems. It was evident that pharmacists could enhance clinical outcomes by providing medication management (pharmaceutical care) services while also managing drug costs. While medication cost savings are a convenient ancillary benefit to the program, the primary objective of CCNC pharmacy projects has not been to minimize medication costs, but rather to achieve therapeutic optimization to maximize health.

This is a subtle but important distinction since the former contributes toward the volume-based system we are moving away from while the latter allows for prescriber and patient-centered interventions such as coaching for adherence that in some instances actually increase medication costs, but ultimately improve care, when appropriate.

A team-based approach—pairing a pharmacist with the case manager—has been used so that an assessment of each patient can be made and points can be prioritized to inform the primary care physician before they see the patient face-to-face.

Throughout the CCNC networks, there are now more than 50 pharmacists who are the lead project managers and facilitators of pharmacy-related activities within a certain geographic boundary. They participate in activities such as developing proposals for new initiatives, reporting to the network leadership on existing initiatives, or presenting at local medical management meetings. The scope of activities in the CCNC networks offers a unique opportunity and challenge for pharmacists, and there is a growing need for more.

Pharmacist Role in Care Coordination

So where else are the pharmacists working within a PCMH environment? It seems obvious that one of the key areas of care coordination between a health care provider and the community is that of comprehensive medication management. To date, predictably, most pharmacists playing an integral “care coordination” role are located within the public integrated delivery systems, such as the Veterans Administration and Health Resources and Services Administration, as well as the private integrated delivery systems, such as Kaiser Permanente. Unfortunately, the “siloed” nature of ambulatory medicine has prevented significant uptake in pharmacist participation to date.

Fortunately, the Patient Centered Primary Care Collaborative (PCPCC) recognized this opportunity and organized a multi-stakeholder workgroup to formalize the role of the clinical pharmacist within the PCMH. That group published the second edition of “Integrating Comprehensive Medication Management to Optimize Patient Outcomes” in June 2012 for physicians, insurers, payers, and pharmacists to follow as they formalize the medication management relationship between a pharmacist and provider care coordinator.

Additionally, previously in 2009, Dr. Edwin Webb from the American College of Clinical Pharmacy authored a white paper entitled “Integration of Pharmacists’ Clinical Services in the Patient-Centered Primary Care Medical Home.” Dr. Webb references several recommendations of the Institute of Medicine’s “Quality Chasm” report, and based on those recommendations, he suggests pharmacist integration into the PCMH should be based on 7 essential principles. These principles emphasize the need for pharmacists’ clinical services in a patient-focused environment, as well as highlight the need for a flexible care delivery design that is focused on outcomes with access to HIT systems. The final principle calls for aligned payment policies to substantiate the medication management process.

Given the momentum to evolve our health care delivery and payment system to one that is proactive, coordinated, and connected, I cannot think of a better time for pharmacists to solidify their place within medical homes across the country. As pharmacists, we must step up if we are ever to demonstrate the critical role of comprehensive medication management in achieving better health outcomes and lowering overall health care costs. What an opportunity for us, and there is no time to waste—the patient is waiting.

Jon Easter, BSPharm, RPh, is senior director, delivery and payment reform, at GlaxoSmithKline (GSK). His primary focus is health care transformation and the health information technology (HIT) policy environment, where he works to maximize its value to enable better health care quality, enhance the US health care delivery system, and ultimately improve patient outcomes. At GSK, Jon has championed the company’s involvement in North Carolina First in Health, one of the nation’s leading patient-centered medical home projects. He was also directly involved with replication of the Asheville Project, a recognized model for care coordination to improve patient outcomes for chronic disease. Jon has spent 20 years in the pharmaceutical industry. In addition to his public policy experience, Jon has implemented patient registry systems within GSK’s care management division, covered the Pacific Northwest for the state government affairs organization, and spent several years as a sales representative and district sales manager.

- See more at:


A highly anticipated drug trial fails to produce the desired results, costing a pharmaceutical company $500 million and 10 years of wasted research.

An energy company finds out too late that several major drilling bets are coming up dry, forcing them to take a $2 billion write-off.

Investigators follow leads for years to uncover a planned terrorist attack on a major city, only to make the fatal error in determining the location.
The pressure to discover breakthroughs is tremendous. In large organizations, it is often the difference between market success and market exit. Today, organizations need to deliver solid results within shorter innovation cycles. Research groups need to show a return on strategic investments. This “need for speed” heaps greater risk on an already risk-laden process and can sometimes make misleading discoveries look like real ones. Luck may shine once in a blue moon to produce an accidental discovery like Herceptin, but all too often misinterpretations can lead to disaster.
The intense pressure to uncover the “Next Big Thing” is our collective reality and it’s here to stay. That has led businesses and government agencies to ramp up Big Data efforts--a Gold Rush of sorts--to compile the richest and most comprehensive treasure troves of data they can to help make the best decisions possible. With greater computing power and collection technology, we now have vast datasets that hold the promise to solve some of our most challenging problems.


Few if any big decisions today are as simple as A v. B nor are the relative opportunity costs clear. Decisions related to drug discovery, energy exploration, fraud detection, and other critical problems can generate a variety of impacts downstream. And today misinformed decisions can cause a company more damage, faster than ever before.
This reality recalls the “Bullwhip Effect,” a concept popularized by Stanford University Professor Hau Lee to describe the oscillating effects caused by incorrect signal data in forecast-driven supply chains. When a person cracks a bullwhip, the small movements at the wrist produce huge waves at the other end of the whip, which describes how information becomes exaggerated and distorted as it moves up the chain, driving up costs and hurting efficiency. Great advancements have been made over the last 30 years to help companies deal with the perils of the Bullwhip Effect.
But there are no such countermeasures to minimize the bullwhip arc if decision makers do not understand what the data is telling them. When trying to develop a new drug, prevent terrorism, or identify fraud, the inputs and attributes are far more diverse, creating a complex puzzle to distinguish leading and misleading indicators.
Despite a wealth of data, decision-making today is harder, not easier. The issue is not the size of data, but the complexity. While data-crunching tools have become faster and better able to deal with large volumes of data over the years, they still all still begin with an Analyst and a query.


On the surface, we seem to have everything that we need to solve these problems. We have relatively inexpensive computation. We have a burgeoning discipline of Data Scientists and Analysts to build sophisticated models. We have faster data-crunching tools than ever before. And, we have large investments earmarked for addressing expensive problems. So why is this still so hard?
Put simply, while IBM’s Watson kills at Jeopardy, we are still confounded by the Jeopardy issue: What is the right question to ask? Every Big Data exploration starts with human assumptions and biases that amount to an educated guess in the form of a query.
With more larger and complex datasets, it is simply too difficult for the brain to the make connections that lead to making the optimal query. Instead, we spend months or years building models that examine only slices of the data, a highly unlikely path to uncovering critical discoveries or actionable insights. When it looks like we’re failing, we pile more humans on the problem. The simple truth is that--with the exponential growth of data--we’ll never have enough trained talent, or enough time to write all of the possible queries, to find the answers that we’re all looking for.


The complexity of today’s data sets--and so many investments in flawed insights--has forced decision makers to question the methods that they use for analysis. Just as in the case of the Bullwhip Effect, research teams need to go back to the start, to fix the fundamental problem that generates sub-optimal or just plain bad decisions.
In the world of Big Data, there is a wide spectrum of interplay between the human brain and machine learning systems. Think of it like a slider. Right now, our reliance on people to ask the right questions and identify the important connections between millions of data points, is too far over. Machine learning systems have made tremendous strides over the last few years and it’s time that we move that slider over and let systems do more of the heavy lifting, particularly at the beginning of the data analysis process. When presented with a holistic view of the data, Data Scientists can then examine valuable data in an agnostic manner and identify the relationships between them in a way they could not before. They can start by finding the answers to questions that they didn’t know to ask in the first place.
Let’s use both humans and machines to their best advantage. Computers do more of the computing over complex datasets and analysts do more of the analyzing. Instead of trying to ask the right question, we let those who best understand the problem--biologists researching cancers, geologists searching for energy sources, intelligence officers working to prevent terrorist attacks and other domain experts--find the right insight that inform sound investments to catalyze growth and save lives. After all, isn’t this the true promise of Big Data that we all dream of?
--Gurjeet Singh is cofounder and CEO of Ayasdi, an enterprise software company specializing in big data analytics. Follow them on Twitter at @ayasdi.
[Image: Flickr user Tausend und eins, fotografik]

Patients with RA at increased risk for DVT, PE

Chung W-S. Ann Rheum Dis. 2013;doi:10.1136/annrheumdis-2013-203380.

  • August 8, 2013
Patients with rheumatoid arthritis had a significant risk for developing deep vein thrombosis and pulmonary thromboembolism compared with patients without the conditions, according to study results.
Researchers used the Taiwan National Health Insurance Research Database to study 99% of the Taiwan population from 1998 to 2008 (n=23.74 million) and to identify 29,238 patients with rheumatoid arthritis (RA; mean age, 52.4 years; 77% women). A comparison cohort of 116,952 people without RA (controls) was matched by age, sex and index year. Cox proportional hazards regression models were used to analyze deep vein thrombosis (DVT) andpulmonary thromboembolism (PE) risk.
During a follow-up of 193,753 person-years for RA patients and 792,941 person-years for controls, there was a significantly higher overall incidence density of DVT for RA patients (10.70 vs. 3.22 per 10,000 person-years). The incidence rate ratio (IRR) was 3.34 (95% CI, 3.22-3.46) for RA patients compared with controls. Patients with RA also had a significantly higher overall incidence density of PE compared with controls (3.60 vs. 1.75 per 10,000 person-years) and an IRR of 2.06 (95% CI, 1.97-2.14). After adjustment for age, sex and comorbidities, patients with RA had an adjusted HR of 3.36 for DVT (95% CI, 2.79-4.03) and an HR of 2.07 for PE (95% CI, 1.55-2.76) when compared with controls.
“These findings highlight the importance of a multidisciplinary team adopting an integrated approach to the intervention of potential risk factors among patients with RA,” the researchers concluded. “Future research concerning RA severity scale, such as disease activity, functional impairment and physical damage are warranted.”

Zen and the Art of Revenue Cycle Maintenance

Maintaining healthy revenue cycle operations is not easy. There are a million moving pieces and it is easy for routine maintenance items to fall to the bottom of the priority list. Left undone; however, a seemingly small chore can grow into a major problem, resulting in huge financial losses. Zen meditation is not enough to deal with these stressors!
To make your revenue cycle operations more Zen-like, you need to build a revenue cycle task calendar. This will help make order out of chaos, prevent the loss of institutional knowledge that comes with staff turnover, and allow you to focus on non-maintenance initiatives.
To build this maintenance calendar, determine and assign responsibility for each task completion. Then determine the frequency. Organize it into daily, weekly, monthly, quarterly, and yearly tasks. To get started on your task list, review the sample tasks below. Also, as you are building your calendar, talk to people in your organization to get cross-functional input. Consider color-coding your task list by people or department. Build a calendar with what you have now – you can always add things as you go.
The following samples of tasks can get you started.

Sample Daily tasks

  • Use work task queues. What tools does your system offer to assist in daily work? Use queues or visit owner tools to track productivity. Organize your queues according to how your billing tasks are divided. For example, make a queue for following up on claims filed more than 30 days ago.  Some programs offer productivity reports based on task queues. You can use this to rebalance the workloads in your billing department.
  • Resolve all payments. Payments entered into the billing system must be posted to patient accounts and not left outstanding. Otherwise, you have money posted to your system that is sitting out there unapplied and unassociated to a patient account. This will affect system closing, reports and outstanding balances on patient accounts. The longer unapplied funds sit around, the more difficult it becomes to post.
  • Close daily batches. Batches are like cash registers for charges and payments. Close your register each day to make it easier to balance and for reporting purposes.
  • Run daily reports. Which daily reports do you run? How do you benchmark and measure success? How do you balance financials? Run your daily reports (even if you save them to a PDF to save paper). Wish you had better reports to match your needs? Most systems have the option for you to request and purchase custom reports for a nominal fee.
  • Balance income. Run a deposit slip report and balance the monies you entered into the system with what you physically have in front of you. Does the cash indicated on your deposit slip match the cash you are taking to the bank? Do your credit card slips all add up to your total on the deposit slip? Try balancing as soon as you can at the end of the day and allow yourself time to troubleshoot and backtrack to find and correct mistakes.
  • Reconcile EMR charges and appointments. To prevent missing charges, audit the appointments on the schedule to ensure that the patient was seen. You may need to have a few days’ lag time between the appointment and the EMR charges to allow the providers’ time to enter the charges. If not done on a daily basis, this could turn into a major chore that can end up resulting in missed revenue and inaccurate documentation.
  • Perform an EMR charge sweep. Depending on your system and setup, there may be opportunities to do a large sweep to retrieve EMR charges awaiting import. This is helpful because this allows you to bring over charges that were entered after the initial visit or charges that do not have a coordinating appointment. Left undone, you may have charges ready to come over from EMR but miss them because they fell through the cracks and were never brought over to billing. EMR charges left unbilled are a costly mistake.
  • Adjust capitated insurance balances. If you have insurances that are capitated and the balances need to be adjusted off, do it on a daily basis so the outstanding amounts are not skewing your accounts receivable. Some systems allow you to setup the fee schedule to automatically adjust off the balance when the charge is posted. Whichever the method, get the charges adjusted off as soon as possible so that your accounts receivable is more accurate.
  • File primary and secondary insurance claims. Regular claim filing will provide a steady stream of insurance payments or denials. File electronic and paper claims daily. 
  • Resolve rejected insurance claims. Stay on top of rejections. The newer the rejection, the easier it will be to resolve. Contact your software support if you do not understand a rejection reason rather than refilling the claim or dropping it to paper. Clearinghouse and payor edits are known to change so contact support and fix the rejection correctly the first time around.
  • Follow up on appeals and denials. Some claims take a little more elbow grease. Do not miss out on revenue due to lack of follow up. Track your appeals and denials and look for trends. Do not be afraid to reach out to your insurance representatives to discuss and resolve.
  • Post insurance and patient payments. Payments should be posted daily as to allow for accurate reporting and to reflect the most current state of outstanding accounts. Aging performance measures include analyzing the number of days between posting charges and when the payment was collected and entered.
  • Perform internal collections tasks. Collections for both insurance and patient balances are important to improve your accounts revenue cycle. The internal collections process can also include payment plans.
  • Follow up with external collections. When you turn over accounts to external collection agencies, adjust off account balances with the appropriate adjustment type so they do not remain on your current A/R. When the payment is received, adjust the amount back on with the appropriate adjustment type. Tracking what you write off compared to what is received is helpful in monitoring the collection agency’s productivity. Also, using the appropriate adjustment types will provide an accurate picture of why amounts are adjusted.

Sample Weekly Maintenance Tasks

  • Send out patient statements. If this is not already in place on a daily basis, ensure that it is a weekly task. Sending out weekly, rather than monthly, statements will aid in leveling out the amount of payments and phone calls received. If you send out monthly statements, you may get a rush of payments to post and calls from patients with questions.  
  • Close out credit balances. Credits and refunds are often overlooked. Left untouched, these will skew your financial reports. Review the balances and find the reasons for the credits. Does a patient owe a balance on another date of service but have a credit on others? Did the patient pay a copay by mistake and the amount needs to be refunded? Get the credit balances off of your A/R.
  • Go through returned mail. It is a waste of time and money to continue to send outstanding patient balances to bad addresses. In addition, you are helping to provide quality patient care by facilitating the correct mailing address for important medical care such as test or lab result notifications sent by mail.
  • Audit “unsigned” items in EMR. There is a common gap between EMR systems and billing processes. If charges are entered in EMR and then imported to billing, you must check in EMR too for all charges that should already be on your “to do” list. Audit unsigned items in EMR, including documents, flags/notifications, orders, referrals, etc. Review your provider and clinic staff desktops on a weekly basis.  Unsigned documents and clinical list changes can interfere with routine patient care and can hold up the billing for the patient visit.  It is all too common to find EMR desktops with hundreds of unsigned documents and changes. Implement a policy for signing off clinical items in a timely manner and enforce the policy when users are not compliant.

Sample Monthly Tasks

  • Review top payor rejections. Often overlooked, a regular audit of payor rejection reasons can help identify and correct issues on the front end. What tools does your clearinghouse or system offer for this analytical reporting?
  • Review top payor denials. Different from rejected claims, what are the reasons payors are not paying on claims? Review EOBs by payor and identify trends. Is there a back-end denial that can be prevented by adjusting the workflow at the front desk or when the patient is with the provider?  See what you can do to prevent denials and get paid.
  • Reconcile and compare monthly reports. Which monthly reports do you run? Monthly reports are important for balancing, trending, and benchmarking. These reports give you a high-level dynamic picture of the financial health of your organization. In addition, reconciling monthly reports will ease end of year closing. 
  • Hard close batches. All financial transactions for payments and charges should be logged in batches. If you do not hard-close batches, the financial data can fluctuate because soft-closed batches can be overridden and the data can be edited. Hard closing batches on a monthly basis permanently locks down the financial data, which allows for accurate reports and benchmarking. If a change needs to be made after the hard-close, the visit can be reversed and recreated with the accurate information.
  • Audit all unpaid visits. Keeping tabs on where your outstanding balances exist in the revenue cycle can help you pinpoint breakdowns and stay on top of problems. It is a healthy practice to audit all outstanding patient visits and break them down by provider, insurance carrier, or financial class. 
  • Audit average A/R days. How long is it taking from charge entry to payment posting? Understanding the life of a patient visit through the insurance and patient collections process can help you identify barriers to speedy payment. Start with examining your current A/R days for your biggest insurance payors. Once you know where you are, you can set a realistic target goal. For patient accounts, examine the workload distribution within your patient accounting department. Review documentation within the visits and queues to ensure that these accounts are worked and followed up on in a timely manner.
  • Audit charge lag time. How long is it between the patient visit and charge entry? This is an often overlooked task that could end up costing plenty of lost revenue. It can also help identify workflow breakdowns or learning opportunities. 

Sample Quarterly Tasks

  • Clean up custom lists. Many systems allow users to create their own “favorites” lists including diagnosis codes. Some are not automatically removed during regular software service updates.  Expired problem codes should be removed from these lists promptly. Review and edit clinical lists to add or remove relevant immunizations, lab codes, modifiers, order sets, or reference tables. If you are sending charges over from your EMR, audit those lists because the system could be sending outdated information to billing. Cleaning the front-end in your database will aid in preventing back-end insurance denials and ensure that the patient’s treatment plan and document is up to date.
  • Install system updates. Most system vendors release quarterly updates. Read the release notes first, print a security report, and then install the system updates on a regular basis. The service updates typically include important patches or fixes to known issues. Some even include advanced features and functionality. Remember to update all the components to your system, including plug-ins or peripheral software. Read the release notes on these updates. Sometimes they include changes to the back-end of the system that may require action in the billing or EDI setup.
  • Review insurance carriers. In most systems, adding an insurance carrier takes a bit of time, as you have to find the electronic payor IT and make all the correct settings for the EDI transmissions. For some, it is easier and faster to set it up to file on paper. Review all of your carriers to ensure that they are going electronic when possible. This will provide a better audit trail for claims filing, allow an additional scrub due to going electronic, and will also promote a faster turnaround time on adjudication.
  • Audit coding and compliance. Perform a quarterly billing audit. Take a few visits from each provider and audit the chart for documentation, audit the CPT codes used and the insurance submission process. Are your providers billing the most appropriate level of service possible? Is your billing staff constantly correcting codes manually on claims but not on the EMR side? Does the billing and EMR office visit match if you were to be audited?
  • Shadow a patient. Observe and shadow a couple of patient appointments from beginning to end. You will see the patient flowing through the office and it is a good time to identify bottlenecks, training opportunities, or workflow optimization opportunities. You will also gain an understanding of routine tasks on the front-end that trickle down to billing.
  • Sweep up inactive users. Does your system still contain users who have not been with your company for some time now? Sweep them up and inactivate users who are no longer with your organization. Doing so will keep your data nice and neat and will remove unnecessary clutter for active users. This includes billable providers who have left your organization.

Sample Annual Tasks

  • Update fee schedules. Fee schedules not only store your prices, but also payor allowed amounts. Knowledge is power. Make a copy of your existing fee schedule and update each year.  Most systems allow this task to be done in advance. Use a fee schedule importer solution to save time. Include the year in the fee schedule name. Doing this will allow you to accurately compare financial data and will provide better reports. Look at the data on your fee schedules and follow up with the allowed stored versus the actual allowed amounts paid by insurance payors. Follow up with your insurance representative if the actual amounts paid do not agree with what you expected. Use your software features to store and report this information. This can give you leverage when negotiating contracts.
  • Clean up schedule templates. How long has it been since your scheduling system was implemented in your office? Does your system have old templates for doctors and resources cluttering up the system? Your office workflow is determined upon how your schedule is designed and how cohesive it is to patient and clinical flow. Your schedule template affects the amount of patients you see and how often, the number of claims sent as a result of the visits, and the volume of visits spent in A/R and collections. Setting a strategic schedule template will ensure smooth patient traffic and a consistent workflow and billing cycle. Make a fresh start, get rid of the old templates, and replace them with organized and clean ones.
  • Run yearly reports. If you run your monthly reports, reconciling and comparing to your yearly reports should be a breeze. Unsure of what to run? Ask your vendor for suggestions or collaborate with other users of your software or specialty.
  • Hard close. If you are not hard closing monthly or quarterly, you should definitely hard close on a yearly basis. 
  • Review system downtime plan. What is your plan if the system goes down or your power goes out? Preparation here is key. All departments review downtime policy and ensure all paper documents are up to date and available in the event of an emergency or if the PM/EMR goes down. Test your plan with a “fire drill” and see how prepared your office is. Review your policy on a yearly basis at a minimum. Make sure that your downtime plan includes a clear process for getting charges entered in billing in a timely manner.

Optimize your software

    Investing in your people and examining your processes will lead to big returns on your investment. Your software likely offers several options for building and customizing its structure as to accommodate your individual practice and specialty. Because of this variability, features are designed to maximize the software’s performance in many environments. During the initial software implementation, users are in “survival mode” learning how to use the basic functions of the software in order to perform their job.  They tend to be overwhelmed with information overload or not really recognize how all the components will work together in the big picture.
    Also considering staff turnover, industry changes, software updates, lack of training, and changes in technology, it is easy to see how data can build up and new features not utilized. The optimization process is key to maximizing the use of the software and to increase staff productivity and satisfaction. Take a regular look at your workflows, review your system setup, find opportunities for education. Engage your staff in all departments and encourage feedback for process improvement. Implement a communication plan and monitor change management when new workflows or changes are made. Reevaluate yearly or even more often on a regular basis for continuous improvement.

    Is it Zen yet?

    Maintaining revenue cycle operations takes patience, focus and insight, just like Zen meditation. So, when the going gets tough, take a deep breath and be grateful that you have built a structure in which the right people are in the right places doing the right tasks. Ahhhh, breathe out.
    Angela Hunsberger is a senior healthcare consultant at Hayes Management Consulting.

    Connected digital health empowers patients and providers

    Ethernet cables

    By: David Pettigrew, Sector Manager for Patient Care at Sagentia
    Published: Thursday, August 8, 2013 - 04:08 GMTJump to Comments

    Connected health is poised to transform the way services are delivered. Sagentia’s David Pettigrew examines how technology innovation is successfully making the transition to commercial reality.

    Ageing populations and the growing prevalence of chronic diseases are placing healthcare infrastructure under greater pressure than ever before. The UK’s Department of Health estimates these issues could require £5 billion in additional expenditure by 2018, yet NHS budgets are currently allocated on a flat-cash basis.
    At a time of significant budgetary constraint, healthcare providers must find new ways to reduce costs and increase the efficiency and quality of care. Treating patients quickly and effectively frees-up hospital beds and critical resources. Ensuring underlying health issues are properly addressed and encouraging lifestyle improvements drives reductions in both the number of people visiting healthcare providers and repeat visits.
    Technology is proving a key enabler in realising these aims, particularly in the form of connected health. Broadly defined as the use of technology to provide healthcare at a distance and improve speed of response, connected health is seeing new levels of capability being realised in areas such as user interfaces, storage, smartphones, low power connectivity, and data processing and analytics.
    These are being combined with medical sector advances around novel sensing and imaging technologies, as well as microfluidics, haptic feedback, and robotics, to deliver practical solutions to some of the most pressing healthcare issues.
    Making the connection
    Connected health is an evolution from existing delivery models such as telehealth and telemedicine services, which are focused on the transmission of raw data between two locations – for example, the electronic transmission of drug prescriptions to a patient, or medical images between clinicians. Connected health takes this further by abstracting these data using sophisticated context-aware algorithms to provide actionable information to the patient, payer or clinician.
    It is this ability to provide real-time data management and decision support that distinguishes connected health. It can be as simple as a bed-side monitor linked to a nursing station that alerts nurses to a critical event, or a series of networked devices collecting clinical data that is stored together with patient records and other administrative and financial data within a central clinical information system (CIS).
    More advanced connected health solutions combine the latest advances in smart sensing technology, fixed and wireless networking, and cloud computing. They also employ sophisticated algorithms and centralised storage (either locally or via remote servers) to enable the mining and analysis of ‘big data’ to uncover trends and insights, and generate decision-making outputs.
    Crucially, connected health solutions can be applied at any point in the care pathway, from a patient’s first contact with a healthcare professional, service, or organisation, through to the completion of their treatment and subsequent aftercare. Moreover, they can be delivered in the home, between the home and surgery, within a surgery or even between surgeries, in areas including vital signs, sleep, and medication compliance monitoring.
    A technology applied
    Monitoring and prevention are two promising areas for connected health. Commercial examples include solutions for monitoring diabetes (blood sugar levels, insulin administration) and for preventing co-morbidities through the monitoring of blood pressure, cholesterol, and weight. There are also PT/INR self-testing solutions (Prothrombin Time/International Normalized Ratio) allowing patients taking medication such as coumadin or warfarin to measure their blood’s anti-coagulation level (i.e. how long it takes their blood to ‘clot’), as well as cloud-based platforms that log patient data and refine algorithms to enable more accurate diagnosis in areas such as cardiology and image analysis.
    Arrhythmia detection is another major area of focus, as it is important for patients to be able to monitor and record their heart rate outside of the surgery. An electrocardiogram (ECG) rhythm monitoring technology has been implemented by AliveCor for example, in the form of a hand-held device consisting of two finger-pads embedded in an iPhone cover. The ECG data acquired via this device can be transferred to a secure online server for review by a clinician.
    Although AliveCor’s system is approved for clinician use only at present, the next step could be to put this device in the hands of patients for recording their own ECG traces for remote review in-between their appointments. This would significantly increase the likelihood of detecting relatively rare arrhythmia events.
    Another connected health innovation under development is the Endotronix system, which uses an implanted sensor to communicate pressures from inside the patient’s heart to a smartphone app via a transmitter. The system is able to accurately capture internal heart pressure data at any time and communicate it securely from a remote location to the patient’s care team. It will be possible for both patients and clinicians to view the data in various formats, and on multiple devices.
    Delivering successful outcomes
    Some connected health solutions are already providing doctors with new levels of visibility of their patient’s progress, and empowering patients to take more responsibility for their own health and care. ‘Health Buddy’, for example, is a personal and interactive communications device developed by Health Hero Network (now part of Bosch Healthcare). It enables a doctor or nurse coordinator to send a set of queries to the patient each day via the internet. The patient answers them by pressing one of four buttons. The device automatically transmits this data to a processing centre, where it is analysed and published to a secure website for review by the coordinator.
    Piloted as part of a computerised interactive asthma self-management and education programme in the U.S., the device was found to increase self-management skills while reducing the number of urgent calls to the hospital. There are now more than 20 clinical trials of the Health Buddy system in post-acute and chronic care coordination, with consistent demonstration of positive outcomes across a variety of disease states and settings. One Health Buddy programme that is supporting chronically ill patients has achieved spending reductions of approximately 7-13 per cent ($312–$542) per intervention patient per quarter.
    The U.S. has been an early adopter of connected health solutions and digital health technology in general. Electronic health records (EHRs) are subsidised under ‘ObamaCare’, while VC funding for digital health is on track for another record year, with start-up incubator Rock Health reporting a 35 per cent increase during the first quarter of 2013 compared with Q1 2012. Last year, total annual VC funding in the digital health industry stood at $1.4 billion and $968 million in 2011.
    In Europe, take up has been slower, but industry commentators believe all the elements are now in place for connected health to make the transition from small-scale pilots to mass market implementation. According to the European Connected Health Alliance, the path for connected medical devices will be smoother in Europe than in the US, because it is easier and faster to get over the regulatory hurdles and the process is better understood.
    Fit for purpose
    The regulatory landscape in the U.S. remains highly uncertain, with the FDA due to publish its final guidelines on mobile medical apps shortly. FDA draft guidelines released at the end of 2012 stipulate that certain types of medical mobile apps will be regulated, placing a large burden on R&D in terms of managing risk. There are also considerable challenges around protecting the privacy and security of personal health information, and concerns over the impact on development schedules and costs should products require FDA approval.
    Nevertheless, the 510(k) number issued by the U.S. Food and Drug Administration (FDA) is considered the ‘gold standard’ for solution developers globally due to the rigour of the regulatory process, and the fact it clears medical devices for sale in a market where providers, payers, and physician groups are forecast to spend over $69 billion on healthcare-related IT and telecommunications services between 2012 and 2017, according to analysts at Insight Research Corporation.
    Functionality of connected health devices varies and is based on their technical sophistication, but their success will depend on end user acceptance. This explains the rising prominence of smartphone apps, which at first glance, would appear to provide an easy route for manufacturers to deliver a ‘consumer friendly’ user interface for their connected systems. However, manufacturers and regulators are increasingly concerned about how rapid changes in smartphone hardware and operating systems will affect the intended function of their medical devices.
    Depending on the level of risk of the intended connected health system, it can still be cheaper and less risky in the long run to develop a platform-independent system that they can control entirely. Alternatively, a model explored by many companies involves the use of custom ‘smart sensors’, which perform the ‘high risk’ data processing functions using sophisticated embedded algorithms. These devices can in turn transmit the result to the smartphone, which displays the data to the user. In this way, the usability of a smartphone interface is brought to bear without adding in the extra risk of using ‘unregulated’ hardware and software to generate the data.
    Connecting the future with the present
    Additional challenges remain, particularly in respect of the networking technologies employed in connected health applications and their respective power requirements and data rates. Using Wifi or broadband for example, has the advantage that the medical device can be connected to a backbone of wireless hotspots using an existing hospital network, and the investment will be relatively low from a technology perspective.
    The drawback of this approach is that it is power hungry and cannot be used if the device is battery powered and has very limited dimensions. In this case, Bluetooth Low Energy (Bluetooth Smart®) is often the preferred solution as it has low-power consumption but also means a low data rate. This constrains the amount of information that can be transmitted back and forth in real time and thus limits the application. This is an area in which leading manufacturers continue to innovate by embedding processes within the portable device so that less data is being exchanged.
    Given that connected health bridges the consumer and healthcare space, development of robust and interoperable platforms is essential. Recent FDA regulations and harmonised global standards are driving manufacturers to increasingly focus on usability engineering, in order to develop devices and services that minimise the risk of patient harm through user error. Considerable progress in terms of interoperability has been made by the Continua Health Alliance, which is developing a system of interoperable personal connected health solutions.
    As these challenges are addressed, connected health will enable efficiencies and improve patient outcomes. It will also free-up healthcare professionals to focus triage on patients where it is needed most. And as people become more open to owning their own healthcare, advances in connected health mean they will have a growing range of tools at their disposal. Ultimately however, the transition to connected health will be borne out of necessity, as conventional healthcare and its associated costs become less feasible in respect of fiscal and demographic pressures.
    David Pettigrew is Sector Manager for Patient Care at Sagentia. David has seven years’ industry experience in developing medical devices and diagnostics. He recently worked for at Sphere Medical managing the sensor development of Sphere's exciting new patient attached, real time blood gas analyser for use in critical care. He has worked on several large projects for device companies across many clinical disciplines, notably; oncology, anaesthesiology, urology and diabetes care. David holds a PHD in Structural Biology and Biosensors from Oxford University.
    If you enjoyed reading the story, register HERE to receive daily email alerts on public policy and public sector service delivery. Follow us @TheInfoDaily.
    The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of The Information Daily, its parent company or any associated businesses.

    Share this article

    Hospitals address readmit penalties

    Two area hospitals will lose a portion of Medicare reimbursements for the second consecutive year after failing to meet national average readmission rates for heart conditions and pneumonia.
    Masonic Home and Hospital in Wallingford will lose 1.14 percent of its Medicare reimbursements for patient stays, a penalty levied under the federal Hospitals Readmission Reduction Program which began last year as part of the Affordable Care Act. The program penalizes hospitals for patients readmitted within 30 days.
    MidState Medical Center in Meriden faces a loss of .78 percent of reimbursements but won’t lose as much money as last year since it brought down its readmissions.
    Both MidState and Masonic lost 1 percent of reimbursements last year, the maximum penalty. This year the maximum was 2 percent.
    Masonic officials said the readmission reduction program penalizes hospitals that take a large number of older, sicker Medicare patients. The penalties amount to about $60,000, according to Masonic spokeswoman Margaret Steeves. Masonic patients, many of whom are referred by nursing homes, are commonly 85 years or older.
    Medicare reimburses hospitals for care given to patients 65 years or older. Readmission rates are compared to national averages but are adjusted for sicker and high-risk populations, according to Medicare spokeswoman Kathryn Ceja. Hospitals with higher than national average readmission rates face penalties.
    Twenty-four of Connecticut’s 31 hospitals will face Medicare penalties in the fiscal year that starts in October. None of the state’s hospitals will lose the maximum amount possible.
    Statewide, Connecticut’s hospitals face an average penalty of .43 percent of Medicare funds for the number of readmissions within a month, which is higher than the national average. Hospitals in 12 states, including Massachusetts and Rhode Island, face higher average penalties.
    Nationally, about 20 percent of hospitalized Medicare patients are back within 30 days, at an estimated cost of $17 billion a year, according to the Medicare Payment Advisory Commission.
    Hospital administrators in the state say they have made many efforts to reduce readmissions in the past two years, and note that the new penalties are based on readmissions through June 2012. Medicare counts patients who originally went into the hospital with at least one of three conditions — heart attack, heart failure or pneumonia — and landed back in the hospital within 30 days for any reason, even if it was unrelated to the original stay.
    Jack Greene, Midstate Chief Medical Officer, said efforts to reduce readmission since last year have shown results. Medicare takes data from the previous three years, and efforts from last year were able to reduce the penalty by 22 percent.
    “We were certainly pleased we improved from last year,” Greene said.
    MidState now works more closely with visiting nurses, rehabilitation centers and patients to communicate what needs to be done after a hospital admission. Howard Dobin, director of MidState’s hospitalist program, said patients at higher risk for readmission are given additional help understanding, for instance, how to take their medication.
    Dobin expects MidState’s penalty to continue to drop.
    Connecticut Hospital Association officials said they’ve worked to change the federal matrix for calculating readmissions. Only patients with heart conditions or pneumonia are counted for readmissions, but any illness that lands them in the hospital will count against that medical center. That penalizes a hospital for admitting a cancer patient for regularly scheduled chemotherapy if the patient had a heart attack within 30 days.
    Mary Reich Cooper, association Chief Medical Officer, said that could and should be changed.
    “The federal government is starting to take into account that some readmissions are planned readmissions,” she said.
    Overall, hospitals have made strides in reducing readmissions.
    “We’re starting to show results,” Cooper said. “We’re really proud of all the hospitals that have improved their outcomes from a year ago.”
    Readmission penalties are among a number of financial pressures weighing on hospitals in Connecticut and nationally. The federal government also is squeezing hospitals to reduce unnecessary inpatient stays, which has led to the controversial use of “observation status” as an alternative to admission. Patients who are deemed to be on observation status during a stay are not counted as admissions, but find themselves without Medicare coverage for nursing home care after discharge. That policy is being challenged in a lawsuit in federal court in Hartford. (203)317-2230 Twitter: @JBuchananRJ