2 Essential Steps for Embedding Case Managers

April 24th, 2014 by Cheryl Miller

Selecting the right practice for embedded case managers, and then getting physicians to embrace the concept, are key to successfully embedding case managers, say two thought leaders, Irene Zolotorofe, RN, MS, MSN, administrative director of clinical operations at Bon Secours Health System, and Randall Krakauer, MD, national Medicare medical director for Aetna. Here, they discuss how to best implement these steps.

Question: How did you select practices for embedding of case managers, and what were the first steps in preparing the practice?

Response: (Irene Zolotorofe) They were chosen primarily at the recommendation of some of our operations directors; also, we began with the physicians who are absolutely willing to go ‘medical home,’ that are excited about this model of care. We like to go into a practice where they are motivated to do that type of transition with their patient population.

Physicians are the key; as a physician group expresses interest, we work with them first, since they are key to getting a whole team going. We work hand in hand with the physicians and then the practice managers, and then we bring the process down to the rest of the staff. It takes us about three months.

Question: What marketing strategy is employed to encourage the physician groups to collaborate and embrace the concept of embedding health plan case managers in their practices?

Response: (Dr. Randall Krakauer) What doesn’t always work well is to start with ‘I’m here to help you.’ It is a matter of meeting with your physicians and discussing some of your mutual goals and mutual interests. We focus on those aspects of the equation in which we have common interests: quality of care, doing a better job for our members, your patients. We focus on areas in which we have the opportunity to work together. We show them what we have accomplished in the areas of care management on our own. We can show them at this point, since we’re not new to the game now, some results that we have achieved with other physician partners. And we initiate a discussion on how we can support each other, how we can work together to meet our mutual goals and how we can both benefit from this process.

And with a little bit of time and effort in a great many cases, some great things can happen as a result of such discussions.

Excerpted from Essentials of Embedded Case Management: Hiring, Training, Caseloads and Technology for Practice-Based Care Coordinators.

Infographic: How the Healthcare Industry Is Reacting to the ICD-10 Delay

April 23rd, 2014 by Jackie Lyons

On April 1, 2014, President Obama signed a law that included the delay of ICD-10 implementation until at least October 1, 2015. Fifty-eight percent of respondents to the Deloitte Center for Health Solutions Live from the Center Webcast Poll expressed disappointment because their organizations wanted the shift to occur as scheduled, according to a new infographic from Deloitte.

This infographic also provides responses from approximately 1,250 healthcare industry professionals regarding optimal ICD-10 scenarios, areas most impacted by the delay and actions that will be taken in response to the delay.

How should your organization be preparing for ICD-10? Learn more in A Best Practice Roadmap to ICD-10 Readiness. This 24-page report documents the process BCBSM has established to resolve discrepancies between ICD-9 and ICD-10 codes, a milestone that has allowed the payor to complete its version of the General Equivalence Mappings (GEMs) — referred to as the Blue GEM Encyclopedia.

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6 Criteria for Evaluating Vendor Partners for Remote Patient Monitoring

April 22nd, 2014 by Patricia Donovan

Just as there are guidelines for identifying individuals most likely to benefit from remote monitoring, healthcare organizations must also choose remote monitoring vendor partners with care, advises Gail Miller, vice president of telephonic clinical operations in Humana's care management organization, Humana Cares/SeniorBridge, who shared lessons gleaned from vendor selection for Humana's nine separate pilots of remote patient monitoring.

I want to share how Humana chose the partners that we work with in these programs, because there are so many potential vendors to work with in the remote monitoring space. We had been evaluating companies off and on for about a year. We ended up doing a request for information (RFI) process with the top 25 we had identified internally. They weren't necessarily the biggest vendors or the companies with the strongest balance sheet, but rather those that met the different capability criteria we were looking for and possessed the flexibility and creativity to work with us.

Some think that it’s a good idea to warn people when you’re going to be working with a large entity like Humana, so that the companies we choose are prepared to deal with our procurement and legal processes, and understand it will take some resources on their side. Since the change to the HIPAA rule in 2013 there iss more downstream liability, so we require additional business liability insurance, and our business information agreements are quite stiff. All of those things must be worked through before we can work with a vendor.

We were also looking for companies that could be easily scalable. You could have a great piece of equipment, but if it’s going to take ten months or a year to procure another thousand, that’s not going to work for us because we have to be thinking on a national basis. We also were looking for vendors willing to work with members with various home situations. We did not want to exclude anybody from our pilot.

For example, some of the equipment we looked at would only run if there were broadband in the home. We needed someone to put some type of device that they could plug in, that would help boost them or create a 4G or 3G network wherever they were. We needed to adapt to the different home situations that our individuals lived in.

Then, the equipment had to be senior friendly. We learned a lesson from a great study with Intel about three years ago. The results had some positives and some negatives, but one thing we learned was that the size of the equipment was important. At that time, the piece of equipment we were using weighed about 37 pounds. Because of the frail nature of some of our members, we had to hire an intermediary to do setup and delivery and then package it up and send it back afterward. It created a lot of extra cost and a little more confusion trying to arrange those deliveries and pickups.

One thing that we are dedicated to doing this time is making sure that whatever equipment we had in the home that we could manage it easily, and that hopefully the senior themselves or their caregiver would be able to set it up.

Excerpted from: Remote Patient Monitoring for Enhanced Care Coordination: Technology to Manage an Aging Population

Infographic: In-Network Vs. Out-of-Network Provider Healthcare Costs

April 21st, 2014 by Jackie Lyons

Consumers typically pay significantly less for in-network providers and more for out-of-network providers. Furthermore, approximately one in 10 Americans goes out of network for care, according to a new infographic from Excellus BCBS.

This infographic also provides comparative examples of the different costs for in-network and out-of-network procedures, as well as how choosing a health plan and provider can affect these costs.

Learn more about health plans and coverage in AIS’s Health Insurance Exchange Directory and Factbook. The new health insurance exchange marketplaces, public and private, will have a profound impact on the under- and uninsured, and will permanently alter the way health insurance is bought and sold. This resource is the definitive health industry guide to insurance exchange implementation and stakeholder strategies.

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Infographic: Healthcare Spending in America

April 18th, 2014 by Jackie Lyons

America spends 2.5 times more on healthcare than other developed nations, despite using it less than these other nations, according to a new infographic from Vitals.

This infographic also shows specific price tags for healthcare procedures and tests, as well as results and life expectancy in America versus other countries.

Looking to drive value-based reimbursement without sacrificing quality of care? In Driving Value-Based Reimbursement with Integrated Care Models, Julie Schilz, director of care delivery transformation for WellPoint, and Terry McGeeney, MD, MBA, director of BDC Advisors, share their visions for this emerging care experience, from structuring incentives and reimbursement to reward high-quality and efficient care to identifying and engaging specialists in a medical home neighborhood.

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3 ACO Opportunities to Improve Patient Engagement

April 17th, 2014 by Cheryl Miller

Patients are 30 percent more likely to enroll in care management during or immediately after an acute event if they are contacted directly and introduced to a program and services, as opposed to being contacted via telephonic outreach, says Colin LeClair, executive director of ACO for Monarch HealthCare, which was a top performer in year one of the CMS Pioneer ACO program.

Through trial and error we found three opportunities to identify opportunities to yield patient engagement. First, getting the principal caregivers’ endorsement or that of the physician staff was by far the most effective means of earning the patients’ trust and getting them actively engaged. If we can say to a patient that ‘your physician has asked us to speak to you’, we get a ‘yes’ from the patient 80 to 90 percent of the time.

The second most effective means of enrolling patients in our care management program is during or immediately after an acute event. The idea is to catch them in the hospital if you can — immediately after they are admitted — and introduce them to the accountable care organization (ACO), our services, and what we can do to help them stay out of the hospital in the future. We found that patients are 30 percent more likely to enroll in care management during or immediately after an acute event, versus the cold telephonic outreach alternative. But this approach requires partnerships with hospitalists or with other hospital staff to notify you of those admissions because we don’t receive those from care management services in real-time data.

And finally, we find that patients are also somewhat receptive to care management services following a new diagnosis and we’re looking for those markers in the claims data as we receive it.

Excerpted from Tactics from a Top-Performing Pioneer ACO: Engaging Patients and Providers in Accountable Care.

Infographic: The Quality of Nursing, Patient Care

April 16th, 2014 by Jackie Lyons

Seventy-five percent of Americans 30 years and older are more concerned with the quality of nursing staff in hospitals than with the availability or accessibility of electronic medical records (EMRs), according to a new infographic form API Healthcare.

While confident in nursing abilities, a majority of consumers feel nurses are spread too thin, which is impacting the quality of patient care. This infographic also provides data on the quality of nursing care, impacts of the Affordable Care Act (ACA), consumer concerns and quality of patient care.

Looking for other ways to increase patient satisfaction? You may also be interested in The Patient-Centered Payoff: Driving Practice Growth Through Image, Culture, and Patient Experience, which is filled with easy-to-implement ideas. This 260-page resource describes how the patient-centered movement has changed medical practice and offer insights into the opportunities this new environment provides to practices.

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Predictors of PHO Longevity and Financial Success

April 15th, 2014 by Patricia Donovan

Today, value-based payment models encourage hospitals and physicians to work together and make each more accountable for the other's actions in a physician-hospital organization (PHO). But what are predictors of PHO longevity and financial success?

Here, Healthcare thought leaders Travis Ansel, MBA, manager of strategic services, Healthcare Strategy Group, and Greg Mertz, MBA, FACMPE, director of consulting operations, Healthcare Strategy Group, debate the question.

Response (Greg Mertz): It’s pretty evident that no one entity is going to be able to meet the needs of the population. If you’ve got a hospital that employs physicians, there’s an excellent chance that the employed physician network isn’t the total answer for caring for the population. They’re going to have to embrace non-employed physicians, other specialties, larger based primary care. Some entity is going to have to be created to make that happen.

But the PHO is an excellent model. Basically, it creates a collaborative entity that can bring in hospitals, employed physicians, non-employed physicians, ancillary providers. The PHO this time is something that is going to be necessary. Value is inevitable. I don’t see any reason that it would not have great longevity.

Response (Travis Ansel): I definitely agree. I think the biggest predictor of long-term success is the culture, but it’s going to be how the governance of the PHO is set up. It’s going to be giving the physicians, both employed and independent, a real voice in the organization and getting their expertise leveraged going forward. That’s going to be the biggest predictor. Beyond that, a willingness to experiment.

We’re in a situation now where organizations can’t really afford to sit on the sidelines for too long with all the different models that CMS and private payors are putting up in order to encourage shared risk between providers and hospitals. A willingness to experiment would be another key to success in my mind because it’s really the only way to learn how to be successful in this new environment, how to get involved in it and not hang on to the current FFS environment until it withers and dies.

Excerpted from Essential Guide to Physician-Hospital Organizations: 7 Key Elements for PHO Success.

Infographic: Does Early Breast Cancer Detection Save Lives?

April 14th, 2014 by Jackie Lyons

An extensive study of mammograms found that they do not decrease breast cancer death rates, and they increase over-diagnosis, according to a new infographic from BestMedicalDegrees.com based on a Canadian study.

Consequences to misdiagnosis include unnecessary radiation, surgery and chemotherapy that come with high costs. The average cost of treating early stages of breast cancer is $22,000, according to the infographic. This infographic also includes the history and statistics of mammograms and early detection.

Learn more about assessing health risks in 2013 Healthcare Benchmarks: Health Risk Assessments. This 60-page resource provides metrics on current and planned HRA initiatives as well as lessons learned and results from successful health assessment programs. It is enhanced with guidance from industry thought leaders on the necessity of HRA and stratification prior to launching a population health management program.

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Infographic: The Growing Industry, Effects of mHealth

April 11th, 2014 by Jackie Lyons

mHealth is currently a $1.3 billion industry that is expected to reach $20 billion by 2018, according to a new infographic from Mobile Future and Infield Health.

This infographic shows savings attributed to remote patient monitoring and medication adherence resulting from mHealth. It also assesses how mobile tools are transforming healthcare as more Americans, including healthcare providers, adopt mobile devices and wireless connectivity, and more.

Learn more about mHealth in 2013 Healthcare Benchmarks: Mobile Health, which delivers a snapshot of mHealth trends, including current and planned mHealth initiatives, types and purpose of mHealth interventions, targeted populations and health conditions, and challenges, impact and results from mHealth efforts. This 50-page resource provides selected metrics on the use of mHealth for medication adherence, health coaching and population health management programs.

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