Leveraging data to drive better value-based decisions: Key thoughts from RCM leaders
These organizations possess a vast amount of clinical, operational, and financial data, but it is exceptionally difficult to process and translate findings into actionable improvements. As a result, healthcare organizations are implementing data-gathering and reporting solutions to more easily identify underperformance.
On Friday, Sept. 21, Ingenious Med sponsored a roundtable discussion at the Becker’s Hospital Review 4th Annual Health IT + Revenue Cycle Conference titled “Leveraging Your Rev Cycle Data to Make Better Strategic Decisions.” Ingenious Med’s Director of Portfolio Management and Analytics, Felice Felser, led the discussion, which examined how healthcare organizations use data and technology to optimize value-based decision-making.
Representatives from healthcare organizations across the country attended the roundtable. They described the challenges associated with being caught between volume- and value-based reimbursement models. Although the primary compensation for most physicians remains fee-for-service, providers must record and gather data that will support future risk-based contracts.
Healthcare organizations typically use data that physicians, nurses, and caregivers record in the patient’s EMR to track patient history, progress, and outcomes. Physicians spend time during and after visits inputting patient information into the EHR.
A study published in the February 2018 edition of Family Medicine suggests primary care physicians now spend more time on EMR than face-to-face care. The physician’s workload has changed because of EMRs, placing additional administrative and legal burdens on their practice.
“Over the last 10 years, there has been a drop in work RVUs by 5 percent,” said Ms. Felser. “Physicians are being asked to do more, but they are being paid less than they were 10 years ago.”
With these statistics in mind, Felser asked roundtable participants how they planned on remaining profitable by implementing different strategies within their organizations.
“We try to leverage data, including consumer relationship management data, to become more efficient,” said the COO of a health information network based on the East Coast. “We need to understand where our outcomes are not in line with or exceed our current trends. It’s going to provide insight when you leverage the data. You have to have the tools to leverage data, whether you have a robust health information exchange or an analytics-driven EMR.”
“We are trying to be more aggressive with the payers because there are cost savings involved,” said the COO of a health system based in Las Vegas. “They need to share some of the cost savings, and that’s why we’re having discussions and renegotiating contracts. If we have better outcomes with a patient population in the long-term, there are savings based on that trend and it needs to be shared with the providers.”
However, most commercial payers continue to operate in fee-for-service models, thus physicians are not compensated for time spent on administrative tasks. According to the American Medical Group Association 2017 survey, 60 to 80 percent of commercial revenue remains fee-for-service.
On the other end of the spectrum, CMS is focused on risk-based payment models for a significant portion of patients. By 2019, AMGA expects 60 percent of Medicare revenue to be risk-based. AMGA estimates that out of all reimbursements, there will be 15 to 17 percent fewer made under the fee-for-service model over the next year for both commercial and government payers combined.
At the same time, healthcare organizations are losing thousands of dollars in unbilled physician fees — charges the patient accumulates during a hospital stay that aren’t billed prior to discharge.
Felser shared a specific example from a large nonprofit health system that realized it was losing money because of missing bills and unbilled physician fees. “They sent people to the health system’s orthopedic group for 10 months to observe processes and realized very quickly that the group was still organizing their charges on paper,” she said. “They would forget to turn them in or get busy with their day, and have a ton of unbilled fees per year that equated to between $22 million and $44 million. That’s a lot of money left on the table.”
To collect on the unbilled charges, the manual recovery process required an estimated 33 to 100 hours per physician per year. The health system could have avoided spending that extra time and resources on recovery if the physician fees had been billed appropriately, and technology solutions exist to identify and fix these coding and billing errors. “We recommend that you monitor your data and financial benchmarks. Benchmark against the national norms as well as other like organizations. Then you can identify and address the root cause of performance issues,” said Felser.
The most successful healthcare organizations have mastered analytics as a core competency and use revenue cycle partnerships to optimize performance. The Ingenious Med solution can quickly show patient volume, bills created per day, average RVU per day, and total charges. The dashboard also shows bills sent and unsent, giving a clear report on where they are in the revenue cycle.
“You don’t want to have many bills left in the ‘unsent’ category because you’re not getting the revenue back into the organization as quickly as possible,” said Felser. “Good partners will be able to drill down into these dashboards so you can get more information from a peer-to-peer perspective and a coding perspective. You can find where the lag is, whether it’s a physician lag or a coding lag, and you can see the entire end-to-end system.”
Claims are typically denied due to billing errors such as mismatched treatment and diagnosis codes or the absence of a diagnosis code for services performed. The top revenue cycle performers are able to:
1. Analyze physician performance, including length of stay and readmissions data.
2. Give physicians access to insights they hadn’t considered before. “If the analytics are there for the physicians to see, they might change their care or best practices,” said Ms. Felser.
3. Implement coding training and educational tools. Physicians may not have the same training as coders, but armed with the appropriate education about the process, they are better positioned to optimize documentation and surgical reports.
“We do a grand round and it’s not a pure clinical documentation presentation,” said the chief medical officer of a Michigan-based hospital. “I use an existing case, then my team and I go over good documentation and how that equates to the severity of illness and mortality. We examine — based on clinical information in the chart — if you choose to improve your documentation, what would it look like? Sometimes a person who is sick doesn’t look like it on paper, and a person who isn’t sick looks like they are based on coding. That makes a big difference, when physicians actually see that.”
4. Identify high-value providers and move other physicians in that direction. Organizations can use peer-to-peer scorecards, performance-based rankings, and data such as length of stay or readmissions to evaluate physicians based on value. Organizations can then see who falls above or below the benchmarks and engage in additional discussion or coaching to ensure all are delivering quality care.
Revenue cycle data can also provide valuable insight for care delivery among high-risk patients and the greatest healthcare service utilizers. The real-time or near real-time analytics can help healthcare organizations with risk stratification to ensure patients receive the best care for their conditions.
As healthcare organizations move more of their revenue to risk-based contracts, revenue cycle data will become more valuable. Insurance companies have collected this data for years, but they are reluctant to share it with healthcare organizations during contract negotiations to maintain an advantage. However, now healthcare organizations can collect and use the same data internally on high-risk patients and care management to negotiate favorable rates for high-cost and high-service conditions and individuals.
In conclusion, hospitals and health systems best prepared for the approaching value-based care environment are collecting revenue cycle data, leveraging the findings to optimize clinical and financial results, and making those insights available to providers.