Analytic Solutions for Payers Payers have routinely looked at data from a non-clinical perspective, for intelligence and financial analytics. It's now time for payers to focus on leveraging next-generation analytics solutions. To reap the benefits that “Big Data” promises, analytic solutions must act as the core platform. In a recent survey, the need to manage new risk levels resulting from the ACA was the number one concern from respondents. The main solution that focus group participants identified for better management and understanding of issues related to the post enrollment risk environment, risk modeling and exchange risk structures: the leveraging of robust analytic solutions, like predictive and comparative analytics tools. Two national quality initiatives - Star Ratings program from CMS and the Healthcare Effectiveness Data and Information Set (HEDIS) from the National Committee for Quality Assurance (NCQA) are of particular concern in reporting and compliance, and payer analytics can play a significant role. …show more content…
As CMS increasingly relies on patient outcomes in establishing Medicare reimbursements to payers, they are using payers’ Star Ratings, as a key factor. For payers achieving the highest ratings of 4 or 5 stars, in 2012 they became eligible for bonus payments from CMS. Payers must also strive to work with providers to get members engaged in managing and improving their own health status. However, to be successful the top three analytics challenges were identified by a panel of experts: 1. Data Integration 2. Data Governance 3. Access to clinical
Since CMS implemented the Physician Quality Reporting Initiative (now known as the Physician Quality Reporting System (PQRS) under the Tax Relief and Health Care Act of 2006 (TRHCA), there have been several changes in participation sanctions, reporting mechanisms and eligibility for incentives and bonuses. During the first two years, the program was technically a temporary, renewable initiative that sought to improve the quality of both delivery and coordination of care. The initiative became permanent when the Medicare Improvement for Patients and Providers Act (MIPPA, 2008) was enacted. The Centers for Medicare and Medicaid Services (CMS) believes the sanction-based initiative will empower consumers and providers to make better informed decisions
Their mission is “to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value”, (Joint Commission, 2014). The accreditation from the Joint Commission can be earned by multiple health care organizations including critical access hospitals, office based surgery centers, behavioral health care facilities, and home care services. For a hospital setting, the Joint Commission places the performance measures into accountability and non-accountability measures. They look at research and if the facility is performing evidence-based care process which improves health outcomes, proximity which the care process is linked to the patient outcomes, accuracy for whether or not the care process has indeed been provided, and any adverse effects. To earn and maintain The Joint Commission’s Gold Seal of Approval™, an organization must undergo an on-site survey by a Joint Commission survey team at least every three years (Joint Commission,
Enhanced IT that supports consumers, payers and providers via analytical tools and resources relieves financial and human capital burdens. Data collection and distribution empowers collaboration and coordination of care, regardless of where a patient receives treatment. End-to-end seamless integration connects facilitates faster registration, efficient referrals and consultations, results sharing and patient
The focus of this paper will be geared toward the impact that the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Health Information Technology have on the cost of health care. The regulations connected to HIPAA have an impact on cost through enforcement, noncompliance, and implementation. HIPAA is a vital tool in the protection of PHI of patients and the improvement of the Medicare and Medicaid programs (Cleverly). Trying to contribute to the improvement of Medicare alone can be a daunting and expensive task alone, but to add the addition of protecting the health records of millions of patients adds to the rising cost. Health Information Technology (HIT), aids in the enforcement of HIPAA and helps with billing patients accurately for services that they have received (Wizemann).
Accountable Care Organizations: The Affordable Care Act (ACA) sanctions the practice of Accountable Care Organizations (ACOs) to bring the advancement in health care space by enhancing the care quality, emphasizing patient’s safety and reduce health care costs in Medicare. This program was begun on January 1, 2012. Its target is not to create any demonstration project, instead it aims to produce an entity which can directly contract with Medicare. The Centers for Medicare and Medicaid Services (CMS) explain ACO as an association of health service providers, i.e. hospitals, physicians, insurers, and others allied with patient care reform that will work together to undertake accountability for the quality of patient care, and how money is spent
Regulations and Implementations The Health Insurance Portability and Accountability Act (HIPAA) is legislation passed in 1996 that safeguards the rights of employees and their families as it relates to their health insurance coverage whenever they transition or lose employment (Health IT.gov, 2016). The law required national guidelines and standards be developed concerning electronic health care exchanges as well as identifiers being assigned to providers, health insurance benefits, and employers to be recognized nationally (Health IT.gov, 2016). The Health Information Technology for Economic and Clinical Health (HITECH) Act was implemented in 2009 granting Health and Human Services (HHS) the control over creating programs to enhance efficacy, safety, and overall quality of health care via health information technology (IT) with a focus on privacy and security during electronic health data interfacing (Health IT. gov, 2016).
Introduction For several decades, government officials and healthcare experts have been discussing the broken and dysfunctional US healthcare system. The US ranks highest for cost and lowest for outcomes. Healthcare accounted for 17.4 percent of the gross domestic product in 2013 (CMS.gov). The Institute for Healthcare Improvement highlighted the quality of healthcare in the US or lack of quality with the 100,000 lives campaign. The Institute for Healthcare Improvement brought national attention and awareness to the epidemic of hospital errors and the loss of life related to those errors.
Moreover, the American Health Information Management Association exhibits their unique attributes to the health care community by assuming leadership roles in informatics, data analytics, information governance, and consumer education, while creating health intelligence that used to lower costs and improve patient care (AHIMA.org, 2017). Equally important are the organizational alliances that support the goals and functions of the AHIMA. In recent view of the organization’s background, the linkage with other organizations such as 3M, GeBBS, MRO, Oxford HIM, AHIOS, AHRQ, and CDC/ National Center for Health Statistics has aided in the success of AHIMA becoming the prime leader in the health care delivery cycle. Furthermore, these organizational alliances equally benefited from this linkage by sharing research, education, and effective marketing
Moreover, the act, in relevance to various Health and Human Services initiatives, such as the Blue Button, will encourage third parties to provide various add-on services, including secure storage of data solutions for personalized health records, APIs and platforms of health that facilitate personalized, mobile devices. Such mandates will probably stimulate innovation in bio-informatics and biometric as regulators aspire to cut Medicare costs via bundled payments and motivate protocolization by providers of care. Protocolization refers to the adoption of evidence-based, standardized and accepted treatment protocols. It is an inherent concept in the ACA and connected incentives for Accountable and Care Organizations (ACOs) and incentivized reimbursement plans in the post-ACA Medicare setting. The consequences of protocolization are reduced discretion for payers, patients and physicians in selecting treatment alternatives, but with increased control over outcomes of treatment and experience of cost.
Health care providers were greatly impacted as HIPAA started implementing and improving healthcare. For instance, “ As providers, group practices are likely to see their volume of patients increase as more employees retain coverage as required by the act” (Mathews, sub-para 5, 1997). With more coverage for patients, it encourages patients to use their insurance and keep themselves healthy without overthinking or worry. Doctors are now more likely to be able
The Affordable Care Act has major impact on the health care system, some positive as well as negative. Although it provides the Americans people with better health security by expand coverage, hold insurance companies accountable, lower health care costs, guarantee more choice, and enhance the quality of care for all Americans, it also cause major issues for providers and small practices. The Patient Protection and Affordable Care Act will bring several changes in within the health care system (Morrison & Furlong 2014). Some of the areas that will be affected by Patient Protection and Affordable Care Act (PPACA) include the way cares are being provided and cost of care. In addition, Patient Protection and Affordable Care Act will focus on designing
The Act has effectively decreased the quality of health care as a result of its compensatory cuts to medical professionals; decreasing funding will undoubtedly destroy the quality of medical practices. Fox New’s Ali Meyer conducted a survey of medical professionals in which half agreed the Affordable Care Act has a negative impact on the medical profession, including reduced quality of
Accountable Care Organizations (ACOs) are comprised of doctors, practitioners, and hospitals, to give healthcare services to patients. The goal of coordinated care is provide high quality of care through an integrated service model while avoiding unnecessary duplication of services and preventing medical errors. The ACO is evaluated through a quality metrics to assess care provided to patients in a cost efficient manner. CMS has established five domains in which to evaluate the quality of an ACO 's performance which include 1) patient/caregiver experience, 2) care coordination, 3) patient safety, 4) preventative health, and 5) at-risk population/frail elderly health. When the ACO is successful in providing care through this system, the savings
As the healthcare landscape continues to shift, medical providers and hospitals are continuously being challenged to develop clear and concise visions and redesign care delivery in ways that will usher proper transitions to value-based care. As value-based healthcare continues to take root, more and more hospitals and providers are finding themselves with little option but to join the movement. However, the jump from previously utilized fee-for-service models to value-based healthcare is not an easy one, and many healthcare organizations are finding it difficult to do so. The greatest challenge lies in successfully making the transition from volume to value-based healthcare in ways that are financially stable. Such inherent difficulties faced by those within the healthcare system are what have necessitated strategic
Quality and measurement theories that abandon the highest levels of appropriateness, will accomplish the healthcare industry evaluates the accountability costs and impacts. Having an understanding of the scrutiny of service, responsibilities, customer satisfaction, effective service and performance, and outcome assessments are all requirements of accountability, which are part of the continuum for accountability (Ledlow & Coppola,