What You Should Know: 

– inVio Health Network and CVS Accountable Care Organization, a division of CVS Health, have announced a collaboration to participate in the new Medicare Accountable Care Organization (ACO) REACH program. This initiative focuses on improving access to high-quality healthcare for traditional Medicare beneficiaries in South Carolina.

– The collaboration builds upon the past achievements of Prisma Health Upstate and Prisma Health Midlands Networks, which merged in 2021 to form inVio Health Network. These entities have a proven track record of success in the Medicare Shared Savings Program (MSSP), another CMS program. Through MSSP, they have demonstrably reduced healthcare costs while maintaining exceptional quality of care for over 60,000 Medicare beneficiaries.

REACH Program: Reducing Barriers and Improving Outcomes

The REACH program from the Center for Medicare & Medicaid Innovation (CMMI) aims to address healthcare disparities. Participating ACOs like the newly formed collaboration between inVio and CVS will work towards:

• Reduced Barriers to Care: The program seeks to eliminate obstacles that prevent patients from receiving necessary medical attention.
• Coordinated Care: A focus on ensuring patients receive well-coordinated care across different healthcare providers.
• High-Quality Patient-Centered Care: Prioritizing patient needs and preferences to deliver exceptional medical care.
• Improved Overall Health and Satisfaction: The ultimate goal is to improve patients’ health, clinical outcomes, and overall satisfaction with their Medicare coverage.

Enhancing High Quality Patient Care

inVio Health Network, a leading physician-led network in the Southeast, brings deep local knowledge and a commitment to high-quality patient care. CVS Accountable Care contributes its extensive experience and resources. Together, they will leverage this combined expertise to:

• Enhance Care Coordination: Advanced analytics will be used to streamline care coordination for patients, ensuring they receive seamless treatment across different providers.
• Value-Based Care and Population Health Management: The collaboration will implement key programs and resources focused on value-based care and population health management. This data-driven approach allows for proactive care and improved health outcomes for the entire patient population.
• Longitudinal Care Management: The focus will be on providing patients with consistent and comprehensive care throughout their healthcare journey.

“We are on a collaborative value-based journey with our physicians and healthcare clinicians to improve the quality and health across South Carolina, regionally, and nationally,” said Dr. Bill Gerard, CEO of inVio Health Network, “This new model allows us to provide enhanced resources and clinical services across our network where we will be collaborating with MinuteClinic locations across South Carolina to be part of our network’s ACO REACH program. We look forward to the incredible opportunities ahead as we transform healthcare together.”

Digital patient engagement is a balancing act of determining where resources should be deployed and how to create cheer-worthy experiences. 

The stakes for delivering the right mobile experience in healthcare have never been higher. A recent Accenture survey found digital engagement has a significant influence on patient retention. This raises pressure for health systems to design digital tools and experiences that strengthen patient loyalty and protect or increase revenue.

Meanwhile, across the country, it’s clear that digital health is driving “healthcare’s regeneration,” according to the College of Healthcare Information Management Executives (CHIME). The most recent CHIME Digital Health Most Wired Survey indicates health systems are increasingly relying on digital interactivity to engage patients and families—and they are doing so in more sophisticated ways. 

How do leading hospitals leverage digital platforms to improve the patient experience—and what could other hospitals and health systems learn from their approach? Here are three insights from the latest Most Wired survey.

1. Mobile functionality is ramping up in healthcare. Among the more than 38,000 organizations responding to the Most Wired survey, one trend that stood out is the increased array of mobile functionalities health systems are leveraging to engage consumers. These include price lists for services (14% increase), health maintenance campaigns (14% increase), mobile check-in (10% increase) and event alerts (13% increase).

There is a clear connection between the increase in the use of mobile solutions and improved scores on the Most Wired survey. 

One example is Nicklaus Children’s Hospital, which put all its consumer-facing digital services into a single mobile app for patients and their families last year and went on to achieve Level 8 on Most Wired. Such an approach offers enhanced access and convenience for families of children with complex conditions, who might travel an hour or more for in-person care. At Nicklaus Children’s, leaders believe digital access to live support and resources is critical to maintaining children’s health and providing peace of mind for parents.

2. There’s a move toward patient-staff digital interactions. While efforts to promote patient-staff interactions via digital devices are still relatively new, more health systems are putting staff in the digital driver’s seat. CHIME’s Most Wired survey revealed notable increases in efforts to train patients and their families on interactive devices (19%) and using technology to support care plan adherence (11%).

To make greater progress in this area, health systems should devote more attention to securing staff buy-in for a health system’s digital offerings prior to go-live. At Baptist Health, when employees learned the health system’s mobile app could support smooth transitions in care for patients, the health system recorded more than 2,000 downloads of its “Baptist Access” app even before the app’s official launch date. Many of these downloads were made by staff members, who recognized the impact the app could have on patient care and service.

3. Video education goes mobile. The Most Wired survey showed a dramatic increase in the use of patient- and family-facing videos to educate patients and families about procedures (16%), labs and test results (16%) and medications (11%). These videos can easily be incorporated into a health system’s mobile app to offer a convenient digital tool for reducing the stress associated with an upcoming procedure or helping patients better manage their care. 

Among the most frequently used video resources: family education videos (83%), videos about procedures (81%, up 16% over 2021) and health education videos (78%). About two-thirds of organizations offer a health library and incorporate video in health maintenance campaigns and education on medication use.

It’s clear that as digital engagement advances, more health systems are leaning into digital to personalize the patient and family experience. This is exemplified by efforts to target specific groups for specific types of digital education and resources, says Michael Saad, chief information officer, University of Tennessee Medical Center, Knoxville. “The pandemic surely accelerated this move to more targeted digital offerings, but the healthcare industry is absolutely headed to personalized digital care and support,” he says.

Engagement by Design

Achieving optimal digital engagement in healthcare is a challenge. It requires the development of a digital strategy based on consumers’ expectations and desire for increased ease in navigating their care journey without adding a burden to the health system. To effectively operationalize a true patient-centric digital strategy, keep the experiences of Most Wired survey participants and award winners in mind.

About Joshua Titus

Joshua Titus, CEO at Gozio Health, is passionate about creating mobile technology that informs and delights users. This passion led him to co-found Gozio after spending two decades in the left lane of high-growth silicon valley technology companies like NVIDIA. He has authored 11 patents and holds an electrical and computer engineering degree from University of Illinois at Urbana Champaign.

In the ongoing transition to value-based care (VBC), provider contracting poses challenges for health plans and providers. In my past role as the VP of Quality at a large health plan, I was part of the team that reviewed provider contracts that included risk around quality. Adding my role to the review process reduced the frustration of the Network and Quality teams because I could identify the reporting requirements that the health plan couldn’t meet and create alignment with measure priorities.

Value-based contracting rapidly evolves, with federal and state regulatory bodies imposing new mandates. The Centers for Medicare and Medicaid Services (CMS) intends to shift traditional Medicare and many Medicaid beneficiaries into VBC arrangements by 2030. The growing emphasis on quality further fuels the demand for VBC contracts as payers push for them and providers recognize their significance in driving volume and revenue.

This acceleration toward VBC results in complex contracts with intricate data management needs to achieve quality outcomes. Here’s how quality considerations and the associated data influence VBC contracts.

Understanding VBC contracting concepts

Most contracts fall along a spectrum, increasing complexity as risk sharing expands. The following are the most common contracting concepts, from minimal to more comprehensive risk sharing:

• Gainsharing: For providers just starting with VBC, they share in the savings and not the risk of loss, giving them an upside-only arrangement.
• Upside/Downside Risk Models: Providers share in both savings and risk. In these contracts, providers receive a per-patient allotment of funds and retain the defined portion of the surplus generated. However, if they spend more than the allotment, they are responsible for a specified portion of the deficit.
• Bundled Payments: The provider receives a fixed payment for all services within a single episode of care or for a specific period, such as joint-replacement surgery. If the provider successfully delivers care and prevents complications or errors, they keep a portion of the savings. However, they are responsible for the deficit if costs exceed the fixed amount.
• Capitation – Professional-Only Risk: The payer establishes risk pools, typically based on a monthly payment per member (PMPM). The amount payers give providers is based on the average expected healthcare utilization and risk profile of the patient pool, among other factors. Providers are only responsible for the professional side risk.
• Capitation – Global Risk: This arrangement is the same as the Professional-Only Risk above, except providers and payers fully share risk in these contracts.

As each party takes on financial risk, the need for VBC expertise and technology to support care and contract management increases. There are several contract considerations to help payers and providers build the proper foundation for VBC success.

Identify the best approach for all parties.

While achieving a perfect contract for all parties may be unlikely, better collaboration is more likely to result in win-win scenarios. Initial negotiations often begin with the health plan’s template, aligned to their goals, but healthcare is diverse. Providers and payers must ensure the right stakeholders are involved to ensure quality metrics are tailored to the provider’s specific patient population, such as children or diabetics. Payers and providers must also align on standards, like NCQA or CMS Core Set, so parties can determine the most appropriate risk-sharing levels, ensure the measures are reportable, and gather necessary data.

Consider how to match measures to members

Plans with multiple lines of business must consider the measures that best reflect the desired outcomes for each population and look for commonality where possible. Another consideration is, when negotiating with a provider practice, payers should consider the specialists. If the practice has an endocrinologist, it benefits all parties to have quality measures related to diabetes in the contract. 

Focus on carrots, not sticks.

The proper contract will encourage compliance through incentives rather than penalties. Payers should tie provider incentives to defined quality measures and promote ease of reporting, such as CPT 2 codes and providing supplemental data to health plans to lower the cost of data acquisition. This approach, emphasized by Jessica Columbus of Apex Health, promotes efficiency for providers, such as using point-of-care alerts to guide actions aligning with contract goals.

One data feed to rule them all 

The ongoing challenge in VBC is building the required infrastructure and technology. Complicating matters is the need for a standardized minimum data set, with health plans having differing specifications for supplemental data files. Even with standardized measures, consolidating data from multiple sources is highly challenging. Efficient use of available data is crucial for health plans to avoid frequent revisits to providers.

Consider the implications for data aggregation. Suppose a provider collaborates with seven plans, each with a distinct gap-in-care list and inconsistent header data. In that case, the payer must invest resources in consolidating this data to manage quality measures effectively.

Nick D’Ambra, former VP of Quality Improvement at AbsoluteCare, shared an essential experience at the RISE HEDIS & Quality Improvement Summit. While working on a state-mandated performance improvement project to streamline clinical practice guidelines, the central question emerged: Could a broader opportunity exist to collaborate with other managed care organizations and create a unified file format meeting all their needs?

Bridging the data management gap 

Collecting and reporting data for Value-Based Care (VBC) is challenging, especially with the increasing volume of data as VBC becomes more common. However, the impact of AI technologies like machine learning, natural language processing, and optical character recognition, including generative AI like ChatGPT and Bing Chat, is significant. These technologies excel at aggregating and synthesizing patient data from various sources.

Unlike spreadsheets, which require manual input and manipulation, health plans can automate AI to operationalize data intake and tasks, identify patterns, highlight relevant information, and streamline processes. For payers and providers managing quality measures in contracts, leveraging data both prospectively and retrospectively is crucial, and AI enables this at scale. 

Winning at VBC

Organizations that effectively leverage AI to precisely identify, monitor, and report quality outcomes will position themselves for success in attaining value-based contracts, thereby enhancing patient health and bolstering financial performance.

About Elissa Toder, MBA

Elissa Toder, MBA, is the Vice President of Quality Improvement Strategy & Solutions at Reveleer. Elissa holds a BS in Health Policy Administration from Penn State University and earned her MBA at Clark University.

What You Should Know:

– Medical Home Network (MHN), a leader in transforming care in the safety net, announced today its partnership with 64 federally qualified health centers (FQHCs) across seven states. These FQHCs will participate in two key CMS value-based care programs: ACO REACH and MSSP (Medicare Shared Savings Program).

– This expansion comes on the heels of an impressive achievement by existing MHN partners: $10.1M in gross savings and a perfect quality score in the 2022 performance year for the NeueHealth Premier ACO.

Expanding Access to Value-Based Care

2024 marks MHN’s first year in the MSSP and its second year in ACO REACH. The participating ACOs will collectively cover nearly 50,000 Medicare lives, significantly expanding access to value-based care for underserved communities.

Empowering FQHCs with Technology and Support

MHN equips FQHCs with the tools and resources needed to succeed in value-based care models. They provide:

• AI-driven analytics: Real-time insights into patient health, enabling proactive care and improved outcomes.
• Care coordination support: Building strong systems for holistic patient management across various providers.
• Technical assistance and guidance: Navigating the complexities of value-based programs.

Advancing CMS’ Vision

This expansion aligns with CMS’ goal of having 100% of Medicare beneficiaries in accountable care relationships by 2030. As FQHCs serve a growing number of Medicare patients and play a vital role in the safety net, their participation in value-based programs is crucial to achieving this vision. This newly formed MSSP ACO includes 17 FQHCs across five states, with Cheryl Lulias serving as CEO. This collaboration signifies MHN’s commitment to expanding its reach and impact.

“Since our founding in 2009, MHN has believed that supporting community health centers is the key to building healthier communities. Enabling their participation in these value-based care models is a natural extension of our mission, and we’re thrilled so many forward-thinking organizations have trusted us and our proven care model to help them on this journey,” said Cheryl Lulias, president and CEO, MHN and CEO, Medical Home Network REACH ACO.

As the healthcare landscape continues to evolve, there’s a clear trend towards value-based care (VBC). This significant shift, which places a premium on patient health outcomes, diverges from the traditional fee-for-service approach. The aftermath of the COVID-19 pandemic has mainly catalyzed the adoption of VBC models, highlighting the importance of care quality and effectiveness rather than the sheer volume of services. This change reshapes healthcare, aligning it more closely with patient outcomes and marking a pivotal move in health service delivery. 

Central to this transformation is the acknowledgment and integration of social determinants of health (SDOH). Factors such as living conditions, economic stability, education, and accessibility to healthcare significantly impact health outcomes. Studies suggest that SDOH accounts for 80-90% of these outcomes. Addressing these determinants, the healthcare industry is enhancing patient engagement and breaking down long-standing barriers, fostering a more equitable and efficient system. 

Modern healthcare systems increasingly employ sophisticated technologies to support these changes. These technologies provide flexibility and adaptability for delivering high-quality care while effectively managing costs. The rising demand for such dynamic and responsive solutions is a response to the rapid changes in healthcare, requiring advanced tools and strategies to meet the sector’s complex and continually evolving demands. 

Innovating Patient Care Through Strategic Risk Stratification 

Risk stratification is an essential strategy within the VBC model for improving community health outcomes. Utilizing data from electronic health records (EHRs), healthcare providers can obtain more profound insights into patient health trends and outcomes. Despite its potential, challenges in data integration can create gaps in patient insights. Innovative, vendor-neutral solutions are being developed to overcome these challenges. North Carolina’s Healthy Opportunities Pilot is an exemplar in this regard. With 13,612 enrollees and 146,485 services delivered as of September 30, 2023, HOP has demonstrated how targeted interventions in housing, food, transportation, and interpersonal safety can significantly impact health outcomes. The program’s effectiveness is further evidenced by the high number of service authorizations (96% approved) and the efficient processing of invoices, with 91% accepted, paid, or in progress, involving a total expenditure of $26,834,860. 

Enhancing Patient Treatment with Precision and Personalization 

At the heart of VBC is patient categorization, which involves analyzing health indicators and medical histories to develop personalized healthcare plans. The healthcare industry is committed to precision in patient categorization, continually refining data accuracy with advanced computational models. The HOP’s impressive service delivery and financial commitment highlight the effectiveness of a data-driven approach in catering to individual health needs, particularly those impacted by SDOH. 

A Comprehensive and Multifaceted Approach to Risk Stratification 

The importance of a robust population health management system is evident, with organizations like Gartner advocating for detailed risk stratification frameworks. Such frameworks categorize individuals into risk groups based on their potential for clinical complications. The Healthy Opportunities Pilot in North Carolina showcases how combining clinical assessments with social health analysis and consumer health preferences can lead to more effective patient management. The program’s operational success, with a high rate of service authorizations and efficient invoice processing, underscores the effectiveness of this comprehensive approach in a real-world setting. 

Redefining Patient Management in the Era of Value-Based Care 

The introduction of VBC is transforming patient management strategies. Healthcare providers now consider a broader range of factors, including SDOH and individual patient preferences. North Carolina’s Healthy Opportunities Pilot illustrates how personalized healthcare strategies can be developed by understanding and addressing individuals’ unique SDOH challenges. 

Charting the Course for Future Healthcare Innovations 

As the healthcare sector evolves, the focus on risk stratification, as demonstrated by North Carolina’s HOP, is crucial for advancing VBC. The pilot program’s experience and data provide valuable insights for replicating and adapting similar models elsewhere, highlighting the benefits and challenges of integrating SDOH in a value-based healthcare framework.

What You Should Know:

• The Ohio State University Wexner Medical Center and CVS Accountable Care, part of CVS Health® (NYSE: CVS), today announced the creation of an accountable care organization (ACO) to improve the quality of care for Medicare beneficiaries by Ohio State providers in central Ohio.
• This coordinated approach to delivering care is centered around each patient’s unique needs and emphasizes preventive wellness and proactive treatment of chronic conditions.

CVS ACO and Ohio State Wexner Medical Center Forge Alliance to Enhance Patient Care and Coordination

The new CVS ACO, LLC (CVS ACO), operating under the Medicare Shared Savings Program (MSSP) Enhanced track ACO, expands the Ohio State Wexner Medical Center’s ACO efforts. 

This collaboration aims to enhance patient care, ensuring timely and appropriate services. By pooling resources, CVS ACO will offer coordinated care and longitudinal management, addressing both medical and social needs for a larger patient population. The Ohio State Wexner Medical Center and CVS Accountable Care teams will focus on supporting post-hospitalization transitions, providing services for high-risk beneficiaries, and strengthening overall care management. Patients will benefit from increased interaction with clinical care teams, including education on complex conditions, assistance with follow-up visits, and access to community resources.

“As we prepare for the nationwide shift to having all Medicare beneficiaries in accountable care relationships by 2030, this collaboration with CVS Accountable Care is a natural progression of Ohio State’s work in this space that builds on our commitment to provide the very best care to every patient, every time,” said John J. Warner, MD, CEO of The Ohio State University Wexner Medical Center and executive vice president at Ohio State. “It’s important that we meet every patient where they are in their health care journey and take the next step in being accountable for our patients’ holistic health and improved outcomes.”

What You Should Know:

– Medical Home Network (MHN), a leading care enablement partner for FQHCs, announced that its partners participating in the NeueHealth Premier ACO achieved $10.1 million in gross savings and a perfect 100% quality score in the 2022 performance year.

– This accomplishment, under the ACO Realizing Equity, Access, and Community Health (REACH) Model, involved 20 FQHCs across Ohio, Missouri, and Illinois serving approximately 10,000 Medicare beneficiaries. The success highlights the effectiveness of MHN’s collaborative approach and its commitment to empowering FQHCs in value-based care.

MHN’s Team-Based Care Model Drives Results

The key to this success lies in MHN’s unique team-based care model. By providing culturally tailored, whole-person care, MHN’s approach empowers FQHCs to:

Hire and train care coordinators and managers: These dedicated professionals provide comprehensive support to patients, addressing both clinical and social needs.

Leverage AI-powered risk assessments: MHN’s proprietary technology identifies patients at risk for adverse events and helps prioritize care interventions.

Utilize performance analytics: Data-driven insights guide care teams in closing care gaps, reducing unnecessary emergency department visits, and optimizing inpatient utilization.

Significance for FQHCs

With over 30.5 million Americans relying on FQHCs for their healthcare, their inclusion in value-based care models is crucial to achieving equitable and efficient healthcare for all. MHN’s success story demonstrates the potential of FQHCs to excel in this domain, paving the way for broader participation and improved health outcomes for underserved communities.

“These nationally leading results are early proof that FQHCs can benefit from our team-based model of care and thrive as they enter value-based care arrangements,” said Cheryl Lulias, president, and CEO of MHN. “This also shows ACOs led by FQHCs can achieve stellar results.”

What You Should Know:

– A new survey by Artera, a leader in patient communication technology, reveals a stark disconnect between how healthcare providers communicate and what patients actually want.

– The findings, based on responses from over 2,000 patients, paint a picture of frustration and missed opportunities, with simple phone calls and one-dimensional text messages falling short of patient expectations.

Communication Breakdown

– Nearly half (45%) of patients have missed or forgotten a bill due to communication difficulties with their provider’s office.

– 43% report negative health impacts from communication challenges, including issues scheduling appointments or sharing crucial information.

– A staggering 79% of patients want providers to offer text-based conversation on any topic, highlighting a desire for more convenient and accessible communication.

Texting: A Double-Edged Sword

– While 77% find automated text exchanges valuable, simplistic “yes/no” interactions dominate, frustrating 69% of patients who long for deeper conversations.

– Two-thirds report incomplete text experiences, with 31% failing to achieve their goals at least half the time, often resorting to phone calls.

– Technical glitches and unanswered messages further exacerbate the problem, with 62% experiencing error messages, invalid responses, or radio silence from providers “half the time” or more.

Financial and Human Costs

– Providers failing to meet communication expectations face financial consequences, as 59% of patients are willing to switch doctors due to poor communication.

– Artera’s research sheds light on the impact on healthcare workers as well, with a December 2022 report finding outdated communication strategies contributing to staff burnout.

Guillaume de Zwirek, CEO and Founder of Artera, emphasizes the importance of patient-centric communication: “As a $4 trillion market, healthcare should offer unmatched customer experience. If patients can’t communicate seamlessly, they won’t engage, leading to a sicker population and more expensive care long term.”

What You Should Know:

– Zocdoc, the healthcare marketplace, has released its inaugural What Patients Want Report, offering valuable insights into what patients seek from their healthcare experience and providers.

– Based on millions of bookings and patient interactions, the report paints a picture of how patients are navigating the healthcare landscape today, and what they expect from their providers and the industry at large.

Key findings of the report include:

• Women driving appointment bookings: Women are more proactive in booking appointments, with Millennial women leading the charge in booking on behalf of others.
• In-person visits and timely access remain crucial: Patients prioritize in-person appointments and prefer to schedule them soon after searching.
• Gen Z leads in mental health bookings: This age group seeks mental health care more than any other, reflecting a growing awareness and prioritization of mental well-being.
• Patient Empowerment Index reveals room for improvement: The inaugural index reveals moderate patient empowerment, with nearly 1 in 5 Americans feeling they have little control over their healthcare and 15% facing access challenges.

Predictions for the Future

• Mental health boom: Mental health bookings are expected to surge in the latter half of 2024, potentially influenced by upcoming elections and increased awareness.
• Convenience triumphs tradition: Patients will prioritize convenience and accessibility for routine care, potentially impacting traditional healthcare models.
• AI to the rescue: AI advancements will free up valuable time for providers, allowing them to focus on personalized patient care.
• Big Tech’s muted impact: Despite heightened noise from tech giants, their actual influence on healthcare delivery is likely to remain limited.
• Digital consolidation: The landscape of patient portals and digital front doors to healthcare will likely see consolidation, offering a more streamlined experience.
• Savvy prescription shoppers: Patients will become increasingly informed and empowered to compare medication prices and make informed decisions about their prescriptions.

The report emphasizes the need for healthcare providers and systems to adapt to evolving patient preferences. By prioritizing patient-centered care, focusing on convenience and access, and leveraging technology for greater efficiency, the industry can empower individuals to take control of their health and wellbeing.

“As the leading healthcare marketplace, we offer patients the ability to search and book with nearly 100,000 providers across every specialty, every state and every segment,” said Zocdoc founder and CEO Oliver Kharraz, MD. “By aggregating a diverse array of providers that patients can choose from, all in one place, we empower them to have more control over their care. We are proud to give voice to what patients really want by highlighting emerging trends and preferences expressed through the millions of bookings made through Zocdoc each year.”

Patient Empowerment Index Survey Methodology

Zocdoc commissioned Censuswide to collect this data via an online survey of 1,000 U.S. consumers aged 18 and up. The survey was fielded November 14 to November 16, 2023. Respondents were assigned scores based on their answers to the three questions. These scores were then averaged to find the Patient Empowerment Index number, ranging from -80 to 120. Censuswide abides by and employs members of the Market Research Society, which is based on the ESOMAR principles.

What You Should Know:

– Clover Health, a physician enablement company committed to bringing access to great healthcare to everyone on Medicare announced that it has delivered notice to the Centers for Medicare and Medicaid Services (“CMS”) that it will exit the CMS ACO REACH Program at the end of the 2023 performance year.

– Written notification will also be sent to all participating physicians in accordance with CMS requirements.

– The decision will have no impact on its ACO REACH beneficiaries, and Clover will continue to fulfill all of its obligations under the ACO REACH Program for the 2023 performance year.

Strategic Decision to Focus on Medicare Advantage

Clover Health’s CEO, Andrew Toy, explained the company’s decision to exit the ACO REACH Program:

“When we entered the ACO REACH business in 2021, we felt that expanding our platform to Original Medicare would have a number of benefits, including increasing the number of lives under Clover Assistant management and enabling us to rapidly increase the number of physicians we worked with directly. And, while we were successful in those goals, we have not seen a clear line to profitability in this business and it has also become quite clear that, over the same period of time, we have made far greater and swifter strides on our path to profitability in our Medicare Advantage insurance business.”

What You Should Know:

• NextGen Healthcare, Inc. a leading provider of innovative, cloud-based healthcare technology solutions, today announced that its clients participating in the Medicare Shared Savings Program (MSSP) leveraged NextGen® Population Health to achieve a cumulative $82 million in total Medicare savings last year.
• The MSSP incentivizes hospitals, associations of physicians, and other healthcare facilities to form accountable care organizations (ACOs) that optimize resources to save costs and better serve Medicare beneficiaries in their communities.

NextGen’s Impact: Transformative Results in MSSP ACOs Across the Nation

In 2022, nine NextGen Healthcare clients across the nation took part in MSSP ACOs, marking the most recent year for available data. Through the implementation of NextGen Population Health, these entities seamlessly incorporated actionable patient insights into electronic health record (EHR) workflows, ultimately enhancing engagement and elevating the quality of care provided to attributed beneficiaries. With an improved capacity to pinpoint and address gaps in care, the MSSP ACOs demonstrated noteworthy advancements in quality performance. The collective outcomes for the 129,000 Medicare beneficiaries served included:

– Total Medicare savings amounting to $82 million

– Shared savings reaching $42 million

– An average shared savings of $27.85 per member per month

– An impressive average quality score of 83.9%

Hutchinson Clinic, a NextGen client catering to South Central Kansas and representing a network comprising over 100 physicians and 600 employees, actively participated in an MSSP ACO during the same period, achieving savings for their Medicare beneficiaries.

“As the healthcare landscape increasingly shifts towards value-based care, NextGen Healthcare is helping ACOs leverage data and actionable insights at the point of care to reach evolving standards of clinical and financial excellence,” said Srinivas (Sri) Velamoor, chief growth & strategy officer for NextGen Healthcare. “We are proud to support our clients’ commitment to providing high-quality and cost-effective care for Medicare patients and manage their transition to risk-based arrangements.” 

It’s no surprise that healthcare is doubling down on software investments for healthcare revenue cycle, including software with an AI component, like predictive analytics. What’s unique is that right-now value from AI in revenue cycle is happening outside the walls of a healthcare facility or medical practice. In fact, it’s originating from the device patients use most: their smartphone.

For specialty groups in particular, the ability to successfully engage patients in their financial responsibility for care can significantly strengthen financial stability and their ability to invest in new services, equipment, staff development and more. That’s especially true for rehabilitative therapy groups, where patients may have two to three visits per week, generating a claim for each appointment.

At a time when many consumers say they pay medical bills faster when they receive payment requests digitally—especially when these requests come by text (49%, according to a recent U.S. Bank survey)—leading specialty groups are exploring mobile payment strategies with an AI component. The best strategies incorporate a data-informed approach that is grounded in predictive analytics.

Applying Data Science to Healthcare Mobile Pay

The value of digital payment for medical expenses extends beyond improved cash flow, although that’s certainly a key consideration. The U.S. Bank survey indicates consumers want mobile options for medical payment. Part of the attraction lies in the convenience of a digital approach, which gives consumers the ability to pay their bill anytime, anywhere, just as they have become accustomed to paying for retail purchases. 

The appeal of mobile goes beyond payment. More than half of consumers (56%) also would be comfortable resolving billing questions via live text chat or video chat. 

But leading specialty groups go beyond a plug-and-play, text notification-based mobile payment approach. They also incorporate predictive analytics, exploring aspects of patient financial engagement such as:

• The patient’s past history of medical payment
• The likelihood that a patient will pay their bill—and the speed with which the patient is likely to do so
• The individual’s communication preferences—critical given that some patients still prefer paper-based payment

They also incorporate behavioral science techniques in crafting the messaging associated with text-to-pay, down to the first words a patient sees on the screen. For example, one specialty practice decreased inbound customer services calls from 15% to 12% when it analyzed consumers’ most frequently asked questions and sought to answer these questions on the first screen patients see when they log onto the payment site.

The easier it is to take action, the faster consumers will pay their bill—sometimes, within seconds. That was the case when Integrated Rehabilitation Group (IRG), a 40-location physical therapy group based in the Northwest, implemented a text-to-pay solution at the start of 2023.

Making the Right Moves for Mobile Pay

At the time, IRG was seeking a way to stay ahead of the cash flow challenges specialty groups typically face at the start of a new year, when healthcare deductibles and out-of-pocket limits reset and most healthcare expenses shift to patient responsibility. It’s a period when patients tend to take more time to pay their medical bills. But the pandemic also had added extra financial stress for IRG. What used to be a 12% no-show rate had grown to 20%. Also distressing: overall volumes had been slow to return to pre-pandemic levels. 

As CFO for IRG, I knew the results other specialty groups had experienced, with 43% of patients who click on a payment link received via text going on to pay their bill. With pent-up demand for therapy, we knew a payment rate like this not only would help us overcome sluggish cash flow at the beginning of the year, but also set us up for success over the long term. 

What we didn’t expect is that we would begin to receive payments within minutes of turning on our digital payment function—or that our rate of payment, at 60%, would surpass the average experience by other groups. It’s a rate of return that helps position us to open new clinics, expanding our footprint to meet the increased demand for rehabilitation services, with four new clinics opened in 2023 alone. It has also empowered us to introduce new services, such as rehabilitation for patients suffering from traumatic brain injuries, concussions, and cognitive challenges.

Within months, IRG’s cash collections doubled—and they’ve remained at this level for the past eight months. We’re seeing patients pay sooner and with fewer questions, freeing staff to focus on more value-added activities, such as patient education.

Establishing the Foundation for a Mobile-Smart Approach

As providers of all types cite revenue cycle management as an area of increased focus, performing due diligence to determine what works—and what works better than most—is essential to capture optimal value. In addition to taking a data-based approach to digital payment, key steps that set the stage for success around mobile pay at IRG include the following.

Sending the right communication at the right time—and in the right format. It’s not good enough to simply have the mechanism to send a text bill. To avoid digital fatigue, specialty groups must be careful not to overload consumers with text reminders around medical payment. Look for a mobile payment provider that uses a Dunning engine to determine when, how and what to communicate to make the greatest impact. 

For example, some physician groups wait seven days to send an electronic reminder. They might also send a paper statement at this point to get a feel for how patients wish to receive communications around payment—and use this data to inform future communications. Engaging patients through their preferred method adds a level of personalization that drives higher conversion rates and patient satisfaction. 

Creating a seamless mobile payment experience. The best mobile payment functionality makes it easy for consumers to navigate from a text to their bill, without having to log onto a portal. This enables them to pay their bill with just a couple clicks. IRG learned the value of seamless navigation from its previous efforts to incorporate online bill pay on the therapy group’s website. While a link for online bill pay existed, it wasn’t easy to find—and consequently, online payment rates were low.

Integrating mobile payment with the specialty group’s electronic medical record system. This is the only way to be sure the amount patients see is accurate—and that’s vital to establishing trust and, ultimately, securing engagement. At IRG, mobile payment integrates with a practice management system that is specially designed for rehabilitative therapy practices.

About Janet Carbary

Janet Carbary is the CFO for Integrated Rehabilitation Group (IRG) and a member of the client advisory board for PatientPay.

What You Should Know:

– Edward-Elmhurst Health (NS-EEH) has announced a significant, long-term partnership with Lumeris, a pioneer in value-based care (VBC). This partnership is a major development in the healthcare industry, representing the largest VBC provider deal since 2018.

– With rising expenses outpacing reimbursement rates, health systems and physician organizations are increasingly turning to value-based care to avoid layoffs and service cuts. NS-EEH, the third largest healthcare delivery system in Illinois, comprises nine hospitals, 25,000 team members, and 300 local offices, serving over 4.2 million residents.

Collaboration aims to drive coordinated care and improve quality while reducing costs

NS-EEH will strengthen its clinically integrated network (CIN) by incorporating Lumeris’ population health data platform into its value-based care strategy. The two organizations also plan to deliver joint services, supporting the CIN’s healthcare providers in care management, pharmacy management, patient engagement and other key areas. NS-EEH’s CIN includes more than 3,000 system-employed physicians, affiliated physicians and advanced practice providers, and nine hospitals across Chicagoland.

In collaboration with Lumeris, the organizations will manage joint risk arrangements, leveraging AI as a central component of their technology and approach. Lumeris stands out as the only value-based care enablement company with experience working across various patient populations, including those covered by Medicare Advantage, CMMI programs, commercial insurance, and Medicaid. This partnership aims to enhance collaboration among patients, physicians, and care teams, ultimately leading to improved clinical outcomes, a better experience for both patients and providers, and more efficient management of healthcare costs.

Formation of New ACO Models

Furthermore, NS-EEH and Lumeris will work together to address healthcare disparities in underserved communities by establishing new models of care under the accountable care organization (ACO) framework. Initially, NS-EEH and Lumeris will focus on the opportunity to participate in the Centers for Medicare & Medicaid Services’ (CMS) ACO Realizing Equity, Access, and Community Health (ACO REACH) model. This advanced value-based care model seeks to streamline care coordination and improve health outcomes for traditional Medicare patients. In the future, the partner organizations will expand their focus to include other types of accountable care and population health models to serve our diverse communities.

What You Should Know: 

– UnitedHealthcare and RUSH Health announced a new relationship that will give UnitedHealthcare Medicare Advantage plan members network access to all RUSH Health locations in Illinois for the first time, effective immediately. 

– The multi-year agreement, effective Oct. 1, provides UnitedHealthcare Medicare Advantage plan members with enhanced access to quality care and provides a new option as they choose which health plan best meets their healthcare needs during the current Medicare Annual Enrollment Period.

– The new agreement covers nearly all UnitedHealthcare Medicare Advantage plan types, with the exception of Medicare Advantage Access plans.

RUSH Health Background

RUSH Health is a clinically integrated network of physicians and hospitals that work together to provide high-quality, efficient health services. The health system covers the spectrum of patient care from wellness and prevention to disease and care management. At the system level, RUSH Health includes RUSH University Medical Center, RUSH Copley Medical Center, RUSH Oak Park Hospital, Riverside Medical Center and more than 140 physician practices.

In Illinois, UnitedHealthcare serves more than 186,000 people enrolled in Medicare Advantage plans with a network of thousands of physicians and other care providers statewide. 

“This new relationship will create greater access to the very best health care for more patients across the Chicago area and Northwest Indiana,” said Lisa Wagamon, president of RUSH Health. “We are pleased to be able to extend the reach of academic medicine to more patients and families, especially those who need care for serious and complex conditions.”

Given Artificial Intelligence’s potential to improve patient care and reduce costs, it’s no surprise that AI applications are gaining momentum in health care. As your organization explores the benefits of AI in your journey towards Value-Based Care, however, you need to carefully assess the implications, for better and worse.

Evaluating AI implications can be tricky. Healthcare AI varies widely, with clinical technology paving the way for advancements in diagnostics and treatment. But pressure on ACOs to achieve savings is spurring consideration of machine assistants for customary clinician services. That’s the message of one recent study suggesting that AI chatbots may outperform physicians in communicating with patients, offering higher-quality responses and displaying greater empathy. The study evaluated how chatbots versus physicians responded to 195 patient questions from Reddit’s r/AskDocs. Surprisingly, healthcare professionals who reviewed the responses favored chatbot answers over those from physicians in terms of quality (78.5 to 22.1 percent) and empathy (45.1 to 4.6 percent). Not a great report card for physicians!

But before planning to use chatbots in patient education, navigation, and coaching – especially given staffing shortages in health care – ACOs should closely examine the underlying assumptions. Consider these very human factors: How do patients feel about discussing treatment plans with chatbots? Was the study validated and reviewed by peers?  What were the study’s limitations and biases? Did physicians couch their responses with caution due to liability or clinical concerns? Either could have negatively affected the tone of physician communications.

The rapid adoption of AI technology risks incorporating human biases into algorithms, perpetuating gender and race biases through AI healthcare recommendations. Before jumping on the AI bandwagon, we need a better understanding of the effects on physicians and patients, as well as a thorough evaluation of potential unintended consequences.

There may be an advantage in time and money to using chatbots to assist in patient education and to support—not replace–human roles in medicine. We still need to preserve essential conversations between patients and physicians to maintain trust. Ceding that direct communication to technology could erode the patient-physician relationship. It would also undermine efforts to recruit talent into the healthcare profession, where shortages of skilled clinicians is already a significant issue, especially in rural and poorer communities.

Under pressure to adapt to Risk, many ACO stakeholders may be eager to deploy AI solutions. To resist being swept up by the momentum, carefully consider your options, support your participating clinicians in their clinical AI applications, and explore how you might collaborate.

Here are three guidelines for leveraging AI to strengthen your organization while recognizing potential weaknesses of machine-based systems:

1. Use AI to analyze complex data for risk identification, patterns, and variations in healthcare services and costs. AI’s ability to efficiently analyze diverse datasets aligns well with Value-Based Care. Personalized treatment plans based on multiple patient data points can be developed using AI analysis. For instance, AI algorithms can drive episodes of care, enabling ACOs to compare procedure costs, reduce variations, target patients for clinical review, and identify opportunities for improvement. However, be sure to exercise caution and scrutinize algorithms for potential biases that may impact population groups and health equity.
   
2. Evaluate the use of AI in creating patient materials for review by clinicians. ACOs have a responsibility to provide patients with factual information, support medical decision-making, promote cost transparency, and engage patients and their families in the process. Chatbot-generated communications, subject to clinical review, can be an efficient way to develop the necessary tools.
3. Defer replacement of direct communications with patients with AI and test the programs first. Pilot AI-driven communication and education tools, such as patient check-ins and self-management programs, with evaluation of changes in outcomes and patient acceptance. The urgency to utilize data wisely will drive ACOs toward AI solutions. Remember that technology is never neutral. Plan carefully for human and non-human resources to ensure that any AI applications benefit your organization and avoid potential, significant harm.
   

About Theresa Hush

As CEO and Co-founder of Roji Health Intelligence, Theresa Hush is a healthcare strategist and change expert with experience across the health care spectrum, including public, non-profit and private sectors. Her accomplishments include leading the transformation of Blue Cross Blue Shield regulations in Illinois, improving access to care as Director of the Illinois Medicaid program, and serving in executive leadership for both private payers and physician organizations. An expert at creating consensus for desired change through education and collaboration, Terry helps organizations take actions that will direct their future through meaningful technology and programs.