Leading the Change Solutions for Today’s Healthcare Challenges Melinda S. Hancock, FHFMA, CPA...
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Leading the Change Solutions for Today’s Healthcare Challenges Melinda S. Hancock, FHFMA, CPA Partner, Dixon Hughes Goodman LLP and 2014-15 Chair-Elect,
Leading the Change Solutions for Todays Healthcare Challenges
Melinda S. Hancock, FHFMA, CPA Partner, Dixon Hughes Goodman LLP
and 2014-15 Chair-Elect, HFMA Women in Healthcare: Lead #likeagirl
November 14, 2014
Slide 2
"If your actions inspire others to dream more, learn more, do
more, and become more, you are a leader. John Quincy Adams
Slide 3
Presentation Overview Organizational Performance Cost
Reductions Business Analytics Payment Reform & Value-Based
Purchasing Population Health & the Care Continuum Capital
Access Revenue Cycle Leadership What does it really mean? 3
Slide 4
4 Cost Reduction The need for rigorous cost management is
clear. Accelerated by unsustainable growth in national healthcare
costs, the emerging value-based business model and healthcare
reform will push hospitals and health systems to improve quality,
access, and outcomes, while reducing expenses. From hfm, March
2012, Kaufman Hall
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AMAs Cost Reduction Strategies The American Medical Association
identified four broad strategies to contain healthcare costs and
get the most for our dollars: 1.Reduce the burden of preventable
disease 2.Make healthcare delivery more efficient 3.Reduce
nonclinical health system costs that do not contribute to patient
care 4.Promote value-based decision making at all levels. Source:
Getting the most for our health care dollars, AMA. 5
Slide 6
Cost of Chronic Care 2003-2023 Source:
http://www.good.is/posts/the-cost-of-treating-chronic-disease
6
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Are We Efficient? U.S. Ranks Last 7 7
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8
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9 Basic Premise: By many estimates the reduction must reach
20%-30% of total cost structure by 2015 to be able to confront a
lean, health-reformed environment. Why? Reductions from government
payers, pressures from lower commercial rates, pricing
transparency, narrow networks all equate to shrinking revenue base.
Deloittes Radical Cost Reduction Source:
http://www.deloitte.com/assets/Dcom-
Singapore/Local%20Assets/Documents/Industries/2012/Life%20Sciences%20and%20Health%20Care/Health%20Care/Radical%20Cost%20Reduction.pdf
Slide 10
Operational vs. Strategic Approach 1. Top down 2. Changes
underlying delivery and profit model 3. Derives value from making
the organization different Strategic 1. Bottom up 2. Looks to drive
incremental change 3. Derives value from making organization better
than peers Operational Source: http://www.deloitte.com/assets/Dcom-
Singapore/Local%20Assets/Documents/Industries/2012/Life%20Sciences%20and%20Health%20Care/Health%20Care/Radical%20Cost%20Reduction.pdf
10
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How Much Is Enough? Capital needs and related shortfalls
Medicare breakeven analysis Current and desired bond rating Market
dynamics Current negotiations and at-risk contracts The impact of
transparency and benefit design 11
Slide 12
Tool For Readiness Assessment Source: A Guide to Strategic Cost
Transformation in Hospitals and Health Systems, March 2012 12
Slide 13
How to Approach Cost Management Understand readiness Define
goals based on capital shortfall Use benchmarks to identify sources
of savings Drill down on staffing methods Focus on key drivers of
staffing & productivity problems Supplement with other data
analytics Streamline overhead functions Ensure targets are
integrated with plans & budgets 13
http://www.beckershospitalreview.com/racs-/icd-9-/icd-10/8-strategies-for-hospitals-to-approach-cost-management
Bob Herman, June 14, 2012
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14 Business Analytics We developed the concepts in this work
from the data we gathered, building a framework from the ground up.
We followed an iterative approach, generating ideas inspired by the
data, testing those ideas against the evidence, watching them bend
and buckle under the weight of evidence, replacing them with new
ideas, revising, testing, revising yet again, until all the
concepts squared the evidence. From Great by Choice, Jim Collins
2011
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Business Analytics Needs in an Era of Change Source: Building
Value-Driving Capabilities: Business Intelligence. An HFMA Value
Project report. 2012. www.hfma.org/valueproject 15
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Untapped Potential of Business Analytics in Health Care 36% 20%
44% Not measuring Measuring Managing Source: HFMA Value Project,
June 2011 16 Costs of adverse events Margin impact of readmissions
Cost of waste in care processes Analytics are available but few are
measuringand even fewer are managing to the metrics.
Slide 17
How to Apply Data Mining to Everyday Clinical Practice
Standardizes knowledge work Systematically applies evidence-based
best practices to care delivery Content System Drives change
through new organizational structures, especially teams Requires
true organizational change to drive adoption of best practices
throughout an organization Deployment System Aggregates clinical,
patient satisfaction, and other data Enables analysts to identify
patterns that can inform decisions Enterprise Data Warehouse
(Analytic System) 17
Slide 18
Harnessing Data to Improve Physician Performance Source: Moving
Toward Population Health. Leadership. Spring 2014. Available at
hfma.org/leadership.
Slide 19
19 Payment Reform & Value Based Purchasing Payment reform
is changing health care, bringing with it the need for new
competencies for success. Healthcare leaders need innovative
strategies to integrate with physicians, manage risk, reduce cost
and price bundled services, and enhance quality while lowering
cost. Business as usual is not an option. Healthcare Payment Reform
Accelerating Success, HFMA
Slide 20
Goals of Payment Reform 20 Source:
http://www.rand.org/pubs/periodicals/health-quarterly/issues/v1/n1/03.html
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Estimated Gains from ACA: $64B Amounts in Billions 21
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Source: Health Care Advisory Board, 2012 How CMS Views The
Programs 22
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The Continuum of Risk 23 Source:
http://www.athenahealth.com/knowledge-hub/ACO/accountable-
care-organizations.php Source: Hancock, M., Hannah, B. Determining
Your Organizations Risk Capability, hfm, May 2014.
Slide 24
The Mandatory Programs under ACA 24 VBPRRPHAC Payment
TypeBonus/PenaltyPenalty All or None Penalty % of Medicare
Inpatient $s 1% 2013 1.25% 2014 1.5% 2015 1.75% 2016 2% 2017+ 1%
2013 2% 2014 3% 2015+ 1% 2015+ Description of Metrics Addition of
domains through 2015 with dynamic metrics every year Three core
diagnoses with additional 2 in 2015 and more to be added in later
years Two domains: Safety and Infections with infections weighted
higher and additional infections added
New NQS Based Domains for FY 2017 27 HCAHPS = 25% Safety = 20%
MSPB = 25% Clinical Care - Process = 5% Clinical Care - Outcomes =
25%
Slide 28
Readmission Reduction Program 3 Performance periods in play at
a time 3% penalty of Medicare Reimbursement at risk each program
year Measured Populations 30 days from DISCHARGE AMI, HF, PN, COPD,
THA & TKA CABG is added in FY 2017 which is in play now
Performance Periods: 3 Year Rolling Program FY15: July 1, 2010 June
30, 2013 3% FY16: July 1, 2011 June 30, 2014 3% FY17: July 1, 2012
June 30, 2015 3% FY18: July 1, 2013 June 30, 2016 3% FY19: July 1,
2014 June 30, 2017 3% Currently participating in 3 performance
periods simultaneously 28
Slide 29
Hospital Acquired Conditions: FY 2017 First Domain: PSIsSecond
Domain: CDC Pressure Ulcer RateCLABSI Foreign Object Left in
BodyCAUTI Iatrogenic Pneumothorax RateSSI Following Colon Surgery
(FY 2016) Postoperative Physiologic and Metabolic Derangement Rate
SSI Following Abdominal Hysterectomy (FY 2016) Postoperative
Pulmonary Embolism and Deep Vein Thrombosis Rate
Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacteremia (FY
2017) Accidental Puncture and Laceration Rate Clostridium Difficile
(FY 2017)
Slide 30
Where Are the First Cohort of Bundles? 30 Source: Centers for
Medicare and Medicaid Services; Health Care Advisory Board
interviews and analysis.
Slide 31
Early Results of BPCI Cohort 2 Tremendous increase in the
number of applications in the most recent open enrollment in April
2014: Nearly Triple! Models 2,3,4 were open for enrollment
Currently in the Phase 1 period which is the non risk, decision
making period. Phase 2 is when the Episode Initiator starts to
accept risk
Slide 32
Where Are the MSSPs? As of January 2014, there are 23 Pioneer
ACOs and 351 Shared Savings ACOs. Source: The Advisory Board
32
Slide 33
Geographical Dispersion of MSSPs Represents Assigned Patient
Population for 2012-2014 Cohorts Source: MLN Webinar 4/8/14
www.cms.gov/NPC 33
Slide 34
Pioneer ACOs: 32 Participants All participants met quality
goals 25 of the 32 reduced readmission rates >1/3 reduced costs,
over $87M 2 providers lost money, $4M 13 providers or 40% getting
distributions 2012 MSSP Cohort: 114 Participants 54 (47%) reduced
spending with 29 (25%) sharing in savings $126M in distribution to
the 29 providers 60 were not able to reduce spending: 2 of which
were 2-sided model 109 reported quality measures satisfactorily: 2
of the 5 who did not were eligible for $ Early Results 34
Slide 35
How to Manage to the Tipping Point 35 Revenue Time How do local
market conditions impact timing considerations? Can market-changing
events create an urgent paradigm shift? What is my step-change
business model risk? Do I have the financial tools to adequately
analyze relevant states? Source: DHG Healthcare
Slide 36
The Changing Healthcare Landscape 36 Source: Leavitt Partners,
LLC
Slide 37
Bear financial risk for the measured health of a population
Align incentives to encourage the production of high-quality health
outcomes Oversee the provision of clinical care Coordinate the
provision of care across the continuum of health services Invest in
and learn to use appropriate IT to manage population health Improve
the individual experience of care Improve population health Reduce
the cost of health care for populations Processes Outcomes
Structure What Is Accountable Care? Source: Leavitt Partners, LLC
37
Slide 38
What They Did Results They Achieved Partnering for Success
Under Value-Based Payment Source: Partnering Around Value-Based
Payment, Leadership, Summer 2014, available at hfma.org/leadership
Who Collaborated Aetna Consultants in Medical Oncology and
Hematology, a 9-physician practice in Southeastern Pennsylvania
Collaborated on a patient-centered medical home model for oncology
Used a common medical home approach: management fee plus shared
savings 71% fewer ED visits and 51% fewer hospitalizations for
chemotherapy patients in 2012, compared to national benchmarks
38
Slide 39
39 Population Health The Care Continuum Improving the heath of
populations is one of three dimensions that make up the Institute
of Healthcare Improvements Triple Aim.
Slide 40
Advancing Population Health Management Best Health, Best Care,
Best Experience Care Delivery Models Care Coordination Patient
Engagement Information Technology and Analytics Alignment of
Incentives Source: Sharp Healthcare, San Diego, CA 40
Slide 41
Care Management Programs Hospital Care Management Complex Case
Management Disease Management End-of-Life Care Management Skilled
Nursing Care Management Out-of-Network Care Management Source:
Sharp Healthcare, San Diego, CA 41
Slide 42
Transitions Program 42 Pre Transitions*During Transitionsp
Hospitalizations, n 71 33 Hospitalizations per patient, mean
(SD).46(.84).21(.55)< 0.01 Hospitalization rate32%17%(26)<
0.01 ED visits, n157 67 ED visits per patient, mean
(SD)1.01(1.3).43(.78)< 0.01 ED visit rate57%(88)31%< 0.01
Total Cost of Care, (SD)$73,025($109,708)$46,588($81,616)< 0.01
*Transitions LOS is unique for each patient: pre-Transitions LOS =
During-Transitions LOS Source: Sharp Healthcare, San Diego, CA
Slide 43
Health & Wellness Disease Management Education and support
customized to the patients level of health, allowing them to
self-manage their chronic medical condition, promote wellness and
prevent complications. Disease Managers/Coordinators Diabetes
Asthma CAD Obesity/Sleep Apnea Heart Failure COPD Pharmacy Focus on
medication therapy management and improved patient adherence. Lipid
Clinic Refill Clinic Medication Reconciliation Chronic Care Nurses
Provide patient support in the Primary Care Offices. The RN
supports and reinforces the treatment plan prescribed by the
physician. 5 or more chronic medical conditions 4 or more ER visits
in the last 12 months 4 or more hospital admissions in the last 12
months Coordination and assessment of care and services for members
who have experienced a critical event or diagnosis that requires
the extensive use of resources and system navigation in order to
facilitate appropriate delivery of care & services. Who Is
Eligible? Promotion of knowledge, healthy attitudes, and practices
to help our patients achieve their personal best health. Healthier
Living- Chronic Disease Self Management Weight Management Dietician
Consultation Heart Failure Healthy Hearts Asthma Stress Management
Strength Training Smoking Cessation Complex Case Management Source:
Sharp Rees-Stealy, Sharp Healthcare, San Diego, CA 43
Slide 44
Disease Management (Ongoing) Evidence based targeted
educational mailings Personalized Face to Face and Telephonic
Assessments with collaborative Goal Setting Regular telephone
consultations and follow- up with a registered nurse Provision of
self-management tools and support Referral, care coordination and
communication with Healthcare providers Pharmacy (Ongoing)
Physician/Patient support Medication Therapy Management
Personalized Telephonic Assessments Resource Care Coordination
Chronic Care Nursing (30-90 days) Personalized Face to Face
Assessments with collaborative Goal Setting Regular office and
telephone consultations and follow-up with a registered nurse
Provision of self-management tools, education and support Attend
Senior post Hospital discharge and post Emergency Department
follow-up visits 44 Complex Case Management (3-6 months) Evidence
based targeted education Personalized Telephonic Assessments with
plan of care and collaborative Goal Setting Frequent telephone
consultations and follow- up with a registered nurse Provision of
authorization and coordination of services Referral, care
coordination and communication with healthcare providers What Do
Patients Receive? Health & Wellness (Ongoing) Source: Sharp
Rees-Stealy, Sharp Healthcare, San Diego, CA Group Classes 1 on 1
Evaluation Telephonic/Web Education
Slide 45
45 Capital Access In an era of healthcare reform, with
declining payment, concerns about reducing costs, and exploration
of new organizational structures to improve accountability for
population health, uncertainty abounds among healthcare providers.
Considerable investment and reinvestments are critical to the
profitability and survival of hospitals and health systems today.
Bond Financing in Volatile Times, HFMA, March 3, 2014, Gould &
Blanda
Slide 46
46 Healthcare Issuance Down in 2013 Source: John Hanley,
Managing Director, Head of Healthcare, Ziegler, Is Capital
Available? Presentation at HFMAs Capital Conference, April 10,
2014.
Slide 47
47 Source: Martin Arrick, Managing Director, Standard &
Poors Not-for-Profit Health Group. U.S. Not-for-Profit Health Care
Sector Outlook. Presentation at HFMA Capital Conference, April 10,
2014.
Slide 48
48 Revenue Cycle The revenue cycle presents unique
opportunities for bottom- line improvement. As payment continues to
decline, hospitals should take a renewed interest in improving
their financial performance through the revenue cycle. HFMA
Slide 49
Revenue Cycle The New Norm - Basic Expectations Efficient Low
cost work flows.. Exception based processing Automation through EDI
Patient Self Service Options Accurate Get it right the first time!
Right Insurance, Right Authorization Right Patient Responsibility
at Time of Service Mandate Real Time Concurrent Review, Open EMR
Timely Introduce expectations early in cycle Patient and payers
timely payment expectations 49
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Revenue Cycle More Than Efficiency Its an Experience! Revenue
Cycle Leaders Should Consider the Service Differentiation..
Employee Satisfaction Why will the best and the brightest want to
work for you? Efficiency How is your Revenue Cycle team creating
intuitively accurate processes? How does the Revenue Cycle team
create patient loyalty? Patient Satisfaction 50
Slide 51
Embrace the Insurance Exchanges Assist with Securing Coverage
Certified Enrollment Counselors Patient Advocates 51
Slide 52
Its a New Era in Revenue Cycle Price Transparency, New Payment
Methodologies and Patient Liabilities Cost Based Chargemasters Self
Pay Initiatives Bundled Payments 52
Slide 53
Leveraging Technology Work from Home Expanding EDI Patient Self
Service Payer Interfaces with Hospital Systems Front end solutions
to guide patients through the Exchange and Medicaid options
Priceline Price Quotes Game Industry Productivity Monitoring Tools
Patient Preference Lists Facetime Chat with a Customer Service Rep
53
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54 HFMA Resources My goal each year is to introduce promising
young professionals and colleagues to HFMA and help integrate them
within the organization. The HFMA network enhances their careers,
strengthens our chapter, and allows us to follow their success. My
chapter leaders did it for me, and I want to pass it on. It's a
win- win! Debbie Teesdale Executive Director of Corporate
Development Paragon Hospital Services, LLC
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Improve the Billing and Payment Experience for Patients 55
hfma.org/dollars
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Discover Revenue Cycle Strategies That Work Strategies used by
MAP award winners and other high- performing organizations
Innovative practices designed to drive revenue cycle performance
Nov. 2-4, Las Vegas hfma.org/mapevent 56
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Take Advantage of Other Educational & Career Development
Opportunities 57 Certification ANI: HFMA National Institute Virtual
Conferences Seminars Webinars eLearning HFMA onsite programs
Slide 58
Stay Up to Date with Online Resources hfma.org Daily and weekly
online news Social media Facebook LinkedIn Twitter HFMA Forums
58
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Add HFMA Publications to Your Reading List hfm magazine The #1
publication for healthcare CFOs Leadership publication Reaches all
levels of the C-suite Newsletters Revenue Cycle Strategist
Healthcare Cost Containment Strategic Financial Planning 59
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Earn CPEs by Reading Newsletter Articles 60
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61 Leadership What does it really mean? Leadership has nothing
to do with titles; it has everything to do with, Do you inspire
other people? Do they want to follow you? Do they want to be with
you? -Tom Atchison, author of Followership: A Practical Guide to
Aligning Leaders and Followers
Slide 62
Collaboration Success Stories Source: HFMAs Leadership
e-Bulletin, available at www.hfma.org/leadership. Transforming
Revenue Cycle (Providence Health & Services CA region): Oct.
2010 issue. Funding a Capital Project (Beatrice Community
Hospital/NE) : Dec. 2010 issue. Redesigning Primary Care (Fairview
Health Services.MN): Nov. 2010 issue.www.hfma.org/leadership. 62
WITHIN A HEALTHCARE SYSTEM A California healthcare system created
core revenue cycle teams with representatives from 10 departments
across all system hospitals. Improvement: $9.4 M HOSPITAL &
COMMUNITY Community banks and residents bought 38% of the $45M in
bonds that a rural Nebraska critical access hospital used to fund
construction of a replacement facility. PAYER & PROVIDER A
payer funded an initiative to make a Minnesota healthcare systems
primary care clinics more efficient and patient-centered.
Physicians, nurses and other clinicians provided the ideas. 62
Slide 63
Anchor Change in Corporate Culture Company cultures are like
country cultures. Never try to change one. Try, instead, to work
with what youve got. -Peter Drucker 63
Slide 64
The people who really succeed in this field have a vision. They
have a high degree of motivation, and they are out to make things
betterto do good and to change the world on whatever scale they
can. They work hard, they have an end in mind, and they will
acquire whatever skills and training and knowledge they need to get
there. Mary Stefl, professor and chair of the department of
healthcare administration, Trinity University, San Antonio, Texas,
and a consultant for the Healthcare Leadership Alliance Competency
Model 64
Slide 65
Create Short-Term Wins A journey of a thousand miles begins
with a single step. - Lao-tzu, Ancient Chinese philosopher 65 Dont
be afraid to start small. - Marty Manning, Advocate Physician
Partners 65
Slide 66
... a leader needs to k You cannot lead without knowing the
needs of your peoplewhat drives them, what makes them do what they
do of the psychology of that, then you can give them opportunities
to succeed based on their own psychology of success. Kerry
Gillespie, FHFMA, vice president, operations, Community Health
System, Inc., Brentwood, TN, and a member of HFMAs Tennessee
Chapter 66
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Everyone Is a Leader. Everyone in this room is a leader. Im
asking each of you to renew your commitment to leading our industry
forward, to ensuring its long term viability and quality. Together,
we CAN improve health care. Together, we can and we must Mentor
young professionals as we have been mentored, Rise above the
uncertainty and frustration of today, and Work in partnership with
our colleagues throughout the industry to lead the change. Kari
Cornicelli HFMA National Chair 2014/2015 67