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Presented by:
Rosemary Sheehan, Vice President
Revenue Cycle Operations, Partners Healthcare
October 17, 2014
Agenda
• Background on Partners HealthCare
• Major Drivers of Change
o External:
Health Care Cost Trends
Population Health Management
Affordable Care Act
ICD 10
o Internal:Implementation of Epic
• Impact to Revenue Cycle Operations
• Summary
• QA
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Background on Partners HealthCare
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• Partners HealthCare (PHS) is a not‐for‐profit health care system that is committed to patient care, research, teaching, and service to the community locally and globally
• Founded in 1994 by Brigham and Womenʹs Hospital (BWH) and Massachusetts General Hospital (MGH), Partners HealthCare includes community and specialty hospitals, a managed care organization, a physician network, community health centers, home care and other health‐related entities
• Revenue Cycle Operations (RCO) processes gross patient service revenue of over $16 billion and cash collections of $5 billion
• The RCO team consists of 800 staff on the Hospital teams including centralized outpatient patient access, coding, revenue integrity, billing, insurance follow up, payment posting, customer service, self pay collections, training, reimbursement analysis and system support
Change Drivers
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Health Care Cost
• Growth in healthcare spending has exceeded economic growth in every recent decade
• Since 1970, healthcare spending per capita has grown at an average annual rate of 8.2% nationwide
• In Massachusetts, from 20013 to 2011, premiums for individual and family coverage grew by 67% and 72%, respectively, far outpacing median income growth
• Membership in tiered and limited network products more than doubled from 2008 to 2012
• There is a well documented trend in health care benefit “buy‐down”, where employers and individuals have shifted to high deductible plans in exchange for lower premiums
• Purchasers are shifting to making value‐sensitive decisions that can impact Total Medical Expense (TME)
o Looking for more financial and quality data
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Massachusetts, FY 01 vs. FY 14, in billions
Health Care “Crowds Out” Other Spending
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Will Reform Succeed?
Impact of Health Reform in Massachusetts
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Impact of Health Reform at the Federal Level
• HITECH Act (part of ARRA of 2009) authorized $19 billing in federal subsidies for Meaningful Use of electronic medical records
• Patient Protection and Affordable Care Act of 2010 include provisions to incent providers to take on more responsibility of cost and quality
o Demonstration projects
o Accountable Care Organizations (ACOs)
• Population Health Management is an approach that providers and hospitals are moving to address these new pressures
• The goal is to keep a patient population as healthy as possible, minimizing the need for expensive
• Requires the use of automation and improved clinical and administrative integration
o More effectively assess patient population needs
• Changes payment methodologies
o By 2020, fee‐for‐value reimbursement is projected to represent 83% of revenue—up from 43% today and 14% in 2010
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Our contracts…2 years inLives under the Accountable Care Model
Medicare Commercial
Pioneer Accountable Care Organization
Elderly population, care management central to trend management
Alternative Quality Contract (AQC)
Younger population, specialists critical to
management
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Medicaid
NHP
Population with significant disability, mental health, and substance abuse
challenges
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Self Insured
Partners Plus
Commercial population, but savings accrue directly to Partners,
and improves our own lives
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Covered lives: ~80kCovered lives: ~25KCovered lives: ~350KCovered lives: ~75k
Partners currently manages roughly 500,000 lives in various accountable care relationships
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The ICD‐10 Mandate
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•More codes: ICD -10 is nearly 5 times larger
•More clinical specificity in the code structure
• Technical changes to the code set
Code Set Changes
ICD-9-CM (Diagnosis)5 characters
~14,000 codes
ICD-9-CM (Procedure)5 characters
~ 4,000 codes
ICD‐10 -CM7 characters
> 68,000 codes
ICD-10 -PCS (Inpatient)7 characters
> 72,000 codes
The primary driver for the move to the ICD‐10 coding structure is to provide increased accuracy in specifying medical conditions – and consistency with WHO
international disease standards.
Simply stated, the science of medicine has outgrown the ICD‐9 code set.
Hospitals & Physicians
Hospitals
Who is Impacted by ICD10?
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Stakeholders throughout the healthcare industry
will be impacted
Transition Change Management
Training
Business OperationsProcedures Policies
Laboratories
Technical Software UpgradesDatabases & reports
Electronic Transactions
Clearinghouses PayersSoftware Vendors
3rd PartyAdministrators
Employers Suppliers Providers MembersNational
Organizations
Care Management Medical & Treatment
Policy Medical Management Reimbursements
Significant technology and process changes in addition to industry adoption will be required to achieve the intended benefits of ICD‐10
The transition will significantly impact business operations and require massive changes to existing software and other technologies, and extensive training for physicians, clinicians,
coders, and general staff. The migration to ICD‐10 impacts many areas across the health system.
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Impact to the Revenue Cycle• All of these pressures mean that we have to be more efficient and cost effective
o Investments in IT and PHM place capital and operating pressure on the entire organization
o Exploring the outsourcing of certain functions to reduce cost
• The industry is shifting to value based payments vs. fee for service
o Still processing all claims and getting paid, annual settlements address the risk impacts
o As the incentives change with providers, revenue cycle still plays an important role in this – valuing clinical activities such as inpatient continuity visits, tele visits, e‐visits, and e‐consults ‐ and also distributing payment for these services
• The middle of the revenue cycle are becoming a key focus
o Capturing the specificity of what care was provided and why, will ensure the health adjusted status is accurately reported and the cost of care is accurate
o ICD10 will reduce coder productivity by 50%
o Coders will be required to capture more and more quality data during the coding process
• Movement for patients from CommCare to new plans has been a costly disrupter to Massachusetts providers and patients
• New benefit structures include higher portions of patient liabilityo Requires more pricing transparency
o Increasing cost to collect
Now what??
• Technology is required to:
o Fundamentally change how care is provided
o Engage patients in their own care
o Address the new payment methodologies
o Measure quality and value
o Be more cost effective in the revenue cycle process
Provide better overall service to our patients
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Partners eCare (PeC) is a system‐wide information technology infrastructure that will support Partners’ patient care, teaching, research, and community mission
by providing high‐quality, accessible, efficient, and
coordinated patient care. PeC reflects a judgment that PHS can and must improve the value it provides its patients every day, and that integration is core to
realizing that goal.
Partners eCare
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Partners eCare
• Partners eCare will:
Represent the full continuum of patient care
Enable a seamless flow of clinical and financial information about a patient anywhere within the Partners system
Complement the growing engagement of patients in their own care
Improve access to knowledge and information
Enable safer, more coordinated, and better care
Improve operational efficiency and effectiveness
Support analytics and compliance reporting
Serve as a future model for innovation in healthcare
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Epic 5 Year Roadmap
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Vision: “One Patient, One Record, One Team, One Partners Statement”
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Major Changes Driven by Epic
• Requires a MAJOR cultural change for Partners clinicians, hospitals and administrators
• Shifting from a provider focus to a patient focus; examples include MyChart, Single Self Pay Billing Office
• Standard workflows, protocols, orders, policies and procedures are required to support one system
• Moving from hundreds of niche clinical applications to one integrated system, losing in some cases highly customized workflow
• Decision making is governed by a system wide priorities not just one individual physician, hospital or site
• First time that the revenue cycle functions are tightly tied to the clinical applications and vice versa
• Requires intense collaborations across the entire enterprise
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Response to Changes
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Typical Response to Change
Informed anguish
Blissful ignorance
Coming to terms
Realistic support
Overtchecking
out
Covertchecking
out
1. UninformedOptimism(Certainty)
2. InformedPessimism
(Doubt)
3. HopefulRealism(Hope)
4. InformedOptimism
(Confidence)
Resistant
Time
Supportive
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If the rate of change on the outside exceeds the rate of change on the inside….the end is near.”
Jack Welch, former CEO of General Electric
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Summary
• There has always been a constant stream of payer and regulatory changes in coding and billing functions
• Now there is an intersection of extensive internal and external change driving the need to lower cost and be more efficient and effective
• Our team is seizing the opportunity to improve the overall process
o Change brings a burning platform to the organization that with the right leadership can achieve great outcomes and results
• The Revenue Cycle team will move from 12 billing systems to Epic with one common approach
o This will allow Partners to provide better service to our patients, increase cash collections and improve overall efficiency
• Collaboration between clinical teams, i.e. case management, clinical documentation improvement (CDI) and coding will be a major focus over the next year
o Specificity of coding, accuracy of patient status, capture of quality metrics etc..
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