Healthcare Insights: Better Care, Better Business

Introduction

People are living longer, healthier, and safer than any time in human history. This book offers insights about health and medical care technology unfolding at the fastest speed in human history, and their limitations in reaching patients due to marketplace economics, bureaucracies, insufficient training, and government rules and regulations. The thoughts here are more focused about how to make healthcare and medical care delivery systems more efficient and effective now rather than theorizing about the futurist world.

Advanced nations deliver health and medical care better than developing countries, but there too governments are ginning up on issues like vaccinations, water safety, maternal and child healthcare, and care for disabled children. Doctors and healthcare workers from developing countries are training in hospitals, medical schools, and science departments throughout advanced nations.

Concomitantly, doctors and healthcare workers work in developing countries on a regular basis not just in crises. They introduce advanced techniques and procedures, new technologies, and cultural perspectives.

Advances in treating HIV and Aids are overcoming cultural and religious based prejudices. With the leadership of the World Health Organization and other NGOs, governments are doing better to stem Ebola and other diseases with early intervention.

Obesity for instance is recognized a major health threat throughout the Middle East and southern Europe where fast foods and processed ingredients are replacing fresh foods and low fat healthy diets. Governments are launching education programs and healthcare incentives. The millennial generations in advanced countries are returning to healthier eating and exercise after a century of disquieting habits.

Public health workers are given short shrift for their contributions in an age of glitz science and high technology. Their passion, intelligence, and curiosity are critical resources in the battle for better healthcare.

Futurism began flourishing as a movement in the 1900’s based in the art world in response to rapidly unfolding new technologies. The old world ways were steeped in a tenacious web of unproven science and philosophy.

New inventions emphasizing speed and technology appeared so rapidly 100 years ago that inventors, academics and philosophers were challenged to foresee the impacts on human interaction, culture, communication, and lifestyles. Innovations like practical uses for electricity, x-rays, radio waves, automobiles, airplanes, and industrialization organized for mass production, rocketed the futurist movement into the 21st century.

Hedge and venture capital fund groups hire futurologists. I know a law firm in Chicago that pays a futurist to think about new directions for the firm. The Association of Professional Futurists was founded in 2002 for sharing strategic foresight.

Medical futurologists think about new technologies and their impact like having a 3D printer in every hospital and medical group office, lab-grown organs, transplants, and digital literacy and medicine. Preventive care is a subject of contemplation being proactive rather than reactive to problems, the impact of DNA mapping, wearable technologies, robotics, and digitization of the healthcare system.

Our purpose here is to expose students and other interested parties to the issues through Insights into Healthcare Solutions creating a better, high quality, and longer life. But, we never lose sight of the human experience where communication is the core ingredient of great care.

Chapter 1:

Business Tactics Benefit Hospitals, Medical Care Groups & Patients

Organizing an efficient and effective delivery system is key to patient outcome success and high levels of satisfaction among care delivery teams.

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1.1 Outsourcing Fuels the Health-Care Analytics Field

The health and medical-care systems are struggling largely because of financial pressures to enhance their effectiveness and efficiency. A relatively new tool they are using is health-care analytics, which improves outcomes in patient-care management and institutional growth through advanced data management and predictive modeling strategies.

Company decision makers and doctors have the same responsibility of a ship's captain. The captain charts a course by applying the most recent data to get to the destination. A doctor does that for patients, and hospital stakeholders set the goals for the institution. They create predictive models of probability of behavioral outcomes based on the data, according to Seymour Geisser (Predictive Inference: An Introduction. 1993. New York: Chapman & Hall).

Predictive modeling morphs into uplift modeling caused by changes in probabilities that occur from external forces and unanticipated consequences of decisions. Forecasting might lead to better disease management, future health-care treatments, access to more effective and safer drugs, and optimizing strategies for large-scale and commercial treatments at a time when one physician complains he barely has time to manage data for paperwork and billing purposes.

Health-care analytics is such a complex field that the most effective way to approach it is by triangulating a commissure of care providers, data collectors, and outsourcers specializing in medical-predictive modeling. Parkland Health & Hospital System analyzes data from electronic medical records. With input from outsourcers, its predictive model helps identify patients at high risk of readmission, addressing congestive heart-failure patients eventually including diabetes, acute myocardial infarction, and pneumonia patients ("Hospital Uses Data Analytics and Predictive Modeling to Identify and Allocate Scarce Resources to High-Risk Patients, Leading to Fewer Readmissions. Innovations Exchange. 2009).

Findings and indicators in other reports are equally tantalizing. A 2015 summary by Health Catalyst claims with the use of health-care analytics and predictive modeling, one Kaiser study found a 22 percent on average drop in patients developing coronary artery disease compared to a decline of 9 percent in a clinic that didn't use the tool. Another study cited by Health Catalyst has Israelis predicting readmissions with 80 percent accuracy. Using health-care analytics in designing predictive models is relatively new, and results are not definitive. Proving the value of health-care analytics requires an expansion of opportunities and applications.

Nevertheless, the prospects are appealing to the business world, and that is always a strong indicator a new approach will work and make money. IBM created a unit called Watson Health to use health-care analytics creating a more complete and personalized picture of health, powered by cognitive computing. Now individuals are empowered to understand more about their health, while doctors, researchers, and insurers can make better, faster, and more cost-effective decisions. IBM is buying Phytel that provides cloud-based health-care analytics software and services to expand Watson Health's capabilities.

Completing the commissure are analysis and service-outsourcing companies. Outsourcers bring value-added professional services combining technology, data, and health-care analytics for creating predictive models. They are skilled at creating a positive team environment harnessing the expertise of care providers, public health workers, doctors, staffs from medical-care facilities, pharmaceutical manufacturers, patient-advocate groups, and nursing-home medical teams producing results in predictive models from health-care analytics.

1.2 Why Hospitals Must Outsource Medical Billing

In some hospitals and large medical practices, IT staff and expenses amount to double-digit percentages of overhead. These medical corporations demand pro-active medical billing systems to bring in reimbursements quickly and correctly. Mistakes delay or deny patient and third party payments. Great IT systems have a point of touch operation that matches reimbursements to services safeguarding tracking of patient services rendered.

Here are reasons to consider outsourcing medical billing in an age when CASH IS KING.

Billing errors and failing to comply with changing medical billing rules are the primary causes of lost profits and leaving money on the table. The office manager of a dermatologist's office tells me that patients on Medicare and Medicaid are unaware or fail to tell the office staff they have moved to HMO coverage under the new law. The office sometimes does not get a rejection letter for bills until four months pass. She resubmits to the HMO incurring another lengthy payment delay. Multiply this by thousands of patients, and we are talking about significant dollars. Tracking down outstanding receivables is time consuming and expensive. To paraphrase the late Senator Everett Dirksen, a few hundred bills in float here and there, and soon we're talking about real money.

A Midwest hospital corporation with four large facilities, outpatient offices, and dozens of off-sight clinics, went paperless three years ago. A department administrator tells me they downsized storage and office space digitizing all patient and billing information. The executives are outsourcing many of the medical billing functions, because there are not enough IT staff to manage all the work in-house. The hospital competes for these people going into commerce and industry where pay is greater.

Jess White and Renee Cocchi writing for Healthcare Business and Technology suggest outsourcing medical billing is successful when companies pay for outsourcing services on percentage of what they collect not bill. The more money collected in less time makes the relationship worthwhile for everyone. They are experts with infrastructure in place to track and push for payments.

Outsourcing billing functions reduces some overhead more on matters like employee benefits, taxes, severance, and downtime before new people are trained and at work.

Third, medical staff need be conscientious in-putting medical data, though that's not always as reasonable to expect as one might think. It can be the outsourcing company's responsibility to make sure medical data are entered in a timely manner, the software is capturing the right pricing, and the outputs are directed to the right insurer paying the bills.

Finally, outsourcing companies train and keep staff aware of proper coding for prompt and full payment. The hospital mentioned above partly bases its bonuses on medical staff completing these functions successfully. One outsourcing company prides itself on customized software development that integrates with and enhances a client's operating platform, Electronic Medical Records, billing and practice management, with all services attuned to compliance with the latest changes in rules and regulations.

The most important goal of outsourcing is to keep patients free from the burdens of bill payment delays that add to their stress and negatively affect their health and care. Below is an exercise every in-house medical billing department can perform semi-annually.

1.3 Case Report: Epic Systems Corporation

Healthcare Information Technology (IT) applications largely focus on cost containment and harboring resources to comply with federal regulations. Loads of money is being spent on improving Medicaid Management Information System (MMIS) for billing compliance. Now medium and large medical centers are investing in IT systems integrating clinical, access, and revenue functions.

One prestigious Chicago medical center uses different software in emergency services than in ambulatory care. Their IT system was built piecemeal, not coordinated, and fractured. This problem spreads across many departments, leaving patients and doctors unable to swiftly and smoothly navigate the care system. It affects billings and research on outcome measures of population health and operational findings.

Epic Systems Corporation is resolving many of these issues. It is but one participant in a $50 billion industry of outsourcing companies working with medical centers. Epic is a privately held health-care software systems company built on a single patient-centric database. Epic’s integrated suite of products holds medical records of 54 percent of US patients and 2.5 percent of patients worldwide.

Epic programs are targeted for functionality of patient care, registration and scheduling; clinical data for doctors, nurses, emergency personnel, lab techs, pharmacists, specialist and primary-care clinicians; billing for insurers and government agencies. Epic Healthcare Systems alleged problems and shortcomings are detailed elsewhere, but medical institutions realize they are not significant enough to keep Epic from filling the void in IT services.

Forbes tagged Judy Faulkner, the owner and CEO of Epic Systems, the most powerful woman in health care. Epic and other companies are doing from the outside what in-house staff is unable to accomplish.

Begin with the mission, i.e., to endorse and adopt the electronic Health Record (EHR) Association’s Developer Code of Conduct encouraging transparency, patient safety, interoperability and data portability, clinical and billing accuracy, privacy and security, and patient engagement.

The goal is safe, interoperable innovation. Epic’s strategy lets the doctor control the flow of data across organizations, and patients control their own health information. The University of Virginia Health System recently implemented two Epic programs. One lets a primary-care physician, for instance, ask a question about a patient via the software that allows the specialist to review the patient history in real time before sending a response. More complicated cases requiring referrals to specialists let the specialist review the client history and determine if a referral is warranted. The programs cut down patient appointments, give them a quicker response time, and more immediate treatment.

Epic does not have an aggressive marketing campaign or large sales force. The products are among the most expensive in the IT health-care world. Institutions wanting to make the switch to Epic or another outsourcing company need to hire an advocate for the institution. The advocate will represent the best interests of the institution, keep progress in line with a budget and work plan, ensure the institution’s priorities are addressed, and more.

The point here is not that Epic needs a third-party partner, but the institution needs one to ensure full and smooth implementation of the Epic programs into the institution’s operating procedures and corporate culture. Change is never easy. Outsourcing companies working for the medical-care provider can assemble data from programs like Epic, analyze them, and report on health-care outcomes and service delivery. It’s not just producing data that is the important function, but getting the staff to use the data to improve