Healthcare Interoperability Poised to Solve COVID-19’s Big Data Crisis

Healthcare Interoperability Poised to Solve COVID-19’s Big Data Crisis

Coronavirus highlights power of big data and the need for interoperability to improve population health. How can health plans lead the way? 

What’s the single biggest weapon used by government, pharma, academic researchers, healthcare systems, and health insurers alike to combat the novel coronavirus pandemic? It’s data. Massive amounts of data. Unfortunately, we’ve said it before, and it bears repeating: healthcare has a data problem. And, like many things in healthcare, the current crisis has brought this deficiency into focus. 

In this article we’re exploring the many uses of big data for the coronavirus and beyond and how health plans can overcome the obstacles to ingesting and processing data from a myriad of sources to achieve interoperability, positively impact population health and secure their competitive advantage. 

Big Data and the Coronavirus: A Unique Use Case

Already, work involving advanced analytics applied to real-world data is seeing success in combating COVID-19. By analyzing publicly available datasets, scientific literature, social media information and their own data, progress of a sort has been made by different groups: from predicting adverse events in coronavirus patients to rapidly developing potential vaccines. But the propensity for healthcare, academics and industry to stick to their silos – and their information right along with them – has limited their potential for reliable successes. 

Challenges to leveraging healthcare data

Despite generating a ton of healthcare data – most of it now digital – much of that data is still incomplete, irrelevant, inaccessible or a combination of these. And the sheer volume makes it difficult to overcome these deficiencies. By some estimates, we’re generating over 2,300 exabytes per year (one exabyte = one billion gigabytes), which is expected to grow at least 36% year over year through 2025. 

While compute power has evolved to handle the sheer amount of information, this data is locked in silos. In the absence of clinical trial data – the gold standard – real-world clinical information from COVID-19 patients is the most useful in guiding medical decisions. Thanks to a decades-long push to digitize healthcare information, this data exists inside electronic health records. Despite the promise of digitization, EHRs have not made it easy to retrieve this crucial data.  

Built as they were with billing efficiency in mind, most of the useful clinical data is stored as unstructured free text. And without a common architecture, labels are inconsistent, which makes sharing difficult – even in rare cases where data is complete. There are reports of providers unable to deliver detailed clinical data on coronavirus cases, largely because it would have to be printed or tediously copied from EHRs, then sent by fax or email, or manually entered into CDC forms. 

Interoperability and collaboration offer keys to success

 

The new rules against information blocking have been delayed to free up resources devoted to the pandemic response, but the need for data interoperability has never been greater. When health data is shared, front-line providers are informed in real time on patient movement, health changes and diagnoses, allowing them to respond smartly. 

According to the Office of the National Coordinator for Health IT’s Don Rucker, M.D., the current COVID-19 pandemic is a clear example of why the data sharing regulations are so critical. “Ironically, if we had this rule several years ago, we would be in a far better spot for knowing what’s going on with this pandemic. There are fundamental things about the biology of this virus that we don’t know, such as latency, duration of disease and how immunity is built up. It would be easier if we had richer clinical information streams.” 

One success story demonstrates just how essential data interoperability is to identifying vulnerable populations and performing targeted outreach. The regional data network had already taken the steps to integrate health information from numerous providers in the area, so they were well positioned to respond quickly during the COVID-19 pandemic. But they were still limited to barely more than a third of the county’s population in this initiative, which shows there’s still plenty of work to be done. 

Other successes tell a similar story. Working together, sharing information – even among competitors and others that don’t traditionally collaborate – accelerates the path toward viable coronavirus solutions. Making quality data more readily available should be the goal. As one expert in public health research puts it, “How can we continue to work together and invest in these infrastructures so that we can collect data, share that data, and analyze that data rapidly in pandemic situations? Or even in smaller-scale situations, like a localized outbreak of food poisoning or salmonella?” 

Where is all this data coming from?

In 1950, the doubling time of healthcare data was 50 years; in 1980, 7 years; and in 2010, 3.5 years. Today, that rate is 0.2 years—just 73 days. These increasingly varied sources of digital data all offer value, though few health plans are able to ingest and parse all of them. 

  • EHR 
  • Claims systems 
  • CRM 
  • Rx data 
  • PACs 
  • Lab data 
  • Clinical Trial Management systems 
  • ACOs/HIEs 
  • Genomics and research registries 
  • Wearables 
  • Apps 
  • IoT 
  • Chatbots 
  • Medical devices and sensors 
  • Social media 
  • Machine logs 
  • PHR systems 

How Health Plans Can Push Data Interoperability Forward 

Now that the pandemic has reinforced the need for improved sharing of healthcare information, what comes next? Like the push for EHRs to streamline healthcare billing, it’s likely health plans will again have to lead the charge in the journey to healthcare data interoperability. We outlined before 4 steps health plans can take to comply with the new information blocking rules. In addition to technical compliance, there are 3 things health plans can do to promote interoperability more broadly in the industry. 

1. Adopt modern technology with interoperability in mind 

The assortment of fragmented technology and manual systems currently in use at many health plans will no longer cut it. Every internal operations system – the claims adjudication system, CRM, fraud detection, payment integrity, provider outreach tools, member service chatbots and everything in between – must be able to “talk” to each other. Moreover, two-way interaction between external provider systems like EHRs and members’ apps of choice also will be required. Advanced integrative technology platforms like Pareo leverage modern APIs built on the FHIR standard to support interoperability. 

2. Use A.I. to process data 

Once health plans have ingested data from myriad sources, processing that information into real-time insights is the next logical step. But even with data interoperability standards in place, healthcare information is still likely to be largely inconsistent and unstructured. Applications of A.I. like supervised and unsupervised machine learning, natural language processing and more can help overcome these challenges, turning raw data into visualized business insights. 

3. Share insights 

Once a health plan has done the dirty work of ingesting and analyzing healthcare data, that’s where the real value of promoting interoperability comes in. Sharing insights with relevant stakeholders – providers, members, even other health plans – builds trust and the ability to realize the benefits of big data across the healthcare continuum. 

Benefits of Big Data Interoperability 

While healthcare data interoperability promises many benefits during a pandemic, innovations pursued now promise to pay dividends long into the future. We’ve written about a few of these during our recent series of articles covering long- and short-term effects of COVID-19. 

For one, without data interoperability, the transition to value-based care is a non-starter. Sharing mutually beneficial information with providers is the foundation of fostering these valuable relationships. It’s up to health plans to take the reins on opening the lines of communication with providers, and supporting them with relevant clinical information can help them reduce costs while improving care. 

The coronavirus pandemic has unfortunately affected members as well, particularly their healthcare coverage and finances. As a result, they have been more likely to delay needed care – even for chronic conditions that make them more vulnerable. At the same time, they are signaling they are more open than ever before to receiving communications from their health plan. This convergence provides an ideal opportunity for health plans to leverage big data insights for population health management efforts. Advanced technology like Pareo surfaces lists of those members most likely to need engagement and care to improve healthcare access, outcomes and quality. 

Finally, greater information sharing allows health plans to make more informed decisions faster. Where are the errors, areas of high-risk and opportunities for driving changes? Access to the “big picture” ensures strategic planning that secures a health plan’s competitive advantage. 

Health Plans Find Success with Tech-Forward Strategies 

COVID-19 has thus far proved to be a harsh but effective teacher, not least by emphasizing the need for an interoperability record that helps to provide comprehensive clinical insights with a 360-degree view of members and patients. This initiative is only feasible through advanced technology. Those health plans with digital-first strategies already in place are better set up for success, but payers that lag can still make progress and secure their competitive advantage. 

By adopting scalable comprehensive technology and leveraging modern interoperability standards, health plans can position themselves to excel at payment integrity, coordinated communication and population health efforts alike. As the COVID-19 crisis evolves – and in readiness for when the next healthcare crisis presents itself – payers will be able to lead the way in identifying those at risk based on their clinical predisposition, genetics, social determinants of health, and other factors as well as coordinating member and provider engagement. 

NOW'S THE TIME FOR TOTAL PAYMENT INTEGRITY

Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies. 

From Volume to Value: Alternative Payment Models Win During a Healthcare Crisis

From Volume to Value: Alternative Payment Models Win During a Healthcare Crisis

As patient volumes drop due to the COVID-19 pandemic, fee-for-service payment models hurt providers. Is this finally the time for value-based care? 

COVID-19 is decimating provider finances. Hospitals are losing over $40 billion per month in lost revenue due to canceled non-emergent inpatient and outpatient procedures. Physician practice revenue has been cut in half. These financial impacts are the direct result of the volume-based contracts in place at many providers, leading some to ask if this might finally be the right time for value-based care. In the words of one payer executive, “If there’s a silver lining to the crisis, it’s that we will now explore a value-based model which is going to be good for patients, good for providers and good for the community.” 

Let’s examine how fee-for-service reimbursement became the norm in healthcare, how it compares to value- and risk-based agreements, and how health plans are better positioned than ever before to successfully promote and implement alternative payment models like value-based care. 

A Brief History of Healthcare Payments 

Our last article in this series on the far-reaching impacts of the novel coronavirus pandemic called out that the structure of our healthcare industry has been in place for almost a hundred years. For the first half of the 20th century, fee-for-service payments made sense as there were limited numbers of interventions and medications that could be offered, and those were relatively low-cost.  

Medical advancements raise complexity, cost  

As medical advancements were made, complexity and cost increased. When the Medicare and Medicaid programs were created to help the elderly and low-income population receive care despite higher costs, their method of reimbursing for services provided the foundation for fee-for-service reimbursement. Later, as costs continued to increase, payment reform concentrated on payment caps but kept FFS reimbursement intact, which led to providers increasing the number of reimbursable services and patient throughput to maintain revenue.  

The rise of managed care and value-based care 

In the 1990s, “managed care” initiatives slowed the growth of healthcare spending by reducing utilization. But they also concentrated healthcare decision making outside of the patient-provider relationship, which unnecessarily increased friction and led to their demise. In 2010 the Affordable Care Act mandated a few value-based care programs administered by CMS. Bundled payments that offered higher fees for higher-quality providers were also introduced as a middle ground between FFS and capitation. 

 

Though there have been gains in value-based care contracts, most provider revenues are still based on patient volume. A recent survey revealed that while 57% of provider respondents were participating in value-based care arrangements, 48% report that over three-quarters of their organization’s revenue is tied to FFS. 

It’s not just finances, it’s personal: Provider burnout exacerbated by COVID-19 

The financial hit that providers are taking is secondary to the fact that many are putting their lives on the line as they stand at the forefront of the novel coronavirus crisis. But health plans are paying attention to an underlying issue many providers face: professional burnout. 42% of physicians surveyed in 2018 reported feeling burned out while 15% admitted experiencing some form of depression. Those most likely to be burned out are the same ones most likely to be working the front line: critical care, internal medicine and emergency medicine.  

It’s possible that a shift to value-based care and telehealth could offer more work-life balance for medical professionals, and health plans are taking note as they look to support their networks of providers during and after this healthcare crisis.  

Why Continue Fee-for-Service 

Especially in the short-term, fee-for-service reimbursement provides a straightforward, familiar model that encourages providers to continue to offer healthcare during a time when its most needed. And, as many states lift restrictions on elective procedures, many providers expect pent-up demand for healthcare to rebound patient volume and revenue right along with it. Close to 40% of people who had elective procedures canceled plan to reschedule. 

ACO experiences 

Accountable Care Organizations make up a big chunk of the providers participating in alternative payment models. But with their large Medicare populations, the coronavirus pandemic created more risk than they had planned on. In a survey, more than half of ACOs, which earn shared savings based on total spending, were considering exiting the program due to uncertainty and expected financial losses. 

Fortunately for ACOs, CMS stepped in with a new rule that aims to protect them from unforeseen financial impacts. These changes remove spending on COVID-19 patients from performance calculations, expand the definition of primary care services to include telehealth, and more. Nevertheless, this scare may deter other providers from participating in value-based care arrangements. 

Risk-averse providers

Historically, providers have been reluctant to take on the additional risk inherent in value-based care contracts. And, who can blame them? It has been difficult to come to consensus on what “value” and “quality” really mean, and lack of data interoperability only exacerbates that issue by keeping essential information on outcomes out of reach for providers. Furthermore, even before the COVID-19 crisis, many providers were already struggling due to burnout, financial issues and hospital closures. 

When providers enter into alternative payment models, it takes significant resources. With increasing Medicaid and uninsured populations, they may not have it to spare. Physician practices are closing and increasing consolidations are expected in the wake of the novel coronavirus pandemic. This translates into reduced capacity for preventive care and less provider incentives to engage in risk-sharing.   

6 Primary Payment Models

While fee-for-service will likely always exist in some form, in response to growing healthcare costs (now almost 20% of GDP), public and private payers have launched innovative provider payment models designed to reward value over volume. Source 

  • Fee-for-service 
  • Bundled payment 
  • Capitation 
  • Pay-for-performance / Shared savings 
  • Blended payment 
  • Salary 

Why Transition to Value-Based Care  

While an immediate switch to at-risk contracts may not be advisable, long-term, value-based care promises to position the U.S. healthcare system to better respond to future healthcare crises. Those providers currently participating in alternative payment models haven’t experienced the same drop in revenues as those whose survival depends on patient volume. And they are more likely to pursue population health improvements that stand to keep their patients healthier during the pandemic. 

Surprise assist from telehealth 

One unexpected boon from the pandemic is the increased adoption of telehealth. Investments in telehealth and other methods of virtual care are key moves by providers that lend themselves nicely to value-based care initiatives of lowering the cost of care and increasing patient engagement. These investments were made because payment parity kicked in. Before, according to one survey, 60% of primary care clinicians reported the majority of their work was not reimbursed or funded, a big portion of which was telehealth.  

Now, telehealth allows them to accommodate surges in capacity, if needed, and focus on caring for vulnerable populations, so important during a pandemic that disproportionately affects these groups. As one physician says about the pandemic recovery and the role of virtual care in population health management, “This is going to be a phased-in thing and the sickest of the patients are the ones that we need to continue to be able to see to provide care for and get reimbursed for in a virtual modality.” 

Change slow but inevitable 

Those providers who continue to cling to FFS may be left behind and unable to participate in many future healthcare initiatives. CMS, in particular, has been transitioning to value-based care at an accelerated rate since the ACA was passed 10 years ago. A 2019 report showed that 35.8% of total U.S. healthcare payments in 2018 were tied to alternative payment models, a year-over-year increase of 34%. 

Moreover, the industry has begun to come together on value measurements and alternative payment model frameworks. Government payers and commercial health plans are still the primary drivers of value-based care, but universal standards go a long way towards removing uncertainty by increasing transparency. 

How Health Plans Can Support Alternative Payment Models 

We’ve written before about how payers can best support the transition to value-based care: improve provider relationships and data transparency with the help of advanced technology. That advice hasn’t changed, though the COVID-19 crisis may have increased the importance of these initiatives. 

Provider communication 

Collaboration and shared understanding enabled by real-time, two-way communication with providers is essential to the success of value-based care programs, and there is still plenty of work to do in this arena. A recent survey showed that as many as 18% of providers have zero trust in the payers they work with, and more than a third have no communication with those payers. We wrote in a previous article that the COVID-19 crisis has led payers to increase their support of providers, which may provide an opening for health plans to shore up these relationships.   

Without trust, it’s difficult to ask providers to assume more risk. In fact, a survey found that primary care physicians who trust the health plans they work with are more than twice as willing to engage in risk-sharing. As a stakeholder at a regional commercial health plan puts it, “Value-based care is payer driven, but provider and hospital partners need to come together and recognize something bigger. We’re not just trying to do something niche. We’re trying to help people prosper across our population.” 

Data transparency 

Value-based care initiatives depend on data as well. Data that reveals which populations need targeted outreach and how healthcare impacts outcomes is valuable to payers and providers alike. Lack of data interoperability between payers and providers is the number one roadblock that prevents healthcare innovation.  

Breaking down data silos can help mitigate the differing interpretations of value and quality that hold back progress on alternative payment models. So, measure everything. Every impact—clinical quality, consumer experience, return on investment, and more—should be quantified, analyzed, improved, reanalyzed and continually improved in collaboration with providers. Work with providers to implement an analytics and communications platform to share data insights and work together on continuous improvements and innovations.  

Advanced technology essential 

Value-based care promises to lower the cost of healthcare and improve outcomes. These goals were important before the emergence of the novel coronavirus and are now essential directives. But these risk-sharing contracts require advanced technology in order to implement them. CMS has suspended data collection and quality reporting so providers can focus on patient care, but health plans executing on advanced digital strategies won’t miss a beat.  

With integrative technology like Pareo in place, health plans can seamlessly communicate with providers and ingest electronic clinical care and claims information without unduly burdening these valuable relationships. They can come together in identifying and engaging those members who are in most need and find efficiencies without sacrificing quality or the doctor-patient bond. It’s the future of healthcare and it’s achievable now. 

NOW'S THE TIME FOR TOTAL PAYMENT INTEGRITY

Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies. 

Coronavirus New Normal: What does it mean for health plan members?

Coronavirus New Normal: What does it mean for health plan members?

25 million Americans projected to lose employer-sponsored healthcare coverage due to the COVID-19 recession. How will this disruption affect the relationship between health plans and consumers? 

As of the end of April 2020, about 30 million people in the U.S. are newly unemployed due to the pandemic-fueled economic shutdown, a sharp uptick from the recent historically low unemployment rate. Because, on average, about half of the people in this country receive health insurance through an employer, this situation is threatening healthcare coverage during a healthcare crisis. How is this disruption affecting health plan operations and consumers, and will it create longer-term changes in how the majority of Americans receive health insurance? 

The Financial Impact 

A variety of government and social policies in the 1940s and 50s led to the current state of healthcare coverage in the U.S. where most individuals receive insurance through an employer-sponsored health plan. While that structure functions fairly well during periods of low unemployment and underemployment, it can leave a gap during a climate of economic and job uncertainty. 

In the 6-week period between mid-March and the end of April, the unemployment rate soared from sub-5% to over 16% as efforts to stem the spread of the novel coronavirus ravaged the economy and led to widespread furloughs and layoffs of workers. By some estimates, that massive job loss has resulted in 12.7 million Americans losing their healthcare coverage at the same time they can least afford to replace that coverage. 

Health plans started to see the fallout of this rapidly changing situation almost immediately. One of the largest health plans in the nation reported that the number of its premium base requesting grace periods and payment plans increased from 0.4% to over 3% by mid-April. However, this standard practice of 60- or 90-day grace periods is expected to be not nearly enough relief for many members, leading one to offer premium credits and other financial assistance. 

Recognizing the potential impact to cash-strapped consumers, assorted medical and insurance groups are lobbying for assorted financial and healthcare coverage support measures: 

  • Offer employer subsidies 
  • Subsidize or cover COBRA benefits cost 
  • Open special enrollment periods 
  • Increase subsidies for ACA marketplace plans 

Already enacted is a 6.2% increase in federal matching Medicaid funds to help states handle the pandemic for the duration of the national public health emergency. Included in the eligibility requirements for the enhanced funds are provisions that require states to not unduly prevent qualifying individuals from receiving Medicaid coverage. 

The Healthcare Impact 

Consumers losing their income and reliable health insurance coverage during a healthcare crisis is an untenable situation. recent survey revealed a potentially precarious financial situation for a segment of the population. When asked if they would seek medical attention if they presented with the signature symptoms of COVID-19, 14% said they would avoid care due to cost. Even when asked specifically to imagine a suspected coronavirus infection, 9% still would avoid treatment. These responses were especially likely for those with lower incomes, a group that has been disproportionately affected by the current economic crisis. 

This hesitation to seek care couldn’t come at a worse time as the delays promise to derail chronic condition outcomes as well as public health initiatives related to the pandemic. However, putting off care due to financial constraints isn’t an entirely new experience. An annual poll, most recently conducted in November 2019, showed that a record 33% of Americans put off needed medical care due to costs, a rate that has increased 50% over the past 20 years. 

Health plans and the government have stepped in to encourage people to continue to seek healthcare if they need it. Health plans by temporarily waiving cost sharing for coronavirus testing and treatment, as well as other services for vulnerable Medicare members, and the government by compensating providers for uninsured care at Medicare rates so providers don’t unnecessarily burden patients without a safety net. 

Health Insurance by the Numbers

The latest healthcare coverage data available is from 2018. After years of improvement in the uninsured rate, starting in 2010 with the enactment of the ACA, the rate has increased for 2 years in a row, particularly in states that haven’t expanded Medicaid. 

  • Employer Insurance 55.1% 
  • Medicaid 17.9% 
  • Medicare 17.8% 
  • Individual Market 7.5%  
  • ACA Marketplace 3.3% 
  • Military 3.6% 
  • Uninsured 8.5% 

The Future of Healthcare Coverage 

With the rising costs of healthcare coverage shouldered by employers, and the opening of the ACA marketplace, some analysts predicted that 90% of employers would have abandoned sponsored health benefits packages by now, in the same way pensions gave way to 401(k) plans. That projected reality hasn’t yet come to fruition, though the rates of “underinsured” individuals with employer plans are increasing  

The number of uninsured employed people is also increasing, according to a recent studyIn fact, 70% of the uninsured were employed but not offered an employer-sponsored health plan while 30% didn’t enroll in employer coverage because of high costs. At the same time, high rates of unemployment bring into focus the potential gaps created by tying healthcare to jobs, and we likely have not reached peak unemployment in the COVID-19 recession. 

Single Payer Unlikely for Now 

Though the past couple of years saw single-payer policies gaining traction, strong lobbying against the structure has prevailed for now. However, much depends on how quickly the economy rebounds and to what degree. Large corporations make up much of the enrollment in employer-sponsored health plans and continue to drive that segment, and many of them have weathered this economic downturn with greater resilience thus far 

Though healthcare independent of the workplace is currently more important than ever before, the current system is still working for many people. Enhancing ACA plans and subsidies and expanding Medicaid to more people are the most cost-effective – and quickest to implement – efforts and stand to benefit those most affected by income hardships. 

Higher Medicaid Enrollment 

Experts released a new report that projects unemployment will reach 20% by June 2020, which would lead to between 25 million and 43 million individuals dropping out of employer health plans. Of those, 12 million to 21 million will enroll in Medicaid, 6 million to 10 million will receive individual coverage through the ACA marketplace, and 7 million to 12 million will become uninsured. According to a senior policy advisor, “Our safety net is about to be tested, and it’s going to work a lot better in states that expanded Medicaid.” 

Data Insights Key to Health Plan Response 

Short-term, for health plans this shift means a dramatic change in their lines of businessHealth plans that cannot quickly pivot based on data and market changes are at risk. If employer-sponsored coverage changes for the long-term, are health plans positioned to navigate these twists and turns 

Some payers are already making moves specifically focused on expanding their Medicaid and Medicare portfolios. As stated in the announcement of one of these deals, the health plan’s “strengths and capabilities will be critical to successfully serving new populations if a recession increases Medicaid membership.” At the same time, health plans report uncertainty in their 2020 projections, as small group enrollment drops and Medicaid rolls increase. Health plans are having to prepare for all eventualities, and advanced integrative technology – along with the data insights it provides – can provide the edge they need. 

Evaluate Consumer Behavior Changes 

Health plans are keen to harvest business insights from member behavior during this time. They anticipate the pandemic changing the way care is delivered for at least 1-2 years and likely, forever. Most health plans are anxiously awaiting the emergence from the “first wave” of COVID-19 cases (possibly this Summer) to see how user behavior is affected and try to strategize on long-term effects. 

With so many workers furloughed or laid off, we may see a return to insurance after this first emergence, which provides a strong opportunity for health plans to find an early indicator of longerterm behavior change that would impact their bottom line. Data on utilization of care, self-insured rates, changes in plan levels and HSAs, and more will prove valuable. 

Reduce Administrative Complexity 

Administering Medicaid MCO plans is a more complex operation, especially as CMS has issued waivers to help states be more nimble in responding to coronavirus. Medicaid lines of business also tend to be less profitable than employer-sponsored insurance. Increasingly, health plans and payers are turning to advanced payment integrity technology like Pareo to streamline coordination of benefits and otherwise ensure proper payments to providers.  

And, by virtue of being an integrative platform, it helps reduce administrative lift in tangential operations related to traditional payment integrity efforts as wellPareo supports health plans in seamlessly shifting internal resources to more easily accommodate changes in LOB, and automating communication with suppliers and providers to ensure changes are relayed effectively and efficiently.  

Improve Engagement 

Leaders of health plans know that the way insurance is delivered may change for many consumers and, particularly for Medicaid enrollees, engagement is paramount. Technology enables them to proactively address at-risk populations, like those with chronic conditions who may be particularly vulnerable to disruptions in care. By delivering broader data insights and supporting communication with internal and external stakeholders, Pareo aligns with a broader strategic effort at health plans to “improve engagement in healthcare.”  

NOW'S THE TIME FOR TOTAL PAYMENT INTEGRITY

Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies. 

Coronavirus Boosts Telehealth Adoption

Coronavirus Boosts Telehealth Adoption

The COVID-19 pandemic prompts payers to encourage the shift to telehealth, a move supported by patients and providers. How will this change the future of healthcare delivery? 

The novel coronavirus stopped traditional healthcare in its tracks, but there’s one bright spot: telehealth. As technology has advanced over the last several years, it seemed as though at any moment, telehealth would finally take off. But while the market size of the telehealth services industry growth has outpaced other areas of healthcare, with 25% average annual growth from 2015 to 2020, relatively few of us have experienced a virtual healthcare visit. That is, until now. 

Recognizing the potential of telehealth to provide safe and continuous care to those in need – both potential COVID-19 patients and those in need of other non-emergent healthcare – the CARES Act stimulus package offered $200 million through the Federal Communications Commission to medical groups to help them install the technology and fund broadband installations. At the same time, CMS and commercial health plans have temporarily introduced payment parity and relaxed some regulations that have traditionally held back progress on the initiative. 

These interim changes and financial support have dramatically increased provider, patient and payer experiences with telehealth, and early surveys indicate general satisfaction and acceptance. What does this mean for the future of telehealth? Here, we explore how telehealth has evolved in recent years, including traditional barriers to adoption, and how the pandemic has accelerated the way forward. 

What is telehealth?  

The Center for Connected Health Policy defines telehealth as “a collection of means or methods for enhancing health care, public health and health education delivery and support using telecommunications technologies. Telehealth encompasses a broad variety of technologies and tactics to deliver virtual medical, health, and education services. Telehealth is not a specific service, but a collection of means to enhance care and education delivery.”  

While the term “telemedicine” is used for traditional clinical diagnosis and monitoring delivered by technology, telehealth is used more broadly to cover the wide range of diagnosis and management, education, and other related fields of health care, including dentistry, counseling, physical and occupational therapy, home health, chronic disease management and more. It also covers live video visits, mobile health data, remote monitoring via connected devices and store-and-forward technologies for secure sending of health information. 

Barriers to Telehealth Adoption  

Even before the novel coronavirus pandemic took hold, telehealth was slowly expanding, but there were numerous challenges to its widespread adoption, the biggest of which were complex regulatory barriers and lack of payment parity. 

First, regulations vary depending on CMS, state Medicaid, and state commercial health plan requirements. All are different but restrictions on type of service, location of service (both provider and patient), provider credentials, cross-state visits and/or state licensure and more are common. That said, according to a recent survey, 42 states and Washington, D.C., now have some sort of telehealth commercial insurance coverage law, an improvement over the last five years. However, only 10 states offer true payment parity, which disincentivizes providers to offer it. 

As a result of this complexity, telehealth has been minimally available to consumers until recently. In a 2016 survey, over half of consumers surveyed indicated they wouldn’t use telehealth and 39% said they hadn’t even heard of it. 

Historic Resistance to Telehealth  

Payers and other entities have historically resisted adopting measures that would expand telehealth adoption by limiting reimbursement and the number of eligible procedures as well as enacting various provider restrictions. A 2018 hearing regarding a Connecticut telehealth bill illustrates the concerns about payment parity. The legislation was supported by providers, but payers and employers opposed the payment provisions citing their desire to negotiate reimbursement themselves as well as arguing that telehealth should fundamentally be a lower cost option. 

A more recent debate holds state medical boards responsible for holding back telehealth progress with their role in continuing to forward credentialing, cross-state and established relationship restrictions. While concerns about malpractice and liability are valid, it’s difficult to say if patient safety is more at risk with telehealth. 

The same argument holds for potential fraud. Though the telehealth industry argues virtual visits are no more susceptible to fraudulent activities than other healthcare encounters, regulators hold that these restrictions are necessary guardrails because of the increased capacity. As one official with the HHS Inspector General’s Office states, “There are unscrupulous providers out there, and they have much greater reach with telehealth. Just a few can do a whole lot of damage.” Health plan SIUs likely will need to adjust metrics currently used to find fraud in in-person encounters, as legitimate telehealth claims may look like previously “impossible visits” regarding provider capacity and geography, for instance.  

Telehealth Benefits During the Pandemic  

The novel coronavirus pandemic has quickly demonstrated the significant benefits of telehealth – both for patients and providers – and thus its market viability. While the pandemic has accelerated telehealth use, one survey indicated that telehealth was already beginning to really take hold with over a third of Millennials and Gen Xers taking advantage of virtual visits. The survey also demonstrates the potential of telehealth, noting that, “based on actual claims costs and coding over the two-year study, approximately 71% of convenience and urgent care visits could have been virtual visits, saving … $3.8 million, or 45% of allowed costs.” 

story out of Pennsylvania illustrates telehealth’s unique benefits for the management of chronic disease, especially for an area with a huge rural and elderly population. Telehealth visits for the region’s largest healthcare provider jumped 3700% from early March to late April. While there were technical challenges for both patients and providers in the beginning, “the satisfaction rate among patients is remarkably high.” They are working on documenting the outcomes during this period to prove the technology’s viability for long-term use, which may be particularly useful for health plans looking to expand risk-based contracts. 

Recent surveys also reveal the pandemic’s impact on physicians and their response. One showed that in-person healthcare visits were down by 67% while overall visits decreased by 54%. However, of the total ambulatory practice visits, 30% were delivered through telehealth, and half of physicians now offer telehealth, up from only 18% two years ago. With 20% of surveyed primary care practices at risk of permanent closure due to the pandemic, many are turning to telehealth to provide continuity for patients as well as to bridge the financial gap. As one physician noted, “The process allows them to keep open that virtual front door in a meaningful way.” 

Telehealth Moving Forward  

So, what’s the fate of telehealth post-pandemic? Bipartisan legislation introduced in October 2019, the CONNECT Act, aims to reduce barriers to telehealth in Medicare, so there is existing support. Additionally, the current situation presents CMS, state Medicaid administrators, state medical boards, and commercial payers alike with several considerations. 

Now that consumers have been able to experience the convenience of telehealth for themselves, they are unlikely to desire a return to the “old way.” Even the elderly population has taken advantage of the safety and flexibility offered by virtual care from their homes. And, combined with payers’ historic focus on digital technology that supports member satisfaction initiatives, health plans may be open to extending telehealth coverage now that consumers are embracing it. 

In addition, more providers have invested in telehealth capabilities to support operational continuity, which reduces infrastructure barriers and promises to mitigate the foretold provider shortage. Because the novel coronavirus has put undue stress on the physical and operational health of providers, continuing the relaxed telehealth regulations indefinitely may prove to be the right move. 

This situation provides an ideal proving ground to test how payment parity and minimizing restrictions affects patient care. If all proceeds without dire consequences, it will be difficult to put the genie back in the bottle.  

Health Plans Turn to Pareo  

Expanding telehealth coverage can no doubt add complexity to an industry that is already shouldering a great deal during this time. Adding to the significant administrative burden of health plans and providers is unsustainable. During the pandemic and beyond, health plans can no longer deny the numerous benefits of digital transformation. Advanced payment integrity technology platforms like Pareo allow payers to support rapidly changing provider contracts and payment policies and seamlessly engage with providers.   

While the expansion of telehealth at such a rapid pace is a new development, most payers have long-anticipated a shift to digital care to improve patient access and intervention for value-based care initiatives and other healthcare cost savings measures. However, health plans who are not agile in data sharing, accessing relevant business insights, or even vendor management may struggle to modernize operations fast enough.   

Administrative burden is a problem that most payers have yet to solve, and the quick expansion of telehealth is sure to exacerbate the issue. Pareo is unique in that it not only unites disparate systems and automates workflow (solving many efficiency problems), but our payment integrity technology also sets the stage for health plans to own the core operations that power revenue. Our clients have seen up to a 10x return on investment, with efficiency gains estimated at 25-50%. 

NOW'S THE TIME FOR TOTAL PAYMENT INTEGRITY

Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies. 

Coronavirus Crushes Providers. Health Plans to the Rescue!

Coronavirus Crushes Providers. Health Plans to the Rescue!

To support healthcare providers financially impacted by COVID-19, health plans rush to provide funds, ease administrative burden with prepay and engagement initiatives. 

Right now, the healthcare industry is in the thick of the novel coronavirus pandemic, with providers bearing the brunt of the impact. Already risking their health in service of sick and scared patients, providers of all stripes – hospitals and private practice alike – are facing another dilemma. How will they survive financially? With the understanding that healthcare providers are one of our best assets in fighting COVID-19 and ensuring a healthy population, the government and private payers are taking short-term and long-term action to shore up this valuable resource. Immediately, by directly and indirectly paying out funds to providers. Longer-term, by investing in prepay and engagement tools to decrease providers’ administrative burden. 

In recent weeks, there’s not a health plan we’ve spoken with that isn’t striving to support those on the front line as best they can. But we know that health plans will also need support. We have had numerous internal discussions around how we view the current industry situation. Here are some of the short-term and long-term actions we see occurring 

Short-Term Action: Inject Monetary Support 

The COVID-19 crisis has created a perfect storm of financial issues for providers:  

  • In order to keep exposure to a minimum, elective procedures have been delayed indefinitely, and patients are self-selecting to avoid preventive care and other non-emergent healthcare. In our largely fee-for-service (FFS) environment, that means a huge chunk of revenue has evaporated for hospitals and physician practices 
  • In some locations, patient volume is not an issue because of the sheer number of patients needing COVID-19 treatment. However, the number of uninsured and patients with high-deductible health plans means the considerable treatment costs – $20,000-70,000 according to some estimates – will be difficult to recoup. 
  • At the same time, providers are having to devote what little funds they do have to high-priced personal protective equipment (PPE) and ventilators, as well as infrastructure to support telehealth visits. 
Direct payments 

From the government, CMS has released the first $30 billion of the $100 billion earmarked for providers in the Coronavirus Aid, Relief and Economic Security (CARES) Act. This federal stimulus money is based on Medicare FFS volumes and does not have to be repaid. In addition, CMS is offered $34 billion in accelerated payments to providers, again based on Medicare FFS revenueas a loan to be repaid within seven months to one yearAdditional stimulus funds, particularly to providers who serve primarily Medicaid populations as well as those in COVID-19 hotspots, are likely forthcoming. 

Commercial health plans also have stepped up with direct cash grants to providers, in one instance providing up to $200 million through financing guarantees, advance payments and the restructuring of contracts. 

Indirect relief 

In addition to directly paying providers, new policies directed toward members promise to relieve providers of the costs incurred to treat COVID-19 patients. Many health plans have pledged to waive cost sharing for testing and inpatient admissions and reimburse telehealth at the same rate as in-person visits. The First Coronavirus Response Act (the FFCRA) and the CARES Act require commercial health insurers to provide testing and care visits at no cost to further increase the chances of providers being reimbursed for expenses incurred. 

Additionally, health plans are relieving providers’ administrative burden short-term by reducing prior authorization requirements, including for those patients not affected by the virus, and providing triage tools so they can make best use of limited resources. Health plans are also re-thinking payment integrity activities most likely to cause provider abrasion and pausing aggressive post-pay claims audits. 

Long-Term Action: Reduce Administrative Burden 

No matter the short-term relief provided, if the “business as usual” response kicks in, providers – many of whom are either at the front lines or have lost revenue – are likely to grow increasingly frustrated with the red tape that characterizes their payer relationships. The goodwill generated by financial support will dwindle as time goes on. But these challenges aren’t unanswerable. Health plans can rapidly innovate, prioritizing technologies that reduce administrative waste and increase collaboration and engagement between payers and providers. 

Strategic shift to prepay 

With as few as 15 days to make a pay/deny decision on a claim, many health plans choose “pay and chase.” But is this a risk that payers want to take during the COVID-19 crisis compounded by a stressed economy? For some health plans, the pandemic serves as a catalyst to grow prepay effortsAlready a long-term goal for many, the commitment to reducing provider abrasion has prioritized this shift 

This risk of delayed income could be reduced if health plans had a robust prepay operation that could quickly identify and respond to overpayment trends before claim payment. Prepay efforts – while not frictionless – create less abrasion among the provider community and can be continued in extraordinary times like the one we find ourselves in now. In addition, a shift to prepay reduces administrative burdens for health plans and providers while reducing improper payment risk.

What codes should providers use for COVID-19 testing and diagnosis? 

New codes have been published to designate healthcare encounters
related to the novel coronavirus:

  • ICD-10 
    • Pneumonia: J12.89 and B97.29 
    • Bronchitis: J20.8 and B97.29, or J40 and B97.29 
    • Respiratory infection: J22 and B97.29, or J98.8 and B97.29 
    • ARDS: J80 and B97.29  
    • Exposure: ruled out Z03.818, confirmed Z20.828 
  • HCPCS 
    • CDC laboratory test: U0001 
    • Non-CDC laboratory test: U0002 
  • CPT 
    • Test: 87635 

For current Pareo clients, it’s easy to move more claims work prepay. The integrative platform allows a health plan to ingest data from multiple sources (such as CMS, states, claims, etc.), apply successful post-pay concepts prepay, configure workflows to effectively stack internal and vendor efforts – including fraud, waste and abuse mitigation – and make fast payment decisions. 

Engage providers 

Some suggest that health plans cannot move swiftly enough on urgent care coordination responses, like prior authorizations, that have left patients without COVID-19 taking up valuable hospital beds as they await discharge. And, strategically shifting the payment integrity mix to include more prepay internal efforts won’t do much on their own to support valuable network providers and decrease abrasion. Solution? Real-time engagement and communication. 

Some health plans already use tools like portals to push messages to providers, like sending prepay information to providers along with education on how to correct incorrect billing issues. While that is a starttrue engagement is a more encompassing initiative, one that mutually beneficial advanced technology can help support. Think of dashboards that highlight key performance indicators of the payer-provider relationship, integration with the EHR to streamline clinical documentation requests, and the ability to automate underpayment and denials inventory management.  

Proactively and continuously opening the lines of communication with providers eases their administrative burden at a time they need it most. This initiative will pay dividends for health plans and providers alike, long after the threat of the pandemic has passed, paving the way for needed innovations that will transform the industry and set us up to weather future challenges. 

NOW'S THE TIME FOR TOTAL PAYMENT INTEGRITY

Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies. 

Your health plan’s best crisis response strategy? Innovation.

Your health plan’s best crisis response strategy? Innovation.

Health plans set themselves up for success – during a pandemic and beyond – by pursuing advanced technology to engage providers, satisfy members, and improve population health initiatives.

The healthcare system is on the front lines of the novel Coronavirus pandemic, working tirelessly day after day to heal the sick and comfort the anxious. Health plans, in understanding the potential impact to members, are taking unprecedented steps in waiving copays and cost-sharing for testing and treatment. What stands before all of us is both crisis and opportunity. How you respond has the potential to cement your place in history as a visionary.

A recent Best’s Special Report lauded healthcare payers’ steps towards innovation in technology and partnerships, noting that these leaps are often prompted by times of change and urgency. Challenging situations often exacerbate whatever is not working as well as it should be, evolving annoyances into major problems that need to be fixed pronto. If necessity is the mother of invention, we should expect accelerated adoption of technology and other innovations intended to alleviate pain points during this “black swan” event.

In particular, health plans are likely to push payer-provider relationships, member service, and population health initiatives dramatically forward, moves that hold the potential to change the healthcare landscape permanently for the better. Let’s explore those three drivers in depth.

Improve Payer-Provider Collaboration While Moving to Prepay

We’ve written at length on the need for health plans and their network providers to open the lines of communication and work together to improve broken processes. During the pandemic, that engagement becomes even more essential. Many providers are on the front lines combatting the COVID-19 crisis, adjusting to new care delivery models overnight, losing revenue, or some combination of these. How is your health plan delivering updates to your providers on changes to telehealth coverage, adjusted reimbursement for novel Coronavirus testing and treatment, and select prior authorization waivers?

Health plans are understandably holding off on aggressive payment integrity pursuits at this time, instead focusing on issuing payment as fast as possible, recognizing that over-taxed provider teams don’t need another stressor to contend with. But even before this crisis came to be, the transition to value-based care and an overall shift from payers denying payment to more guiding of care were impacting the payer-provider relationship. Immediate solutions to ease burdens on providers are great in the short-term, but payers will have to think long-term about shifting more claims work to prepay to avoid pay and chase activities.

Shifting to prepay has long been a challenge for health plans because payment decisions on claims must be made quickly, often within two weeks. With numerous disparate data streams and systems at play, payers have not been able to be as agile in prepay as they would prefer. But advanced technology facilitates more seamless coordination with providers, which is required for frictionless payment integrity strategies, including prepay, as well as advanced payment models.

Pareo enables users to easily apply post-pay concepts to prepay and access the information they need to make payment decisions in real-time, which supports your most ambitious internalization strategies. And because Pareo offers a Provider portal to facilitate communication between plans, third-party suppliers and providers, Pareo clients can shift more work prepay while avoiding provider abrasion.

Focus on Members

While health plans have put member service upgrades at the top of their investment lists for a while now, the pandemic has fast-tracked a few of the most crucial. Primarily, technology initiatives that make healthcare available from anywhere, both for convenience and safety reasons.

Providers rely on wearables and remote monitoring devices to manage chronic diseases and detect infections earlier – early evidence shows wearables can even be used to monitor Covid symptoms. Changes in acceptable parameters for telehealth reimbursement by CMS combined with patients embracing the interface promise to change that encounter mix long-term. A recent survey illustrates consumers’ changing mindset around telehealth visits, due to the novel Coronavirus. Though only 25% have ever had a remote health visit, 59% said they are more likely to use telehealth services now than in the past, and 36% would switch their physician in order to have access to virtual care.

Health plans are also embracing technology for streamlined and relevant communications with their members, including chatbots and responsive risk-assessment tools. As one leader of a tech-forward health plan puts it, “It’s all of our digital engagement channels that are required to come together in order to help guide our members through this anxious and uncertain time.”

Make Strides in Population Health Management

One shortcoming this pandemic has highlighted is that the drive towards value-based care is warranted. Value-based care contributes to improved rates of preventive care, leading to a healthier population. This is important, because pandemics like the coronavirus have been shown to prey on those who have certain pre-existing conditions at greater rates than those who do not. Yet addressing population health at a national level requires a great level of coordination among all stakeholders to identify, treat, evaluate and quantify investments in population health management.

Interoperability and the ability to process big data take outsize importance, too. During a disease outbreak, early mapping data could help healthcare organizations and government agencies identify areas where there’s a concentration of people with likely symptoms and therefore higher needs. Testing and disease tracing have proved more effective at containment. Even HIPAA recognizes the advantages of sharing health information during a pandemic and announced a temporary, narrow relaxation of enforcement during this time. “Granting HIPAA business associates greater freedom to cooperate and exchange information with public health and oversight agencies can help flatten the curve and potentially save lives.”

Pareo can assist in care management for health plans by identifying populations at risk, engaging patients and optimizing the care pathway:

  • Predictive modeling that analyzes the patient population from millions of data points helps identify risk factors of early disease.
  • Data modeling delivers lists of current patients and non-patients at risk so they can be engaged, leading to earlier diagnosis and treatment.
  • Care pathways are optimized to provide better, more affordable patient care while increasing the efficiency of your provider network.

Many health plans have already piloted initiatives that address social determinants of health and otherwise target vulnerable segments of the membership for early intervention that promises to improve outcomes and lower costs. A global public health issue like the novel coronavirus prioritizes exactly this sort of useful application of big data analytics.

Technology for the Win

Health plans have been increasingly turning to advanced technology as it evolves to better address a number of operational challenges. Platforms like Pareo that bring together disparate systems and stakeholders, allow for secure remote access, and leverage modern analytics and applications of A.I. to harness the power of big data offer payers a competitive advantage during the best of times and less predictable situations alike. By controlling more of your payment integrity continuum, you are in a better position to optimize your medical spend and drive improvements in the industry as a whole.

Health plans have long been bracing for disruption in an outdated industry. And like all innovators, they’re likely realizing that a global pandemic creates an opportunity to improve on processes and technologies quickly. Improving provider-payer engagement, moving more claims work to prepay, and leveraging technology to improve member satisfaction as well as health plan operations all contribute to broader goals like value-based care and interoperability.

NOW'S THE TIME FOR TOTAL PAYMENT INTEGRITY

Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies.