Tiffany Huston

Organization: Door County Medical Center
 
Position: Manager Patient Financial Services
 
HFMA Certification: Certified Revenue Cycle Representative (CRCR) and currently pursuing additional certifications
 
Why did you decide to pursue certification through HFMA? I asked my Senior Leader for more educational opportunities for the Revenue Cycle as my new role included being the chair of the RevCycle Committee. 
 
What have you found most valuable about being certified? The ability to continue my own growth and now sharing it with the entire organization with our Enterprise Membership.
 
What would you say to someone considering HFMA certification? Do it, and keep doing it.  The best way to completely understand is to put together the bigger picture and understand the pieces.
 
What do you most enjoy about your current role? The ability to make positive advancement for our organizations and support our patients and my team.
 
What are 3 words that describe you? Driven, Insightful, Compassionate  
 
What is your favorite place to be? In Washington DC with WHA working with our WI representatives on price transparency and surprise medical billing.  The mission work I have been blessed to participate in and sending the medical supplies to countries in need.  Traveling with my family and experiencing new places with my children.
 
Favorite quote: “What you do today can change all of your tomorrows” by Ralph Marston.

Thank you for your involvement in HFMA, Tiffany!

Learn more about HFMA Certification.

Chirag Bhargava

Organization: Chi-Matic Inc.
Position: CEO & Co-founder
 
HFMA Certification(s): Business of Healthcare, Certified Revenue Cycle Representative (CRCR)
 
Why did you decide to pursue certification through HFMA? HFMA is great source to keep up with changing landscape of healthcare specifically for finance and revenue cycle leadership. There are numerous case studies and career advancement opportunities. I decided to pursue certification to learn the details, use the program as refresher and gain useful knowledge.
 
What have you found most valuable about being certified? The curriculum is very well laid out, the most useful aspect I found was section on costing and budgeting. It will help understand big picture items when working on items that can eventually impact the operating margin and how the future shapes up for health systems.
 
What would you say to someone considering HFMA certification? Highly recommend it and do it diligently. Best way to do it is study everyday regularly and then take the exam.
 
What do you most enjoy about your current role? Working with health systems to solve complex revenue cycle challenges, guide them on how to use technology for business process improvement, guide on AI and ML and make it easier to do projects in this area.
 
What are 3 words that describe you? Curious, Tenacious, Decisive
 
What is your favorite place to be? My hometown Jaipur, India
 
Favorite quote: “Vision without execution is just hallucination” – Henry Ford
 
Thank you for your involvement in HFMA, Chirag!


 Learn more about HFMA certification.

Amanda Nádas

Organization: UW Health  
Position: Sr. Financial Analyst

HFMA Certification(s): Certified Healthcare Financial Professional (CHFP), Certified Specialist Accounting & Finance (CSAF)

Why did you decide to pursue certification through HFMA? CPE

What have you found most valuable about being certified? Developing a deeper understanding of healthcare finance.

What would you say to someone considering HFMA certification? Certifications present a great opportunity to learn about topics inside or outside of your focus area. As an HFMA member you should highly consider taking advantage of the free opportunity!

What do you most enjoy about your current role? The opportunity to pursue my passion for healthcare reimbursement at a remarkable organization
 
What are 3 words that describe you? Compassionate, Enthusiastic; Trustworthy

What is your favorite place to be? Wherever family is!
 
 Thank you for your involvement in HFMA, Amanda!

Interested in learning more about HFMA certification? Visit the Certification page.

Scholarship Application Deadline: March 31, 2020

The HFMA Wisconsin Chapter is proud to support the next generation of healthcare business professionals through our scholarship program.

The 2020 Scholarship Program will award up to two $2,000 scholarships for students pursuing a college degree in a field related to healthcare finance.

Plus, scholarship recipients and selected applicants will receive a free HFMA student membership and waived registration fees for chapter programs for one year.

For more information and to apply, visit the Scholarship page.

​The WI HFMA Fall Conference held in Madison was another successful event.  Attendees kicked off Wednesday evening at The Rigby Pub and Grill.  The networking committee hosted an entertaining event that included our 1st Annual Wisconsin HFMA Trivia night paired with appetizers and drinks. It truly was an exceptional opportunity to network, socialize, and relax after a few stressful days at work.   
 
Our keynote speaker, Patrick Henry, started Thursday morning with a funny yet informative keynote. The day was filled with great breakout sessions including topics on patient access department strategies, leadership development, accounting/budget standards, public policy, and employee engagement. Our first H2O breakout session provided insight regarding the benefits of the new All Access Membership offered through HFMA. Next, we heard the positive impact of having a revenue assurance dedicated team and billing statement design as well as payment plan reform.  After an informative packed first day dinner was another great chance to catch up with other attendees. As an added bonus, Patrick Henry provided comical evening entertainment.    
 
Early risers attended an informational meeting on our current mentorship program.  It was great to have long tenured members join in the conversation offering insight into how they achieved the great milestones they had and those instrumental people in their careers.  Afterwards, breakfast was served and attendees heard about something most struggle with in organizations, information security and compliance. Lastly, Lisa Ellinger moderated our payer panel which led to very insightful discussions on trending topics in healthcare from their prospective.  We wrapped up the conference with a few door prizes congrats to our lucky winners.
 
A huge THANK YOU to Mary Kaja, Kyle Kovacevich, Leslie Claas, Art Mertig, Matt Clark, and Eric Lopata for all of their help planning our Fall Conference.  Our chapter is lucky to have great volunteers like them.  Also, thanks to all of our speakers and attendees! Without people like yourselves we would not be able to continue to host events like these. Lastly, if you have any suggestions for topics or would like to speak at future events, please let us know.
 
Thank you,
Britt Tillman 

2019 Spring Conference and Annual Meeting
The WI HFMA 2019 Spring Conference and Annual Meeting in Appleton was a great success. The event opened on Wednesday evening at the Timber Rattlers Ballpark with beer, brats and baseball for everyone. Despite some cooler temperatures in the later hours, it was well attended and a great networking event.

Thursday morning kicked off with a rousing keynote by Ron Galloway on “The Disruptors” in the healthcare industry and held the audience riveted through all of his 200 plus slides. The day continued with multiple sessions on topics ranging from the future of accountable care, communicating to be understood, and, of course, our always popular and interesting H2O sessions. The educational sessions for the day concluded with a closing keynote by Lauren Schieffer on “Generations in the Workplace.” Thursday evening was a celebration of all of the volunteers, sponsors and past leadership of the Chapter, concluding with the installation of the 2019 -2020 Chapter Leadership and a President’s Reception for incoming President Matthew Streeter.

Friday kicked off with the Early Riser Coffee and Mentorship Program and a Brunch and Learn session on “Universal Health Care is Coming” by Douglas Trueck, Sr. The day concluded with a closing session on transparency and our door prize give away.
​
Thank you to everyone who attended and we look forward to seeing you all at our Fall Conference (September 18th -20th) in Madison.

  ​When we examined the rural health care landscape in 2016, the overarching challenges were affordability and accessibility. Two years later, those challenges persist, as was evident in the Senate hearing on September 25 titled “Health Care in Rural America: Examining Experiences and Costs.”
The hearing featured the Subcommittee on Primary Health and Retirement Security, and testimony from Tom Glause (Commissioner, Wyoming Department of Insurance), Morgan Reed (Executive Director, the Connected Health Initiative), Alan Levine (CEO, Ballad Health), and Deborah Richter, MD (Family Physician).
The hearing presented a unique perspective on what is currently preventing hospitals and doctors from delivering affordable and accessible health care in rural areas. More importantly, the hearing also provided insight on possible solutions to these issues with the goal of creating an environment where hospitals thrive in rural areas, and as a result, residents have access to affordable quality health care.
Defining Rural The U.S. Census Bureau identifies two categories of urban areas: the first is an urbanized area of 50,000 or more people, including cities and metropolitan areas; the second is an urban cluster of at least 2,500 and less than 50,000 people, including suburbs and large towns. Rural encompasses all population, housing, and territory not included within either of the designated urban area definitions. According to 2010 census data, approximately 20% to 25% of the U.S. population lives in rural areas.
Typical demographic trends of rural areas include lower median incomes, a high proportion of seniors, higher acuity levels and lower life expectancies. There are also specific ailments that impact these communities at a higher rate than urban communities. Obesity, lung cancer, chronic obstructive pulmonary disease (COPD) and heart disease are statistically more common in rural areas. Finally, the gap between urban and rural life expectancies is growing. According to a 2014 study published in American Journal of Preventive Medicine, consistent overall increases in U.S. life expectancy were noted during the past 40 years, from 70.8 years in 1970 to 78.7 years in 2010. However, the study reveals the rural-urban gap widening from 0.4 years in 1969 to 1971 to 2 years in 2005 to 2009, with those in urban areas living longer.
Challenge One: Access to Health Care Access remains the primary hurdle for health care in rural America: it is too difficult for residents to obtain and for hospitals to provide. There are inherent features of rural settings that contribute to this issue, such as geography and number of facilities. Hospitals are few and far between in rural areas, and reliable transportation services (e.g., buses, taxis, etc.) are not available to help overcome this. To illustrate this point, consider that only 24% of rural residents can reach a top trauma center within an hour, according to Glause’s testimony at the Senate hearing.
Aside from physical distance and lack of facilities, several other factors further constricting rural America’s access to health care were discussed at the hearing. Two notable items included workforce shortage and the outdated “brick and mortar” approach to rural hospitals.
Workforce shortage – It is no secret that rural America struggles to attract and retain talented workers, and the health care industry is no exception. According to Glause, rural areas make up 57% of the primary care health professional shortage areas. There are some fundamental reasons that contribute to this shortage, including the urban-centric nature of the current health education system and the general draw of opportunities in urban areas. Workforce shortage exacerbates the access issue, as it lessens the supply of doctors, nurses, and other health professionals able to care for residents in rural areas.
Brick and Mortar – The traditional standardized hospital does not cater to the unique health problems in rural communities. For example, diabetes, heart disease, curable cancers, and drug overdoses disproportionately affect rural Americans relative to the general population, according to Levine’s testimony. Thus, not only do rural residents have fewer hospital options, but those they do have are further away with less doctors and nurses. Further, the ones that do exist are not properly tailored to their needs.
Challenge Two: Affordability Affordability continues to be a double-edged sword preventing the obtainment and delivery of quality health care in rural America. Rural residents have very limited coverage options and rural hospitals struggle to implement a cost structure that could spur more affordable services.
Rural areas have fewer insurers in the market, which increases premiums that residents are ill-equipped to afford. In fact, “nearly 30% of rural residents report delayed care or report they did not receive care in the previous year due to cost,” said Glause in his testimony. It is not just the private insurance market that contributes to affordability issues. In Wyoming for example, Medicare reimbursement covers only 65% of the hospital’s costs, which according to Glause shifts more costs to the non-Medicare population. This is a deliberate feature of the current system as both government and private insurer payment policies are “designed to contain or even reduce per-unit reimbursement,” says Levine.
Fewer patients and tighter reimbursement directly leads to less revenue. This hinders a hospital’s ability to deliver high quality health care and cover its fixed costs. According to Levine, more specifically, with less revenue to cover fixed costs such as debt service, increased compliance imposed by Medicare and Medicaid, and general overhead, cash flow takes a severe hit. This inhibits employee recruitment and retention, equipment and technology updates, and capital investments, all of which can reduce the quality of care to rural patients. Unfortunately, it does not stop there – if cash flow continues to suffer, bankruptcy and closure begin to enter the picture. Hence, 85 rural hospitals have closed down between January 2010 and July 2018.
Solutions The hearing was not all doom and gloom though, as many ideas and interesting solutions were discussed. These included strategies such as increasing telehealth availability and opening rural clinics to augment an existing facility. Other notable solutions include:

• One solution suggests creating a federal grant program to help both hospitals and insurers to reduce cost and increase quality of care in rural areas. For example, according to the Glause testimony, if the grants funded assistance to hospitals, new technology and transportation services, the cost would not be passed to the insurers, which would lower premiums, and in turn the rates for consumers.
• Another possible solution involves tailoring hospital services to the specific needs of communities. For example, renewable block funding based on estimable costs could enable hospitals to create new jobs and repurpose old assets. For example, according to Levine’s testimony, two rural hospitals in Green County, Tennessee consolidated the inpatient acute care services at one hospital, and then repurposed the other to focus on specific outpatient services particular to that community.
• Finally, another proposed solution involved shifting from the traditional fee-for-service model to a pay-for-value that would better align doctor and hospital incentives. This could potentially attract more physicians to the area, as they “would be able to diversify their income to include the upside of the hospital’s financial performance,” says Levine. Additionally, such alignment would likely lead to consistency between doctor, hospital, and community as all focus on managing chronic conditions, rather than performing a reimbursable procedure.

Capital Considerations In terms of cost savings, a thoughtful capital structure is still an important point to consider. Therefore, rural hospitals should be examining all financing programs and options as it pertains to bolstering much needed cash flow. This would allow rural hospitals to reinvest in their facilities, open specialty clinics, upgrade equipment and technology, and ultimately increase the affordability, availability, and quality of health care for rural America. Specific programs that can assist in this manner include the USDA Community Facilities Program (USDA CF) and the Federal Housing Administration (FHA) Sec. 242 mortgage insurance program. USDA CF is reserved for rural nonprofit organizations, including hospitals and skilled nursing facilities, and provides below market fixed-rate, long-term, non-recourse financing for construction and refinance. The FHA’s Sec. 242 program provides agency-insured, long-term, fixed-rate debt at relatively high leverage points.
A holistic approach to these challenges, one that includes careful consideration of both financing and operational options, will help to ensure that hospitals are doing all they can to mitigate risk and provide quality care for their communities. As is evidenced by the hearing in Washington, this is an issue that is on the minds of not just operators, but legislators as well. As the political landscape affects organizational decisions, it is important to stay aware of both changes and potential solutions available to rural facilities that will align a facility’s operations with best practices that maximize financial stability.

​Contributed by Lancaster Pollard - Authors Brett T. Murphy and Husam Atari

​Organization Name
John W Kelly Management Consulting


Tell us a little about yourself?
Live in Wausau Wisconsin. Over 30 years of executive leadership experience in health care - hospital, group practice, integrated health systems and health insurance/managed care. In 2016, I formed my own consulting practice with a focus on executive coaching, strategy development and helping organizations achieve results on value-based payment strategies. With my new company, I'm also able to pursue my other passion - domestic and international Christian mission work.


What are 3 words to describe your company?
Client-focused
Responsive
Custom


What does a typical day look like for you?
When I'm not on-site with a client or working up project plans, you can often find me on the ski slopes (winter) or hiking in nature (summer). My typical day is a mix of consulting work, fun and taking the next steps on a mission project.


What is on your wish list for the next 10 years?
* Travel Europe
* Revisit favorite national parks - Glacier, Yellowstone, Rocky Mountain, Yosemite
* Find the ultimate trout stream 


If you were stuck on an island what three things would you bring?
Bible
Hammock
Fishing gear


Any random facts you could share with us?
Still ride the same bicycle that I got when I was 14 y/o


You’re happiest when?
With my family


Why did you join HFMA Wisconsin? 
Great organization. I love the learning content that the association provides. In addition to that, the members are incredibly helpful -- a call/networking contact is almost always willing to lend a hand, explain something or make a referral.

 
By: Andrew Snyder, Chief Medical Officer, and Anita Cattrell, Chief Innovation Officer, Evolent Health
 
Years of research and data have shown that social determinants of health have a significant impact on the profitability and sustainability of the health care industry. In fact, when considered broadly across racial disparities, education, social support, transportation, healthy food and poverty, social determinants of health have been shown to account for more than a third of total deaths annually in the United States, and up to 60 percent of health care costs, eclipsing actual direct medical expense. This is most likely attributed to the imbalance of medical and social spending in the U.S. On average, nations that are members of the Organization for Economic Cooperation and Development (OECD) spend about $1.70 on social services for every $1 on health services; the U.S. spends just 56 cents.
 
To correct this imbalance, we need to shift a portion of our current health care expenditures to investments that address upstream social factors that heavily influence downstream outcomes. Evidence suggests that addressing social determinants of health is not only important for improving overall health, but also for reducing health disparities that are often rooted in social and economic disadvantages. For example, in addition to lower body mass index and fewer risk factors for chronic disease, early childhood education has been associated with higher levels of education attainment and income and lower rates of violent crime and incarceration.
 
Given the far-reaching impact of these efforts, the return on investments addressing social determinants accrues not only to the health system in the form of reduced health care expense, but also to the broader community. However, current financing structures make it challenging for public sectors to pool resources together and measure the “full” return of these investments, which consist of capital infusion, tools and community-level mechanisms to deliver services. Most provider organizations don’t have the means to make these investments on their own, and those that have the means will likely find it difficult to see a near-term monetary ROI, as downstream efforts take time to take effect and may be extended beyond the health care system.
 
Pushing Forward by Working Backward
Until broader community impact can be measured, such that other sectors are helping fund these services, health systems will need to be thoughtful and targeted on where and how they invest in social determinants of health to ensure a positive ROI. By developing approaches that work backward from the outcome they’re trying to change, health systems can take progressive steps toward targeting the underlying causes of these issues, rather than siloed steps that treat only symptoms.
 
Some of the cursory discussions of social determinants of health suggest that addressing single factors can have a large impact on outcomes. Analysis shows this not to be true, yet most organizations are still tackling these issues in a silo. For example, we’ve seen evidence that providing free transportation services to Medicaid patients does not decrease missed primary care visits, and that building grocery stores in food deserts does not alter dietary habits.
 
One big reason why these interventions are not showing impact is because they are not targeted at those who would benefit most, and another is that they frequently lack an agreed-upon point of accountability for integrating these social services into the broader health care planning for these individuals. For example, through our own analysis, we know that for a specific set of individuals, having a transportation barrier is associated with a 63 percent increase in risk of readmission. However, providing just a ride for those patients isn’t enough. This needs to be coordinated with a medical professional visiting the home and ensuring that the conditions are conducive to a successful recovery. This includes making sure the patient has a follow-up visit with his or her physician; conducting a comprehensive medication review; and ensuring the individual has the support they need to obtain and adhere to the prescribed regimen to avoid a readmission.
 
But without someone taking accountability for coordinating this transportation service with all the other services needed, the chances of avoiding that readmission are low. It’s the diffuse responsibility that’s led to symptom-focused and ineffective solutions, and that’s what needs to change to see widespread impact and an actual ROI on these types of investments.
 
When accountability is present, however, a chain of connections answering to one another can help identify overall goals that can be approached in a concerted way. The team can work backward from there to drive forward progressive steps toward bigger goals and address social determinants of health in ways that show marked impact on health outcomes. To help ensure that social determinants of health efforts are accountable and productive, health care organizations can use these three action steps as a guide:
 
1.       Define accountability. As a care team comes online, they’ll need a leader—one who is not necessarily responsible for addressing individual social determinants, but who is accountable to the patient for the results. Primary care physicians—already the “quarterbacks” for their patients’ care and accountable for total cost of care in new payment models—are perfectly positioned for this role. To succeed, though, these quarterbacks must have a strong team behind them, consisting of dedicated clinicians who are integrated into a care delivery team and who themselves are empowered to advocate for change, act on data-informed recommendations and coordinate or monitor interventions within and without the health care provider. 
 
2.       Use AI and machine learning to create and follow a comprehensive map. To change a patient’s health status and trajectory, one needs a clear understanding of where the patient is headed, what’s pushing them in that direction and any roadblocks to better paths. Can they easily access a store that sells food appropriate to their recommended diet? If told to come in for a follow-up, can they make time during the day, or are they a sole caregiver to a disabled relative? 

Disparate data sets can shed light on neighborhood food and public transit access, household type, education and financial history, clinical notes from the electronic medical record and other variables. When these data sets are aggregated, artificial intelligence and machine learning can flag variables that, when viewed together, can pinpoint both clinical and social risk factors and flag opportunities for either physician or community intervention. Such machine-learning resources can be designed to provide push-notifications and other interactive support tools that convert data sets into actionable insights while minimizing any additions to administrative time.
 
3.       Redefine your measurement strategy by collaborating across stakeholders on shared goals. Realizing an ROI is muddy business when the investments made affect patients from multiple touchpoints. Metric definition and metric measurement, like interventions themselves, need to extend beyond a care provider’s four walls. Work that has traditionally been done purely at the social level should now be married with health and outcomes data to more robustly predict areas of need and define success. Considerable barriers remain, as clinicians who answer to their own facility’s balance sheets must answer to financial overseers who may not be willing to count a community benefit as a realized return. We may need to see new public discussion on tax exemption and definitions of community benefit here, but there’s strong potential, if we get it right, to truly redefine managed care and community health if we can redefine the metrics of care outcomes.
 
Andrew Snyder is the Chief Medical Officer and Anita Cattrell is the Chief Innovation Officer at Evolent Health. They can be reached at AMSnyder@evolenthealth.comand ACattrell@evolenthealth.com.
 
 

​​About PEPPER
The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a Microsoft Excel file summarizing provider-specific Medicare data statistics for target areas often associated with improper Medicare payments due to billing, DRG coding and/or admission necessity issues. Target areas are determined by the Centers for Medicare & Medicaid Services (CMS).
PEPPER facilitates the prioritization of areas on which a provider may want to focus auditing and monitoring efforts.  Providers are encouraged to conduct regular audits to ensure that medical necessity for admission and treatment is documented and that bills submitted for Medicare services are correct.
PEPPER can be used to review three years of data statistics for each of the CMS target areas, comparing performance to that of other providers in the nation, Medicare Administrative Contractor (MAC) jurisdiction and state.  PEPPER can also be used to compare data statistics over time to identify changes in billing practices, pinpoint areas in need of auditing and monitoring, identify potential DRG under- or over-coding problems and identify target areas where lengths of stay are increasing.  PEPPER can help providers achieve CMS’ goal of reducing the likelihood of improper Medicare payments.
TMF, at CMS’ direction, has developed various types of PEPPER including:
•          Short-term acute care hospitals (developed in 2002),
•          Long-term acute care hospitals (developed in 2005),
•          Critical access hospitals, inpatient psychiatric facilities and inpatient rehabilitation facilities (developed in 2011), 
•          Hospices and partial hospitalization programs (developed in 2012),
•          Skilled nursing facilities (developed in 2013), and
•          Home health agencies (developed in 2015).
Visit PEPPERresources.org for more information on PEPPER, including sample reports, user’s guides, recorded training sessions and national-level comparative data. View the PEPPER distribution schedule and information on how to get your organization’s PEPPER.

Hospital Rating Agency Update:
Balance Sheets and Business Combinations Provide Buffer in Difficult Operating Environment

Continuing a theme from last year, 2017 saw operating margins deteriorate because of long-term industry trends on the revenue side and rapid expense increases. Furthermore, capital spending needs remain high but mainly for shorter-lived assets such as IT, outpatient clinics and ambulatory services. Fortunately, 2017 was a better year than 2016 from a non-operating income perspective, as investment returns were good and the strong economy helped bolster contributions for many nonprofit health care providers. Industry forces continue to favor larger providers, leading to acceleration in mergers and acquisitions (M&A) and affiliation activity. The combination of good non-operating income and consolidation improved the balance sheet of most hospitals and systems, particularly the large and highly rated ones. This balance sheet strength is always considered an extremely important credit attribute but especially in an environment where unpredictable but certain changes are coming.
Each of the credit rating agencies (CRAs) issue an annual report that summarizes past performance and provides a forecast for the upcoming year. With approximately 95% of the world market share for credit ratings, Fitch Ratings (Fitch), Moody’s Investor Service (Moody’s), and Standard & Poor’s (S&P) reports provide a wealth of information which systems and standalone hospitals can use to make meaningful comparisons to financial benchmarks and emerging trends.
Operating PerformanceAfter three years of robust revenue growth from the end of 2014 through 2016, 2017 saw the winding down of increases attributable to Medicaid expansion resulting from the Affordable Care Act (ACA). All three CRAs reported revenue growth slowing rather dramatically. Meanwhile, the economic recovery that started nearly 10 years ago has slowly driven up labor costs in many service sectors. Health care is acutely affected by labor costs, as the supply of workers with the necessary skills or experience is limited, and consumer demands place a premium on quality and availability. In addition, pharmaceutical costs increased at a rate faster than inflation for the second consecutive year.
Moody’s reported that the median expense growth rate slowed from 7.1% in 2016 to 5.7% in 2017, but the revenue growth rate was even slower, dropping from 6.1% to 4.6% over the same period. The CRAs all expect the negative operating factors to continue for the foreseeable future. In addition to the current expense challenges, demographic and consumer preference changes stand to dampen revenue growth for many years to come. Common themes among all three agencies include:

• Aging population and changing industry dynamics weaken payor mix. All three agencies noted that Medicaid expansion from 2015 through 2016 contributed to slight improvement in payor mix, as the proportion of self-pay declined. However, the population continues to age, leading to a conversion from commercial payors to Medicare. Both Medicare and commercial payors have pushed initiatives for value or risk-based payment plans, which if nothing else, create uncertainty of reimbursement. In addition, more employers are pushing their covered employees into high deductible plans, which can lead to a reversal of the decline in self-pay. Finally, “the current administration continues its efforts to chip away at key components [of the ACA]…including diminishing support of the exchanges and benefit reductions.”[1] This weakening support for the ACA also contributes to a rise in the uninsured rate, which contributes to higher bad debt expense and/or charity care.
• Weak volume growth. Outpatient volume growth continues to exceed inpatient, but overall demand was very weak in 2017. Moody’s notes that “median 1% growth in inpatient admissions marks the lowest rate of growth in three years, while outpatient growth slowed to 2.2%--down for the first time in five years.” [2]
• Slow transition from fee-for-service. Although movement has been slower than anticipated, a gradual shift from fee-for-service to at-risk sharing and value-based compensation models is changing the industry. The consensus view is that the change will favor large systems that can develop and maintain infrastructure to adapt to a population health environment.
• Competition from specialized and non-traditional entrants. In addition to the decline in inpatient and outpatient growth, Moody’s noted a decline in the growth of outpatient surgeries because of “an increasing supply of competing sites providing these more lucrative services.” All three agencies emphasized the competitive threat from alternative providers. S&P commented that “the industry is also experiencing an unparalleled rise in nontraditional competitors aiming to provide care that is more consumer friendly, higher quality, and lower cost.”
• Consolidation as a means to gain negotiating leverage and framework for population health. With the gradual shift from volume to value, the increased need for and opportunities to use technology, and the general uncertainty of future changes, more providers are seeking to affiliate with other players through a combination of horizontal and vertical integration, network collaboration and M&A. Networks will be important in gaining negotiating leverage from a revenue and expense perspective and enabling providers to have sufficient infrastructure to manage in an environment where population health and access are key aims.
• Management teams seek efficiency through varying strategies. As reimbursement mechanisms continue to change and margins get squeezed from both sides, it is imperative for organizations to adapt. Again, size offers an opportunity to achieve economies of scale, and the ability to afford stronger and deeper management teams. By focusing on expense efficiency and revenue cycle optimization, organizations can maintain acceptable cash flow.

Non-Operating Income and Cash FlowPartially offsetting the difficult operating environment, investment returns were generally excellent in 2017 and many providers enjoyed above average charitable contributions. Consequently, overall earnings before interest, depreciation and amortization (EBIDA) margins were barely lower, despite the sharp decline in operating margin. The CRAs have observed a gradual reduction in debt burden in recent years, and the interest rate environment remained favorable throughout 2017. As a result, debt service coverage (DSC) was relatively unchanged from 2016 to 2017; although, some lower rated categories did see a decline. Median maximum annual debt service (MADS) coverage remained at 3.9x in 2017 for the S&P portfolio of health care organizations. It remains to be seen if non-operating income can continue to make up for operating challenges, but we can assume the U.S. equity markets will slow down.
Liquidity and Capital SpendingThe strength of non-operating income helped to offset declines in operating margin, resulting in another year of improved balance sheets. Fitch states that liquidity metrics, “by any traditional ratio are at an all-time high point in the sector.”[3] The CRAs also noted that the sector has experienced a long-term trend of moderating leverage resulting in improved debt/capitalization ratios. Capital spending remained above depreciation expense for the third year in a row, but average age of plant declined in many rating categories. For the most part, hospitals are shunning large replacement or expansion projects. However, capital expenditure remains strongest for the highest rated organizations, who “continue to try to lock in their business advantages—highlighted by continued spending on information technology, ambulatory care and population health infrastructure.”[4] 
Trends and ExpectationsThe following themes were common to all median reports:

• There are few signs that the expense pressures will abate in the near term, revenue growth will remain slower and operating margins will be challenged.
• The sector outlook is generally negative, but rating changes have been limited. Despite the headwinds facing the industry, ratings downgrades only slightly outpaced upgrades and the vast majority of ratings for all three CRAs remained stable. One reason for the ratings stability is that some highly rated systems acquired lower rated and struggling providers, thus there was a reduction in the number of low investment grade and non-investment grade organizations.
• Hospital management and boards must strive to control expenses, find growth opportunities, respond to threats from a variety of competitors and maximize competitive advantages. The skill, experience and creativity of health care management teams will be increasingly important to the overall success of an organization. Therefore, the CRAs, as well as creditors and investors, will be increasingly interested in regular interviews with management teams.

As we mentioned last year, S&P, Moody’s, and Fitch all signaled that 2015 was likely to be as good as it gets for the hospital sector. Revenue growth in 2016 was better than expected, but extremely fast expense increases squeezed margins. The following year, 2017, was indeed a very challenging year from an operational perspective, as margins were compressed even further. On the other hand, many hospitals used the recent “fat years” to shore up their balance sheets. Today, liquidity and debt/cap ratios are at all-time strengths, while debt service coverage is within the range experienced since 2008. The significant buildup in liquidity over the last 10 years helps provide a margin of safety, as operating margins continue to compress.

As the expense pressure and anemic revenue growth will likely not abate in the near-term, hospitals must continue to focus on efficiency, while investing prudently in capital projects that enhance the patient experience and/or improve the availability and use of technology. The management teams that can adapt to the change from volume to value and embrace the goal of population health will be poised to succeed in the future.
 
Ritchie Dickey is a vice president with Lancaster Pollard in Atlanta. He may be reached at rdickey@lancasterpollard.com.


[1] “U.S. Not-For-Profit Acute Health Care Ratios: Sector is Buffeted by Disruption, Yet 2017 median Trends Remain Unchanged from Last Yea” (S&P Global Ratings, www.spgglobal.com/ratingsdirect)

[2] “Medians-Operating pressures persist as growth in expenses exceeds revenue” (Moody’s Investor Service”)

[3] “2018 Median Ratios for Nonprofit Hospitals and Healthcare Systems” (FitchRatings, www.fitchratings.com)

[4] “U.S. Not-For-Profit Health Care System Median Financial Ratios -- 2017 vs. 2016” (S&P Global Ratings, www.spglobal.com/ratingsdirect)

Organization Name
Southwest Health


Tell us a little about yourself?
I have worked in health care finance for over ten years, the first eight of those in revenue cycle leadership, and more recently as a CFO. I grew up between Manitoulin Island, Ontario, Spring Valley, Minnesota and Eagle River, Wisconsin. I hold a BBA Finance from University of Minnesota, and MBA from University of British Columbia. My favorite pastimes are spending time with family, traveling, coaching, and woodworking.


What are 3 words to describe your company?
Community-focused, Innovative, and Fun!


What does a typical day look like for you?
Spending time building relationships, both within the organization and the community.


What is on your wish list for the next 10 years?
Take more time to travel
​

You’re happiest when ?
I’m at the family cottage.


Why did you join HFMA Wisconsin? 
Starting out in healthcare finance in a director role having no prior healthcare experience, HFMA offered a great network of resources to be successful.

​We have crossed the Labor Day line and fall is here. Some of you may be lamenting the coming cold, some welcoming a reprieve from the kids, and others the return of the Packers and the Badgers. But, everyone I know is looking forward to HFMA! We are not holding a WI Chapter Fall Conference this year, but are asking you get involved in The Region 7 Conference and Partner Showcase starting September 26th or the Women in Healthcare Leadership conference on November 9th. Please check your schedules and make plans to attend, but also to get involved, learn and network. We have some amazingly talented folks in our chapter and region. Find and meet them!
 
HFMA National has been shaking things up for our Chapter, our Region (7), and how they measure us as a chapter. One of the most critical pieces for WI HFMA is our Net Promoter Score (NPS). The NPS is a chapter management tool being used to gauge member satisfaction / loyalty to HFMA and the WI Chapter. It serves as an alternative to traditional satisfaction surveys. Basically, it measures the number of promoters vs. detractors, excluding the non-committal in the middle. Our Chapter Success goals and plans revolve around improving our score – improving the way you all view and value WI HFMA. We want everyone to rally around WI HFMA as a community and make it stronger.
 
Please don’t remain on the fence about our Chapter. If we are off the mark, going in the wrong direction, or just aren’t meeting your needs, tell us and help us fix it! If we got something right or have found a new way to exceed your expectations, tell us and others. We want to get to the point where every member will recommend the WI Chapter – be a Promoter - without hesitation.

​Western Wisconsin Health (WW Health) is pleased to announce that Adam Gingery, Chief Financial Officer, joined the team on August 13, 2018.
Adam Gingery has been working in the healthcare industry for over 10 years. Prior to moving to Western Wisconsin Health, he was the Chief Financial Officer at Door County Medical Center in Sturgeon Bay, WI. Adam received his Bachelor of Science degree in Accounting, Business Administration and Computer Information Systems from Northern Michigan University in Marquette, MI. He later received a Master’s of Business Administration with an emphasis in the Value-Driven Organization from Central Michigan University in Mt. Pleasant, MI. Adam has served on numerous boards and is an active member with the Wisconsin Hospital Association and the Rural Wisconsin Health Cooperative. He is also a National Rural Health Association Fellow.

​Intentional Networking – Committee volunteers needed
According to Chapter survey responses, one of the biggest benefits of a HFMA membership is the networking opportunities available throughout the organization.  Because networking is such an important component of membership, the Wisconsin Chapter has decided to make intentional networking experiences a part of the WI Chapter success plan.  The goal is to create more opportunities for members to be engaged in building connections with other members who have a career focus in health care finance.
We want to form a committee so that we can “socialize with a purpose”.   If you would like to become more involved in the WI HFMA Chapter, and like the idea of helping to plan social outings, please send an e-mail to Mark Herder at mark@creditmgt.com.  We will schedule a conference call for those interested in the committee to brainstorm ideas about how we can improve and enhance networking opportunities for our chapter membership.
Wisconsin HFMA is not hosting a Fall Chapter Conference in 2018, so we hope we can instead offer members some type of social outing in September/October for those interested in staying connected.  Think of it as an opportunity to go to a conference without having to sit through all those educational sessions!  If you’re interested in helping out with this new Committee, please let us know.

During the past year, there have been notable changes to capital markets conditions that have impacted financing alternatives for nonprofit health care and senior living organizations. After years of low interest rates, we are finally beginning to see rates rise in a meaningful way. This is because the Federal Reserve has increased the federal funds rate seven times since December of 2015, after effectively lowering the rate to zero in 2008. In addition, recent federal tax law changes have impacted the market for tax-exempt borrowers. Health care and senior living organizations need to be cognizant of current market conditions as well as the recent changes to the financing landscape, as doing so will enable these organizations to adapt and position themselves for success.
Impact of Tax Reform on Health Care FinanceSigned into law on December 22, 2017, the Tax Cuts and Jobs Act lowered corporate tax rates and had two notable impacts on health care and senior living borrowers, particularly those utilizing tax-exempt financing. First, the Act eliminated the ability of organizations to complete an advance refunding of existing tax-exempt debt with new tax-exempt debt. During periods of falling rates (like much of the past decade), many organizations used a tax-exempt advance refunding to lock in savings prior to the existing debt’s optional redemption date. As of January 1, 2018, however, organizations are no longer able to use tax-exempt proceeds to advance refund existing tax-exempt debt. Organizations must now use taxable financing, including taxable bonds, loans, and governmental agency finance like U.S. Department of Housing and Urban Development/Federal Housing Administration (HUD/FHA) and U.S. Department of Agriculture (USDA) programs, in order to advance refund existing debt or wait until the existing debt is currently refundable.
Secondly, during the past decade, many organizations used tax-exempt financing via a private placement, or direct purchase, of bonds by banks and other financial institutions (the “lender”). In some cases, the underlying bond documents linked the interest rate to the lender’s corporate tax rate via a “gross up” provision. Accordingly, the lender is able to increase the bond interest rate if there is a decline in the Internal Revenue Service (IRS)-stated corporate tax rates, so that the lender is able to maintain the same after-tax yield. To illustrate, assume that the initial fixed rate was 4% and that the lender’s corporate tax rate declined from 35% to 21%. Many gross up provisions were written such that the initial fixed rate is multiplied by the result of one minus the new tax rate, divided by one minus the original tax rate [e.g., 4% multiplied by (one minus 0.21) / (one minus 0.35)]. In this scenario, the organization’s interest rate would increase to approximately 4.92% as the result of changes to tax law. Gross up provisions do vary; therefore, organizations should review their bond documents and seek guidance from their bond counsel, financial advisor and/or investment banker as appropriate.
Yield Curve: Now vs. ThenThe most recent tightening cycle began in December 2015 with the latest increase in June 2018. Presently, two more federal funds rate increases are projected for the remainder of 2018, with three more penciled in for 2019.


The Fed’s decisions have considerable impact on the short end of the yield curve. Figure 1 illustrates the difference between the AAA general obligation bond yield curve as of June 28, 2017 and 2018 for bonds maturing between one and 30 years. The yield curve flattened as short-term interest rates increased more than long-term rates. For example, yields on one-year maturities increased by 61 basis points while the 30-year yields increased by only 20 basis points. Accordingly, the slope of the curve, as measured by the difference between the one and 30-year bond yields, is currently 145 basis points versus 186 basis points a year prior.
The upward shift in the AAA yield curve also impacted taxable rates and popular borrowing indices like one-month (1M) LIBOR and the prime rate. Over the past 12-months, 1M LIBOR increased by 89 basis points from 1.22% to 2.09%. As such, organizations with floating-rate debt tied to 1M LIBOR and the prime rate have experienced a noticeable increase in their interest cost. Given the slope and continued pressure on the short end of the yield curve via the Fed’s potential action, organizations may consider evaluating potential fixed-rate financing options to take advantage of long-term rates and eliminate interest rate risk. Additionally, since most variable rate structures are callable at any time, tax law changes prohibiting advance refundings probably do not apply.
Health Care Yields and SpreadsGeneral market health care yields remain favorable when compared to their historical averages dating to the beginning of 2008. As of June 29, 2018, the current 30-year yields for A and BBB health care were 3.58% and 3.90%, respectively. Likewise, the historical average yields for A and BBB health care were approximately 4.6% and 5.2%.


Credit spreads between yields for different credit ratings represent the additional premium investors charge over a benchmark yield. For health care and senior living organizations, the focus is typically on credit spreads between A and BBB health care yields and AAA general obligation yields. Presently, the A and BBB health care spreads are 0.64% and 0.96%. Since 2008, however, the average credit spreads for A and BBB health care credits were 1.07% and 1.65%, respectively (Figure 2).
Accordingly, for the general health care market, long-term rates for investment grade organizations are stable and relatively low. We also continue to realize narrow credit spreads. As a result, accessing long-term, tax-exempt fixed rates continues to offer attractive financing for health care and senior living organizations.
Supply and DemandSupply and demand of tax-exempt bonds also impact market conditions. As discussed above, tax reform pulled significant tax-exempt volumes forward from 2018 into 2017, as organizations raced to beat the changes impacting advance refunding rules. Total issuance (supply) through June 2018 is down nearly 19.5%, which can make new tax-exempt bonds relatively more attractive as investors (demand) have fewer buying opportunities.
Going forward, prudent health care and senior living organizations should keep a close eye on the changing market conditions, as doing so will enable them to modify financing plans and position themselves for a bright future.      Submitted by Lancaster Pollard - Author: Kyle W. Hemminger

Although some details are still pending, HFMA Region 7 information will be available soon.  Use the link here to view the webpage dedicated to everything Region 7 – including schedule of events, session information, lodging and registration (opening soon). 

HFMA Region 7 Conference
September 26-28
South Bend, Indiana

​Organization Name
Aurora Health Care


Tell us a little about yourself?
I have been in the health care field for 20 years. I oversee accounting for hospitals, clinics, research, and foundation. I have recently gone through my first single audit which was challenging but I learned a lot. 
I would say my primary focus outside of the standard job duties is to always look for efficiencies in processes, challenge my staff to do the same, while maintaining internal controls.


What are 3 words to describe your company?
Challenging
Changing
Quality


What does a typical day look like for you?
A typical day consists of constantly changing priorities while managing the day to day tasks. Email seem to multiply constantly and there is never a lack of projects to be done. Often times I find myself working late due to volume of meeting throughout the day that limit my ability to keep up on daily tasks.


What is on your wish list for the next 10 years?
Continue to develop in my field, improve on my delegation skills, be the best leader possible for my staff to encourage their own growth and improve on staff engagement.


If you were stuck on an island what three things would you bring?
My family
My Kindle (of course I would need unlimited power supply and internet to load new books)
Food


Any random facts you could share with us?
I enjoy the quiet of my rural home. 
I have two wonderful sons that are now both in high school and a step son that just completed his masters.
I spend too much time working and not enough time relaxing.




You’re happiest when?
I can sit with a good book and not feel guilty that something else is not getting done.


Why did you join HFMA Wisconsin? 
I would like to meet new people in the industry and have access to resources for professional growth and to assist me in my position.

If you haven’t heard about Enterprise Membership for your organization, you’re missing out!  This new offering from HFMA allows organizations to pay a yearly membership fee for an unlimited number of the organization’s employees to join.  While individual memberships cost $425, Enterprise membership is priced to meet the needs of various organization types.  Fill out the information form here to obtain exact pricing.  There is an Enterprise Membership built to fit the needs of any organization!

Learn more at:  
www.hfma.org/membership/enterprise.html

Coming soon…   the WI Chapter of HFMA, along with all other HFMA chapters across the country will be implementing a new event management software, ‘CVent’.  What will this mean to you?   When registration opens for the Region 7 Fall Conference, as well as all other future HFMA conferences and events, there will be a new look and feel to the communication, registration and post event surveys.  The implementation of CVent nationally will provide for a unified data set that can be used to gather information on member engagement across all levels of HFMA and to set future chapter and national goals.

​​Care Pathways: A Map to Consistent, High-Quality Care
As hospitals and health care systems look for ways to improve patient outcomes while simultaneously cutting costs, one promising opportunity is the use of Care Pathways. Pathways are a workflow document of best practices for patients with specific diseases and conditions, designed to ensure patients receive consistent, high-quality care.
According to Scott Livingstone, chief operating officer (COO) of Tri-City Medical Center, Care Pathways are evidence-based, coordinated care protocols that implement standardized best practices. One notable example of Care Pathways is the Perioperative Surgical Home (PSH)—a model of care developed by leaders within the American Society of Anesthesiologists. Tri-City uses a PSH for colorectal elective surgery cases. The process begins as soon as the surgeon schedules the procedures and continues until 30 days after the patient is discharged.
“This process enables the patient to better withstand the procedure,” said Livingstone. The result is a reduction in the average length of stay (LOS) of one to one-and-a-half days, a decreased infection rate, and a drastic reduction in opioids for pain management after the procedure.
The use of Pathways within hospitals is an extension of the quality and cost-saving initiatives manufacturers began using decades ago, referred to as industrial quality management. The objective is to create standard operating procedures (SOPs), with the primary goals being quality and the efficient use of resources. The health care version of SOPs, Care Pathways, or Clinical Care Paths, were first introduced in the 1980s by Karen Zander and Kathleen Bower at the New England Medical Center.
But are they effective? In a study by Seattle Children’s Hospital (SCH), Pathways were implemented for a range of pediatric conditions with the goal of improving patient outcomes, decreasing costs, and reducing LOS and readmissions. The results revealed that both patient costs and LOS trended downward after Pathways were implemented (Figure 1). Overall, the study found that post-Pathway care was associated with a significant halt in rising costs, and “significantly decreased LOS without negatively impacting patient physical functioning improvement or readmissions.”

Extending Care Across Facilities
Pathways provide the opportunity for synergy across multiple facilities and solidify a consistent approach to patient care. Hospitals are accountable for the patient’s care three days before admission and 30, 60 or 90 days after discharge, whether the patient goes to a skilled nursing facility (SNF) or home with outpatient care.
The cost savings and improved patient outcomes as a result of this synergy can be dramatic. In addition to the results from SCH, The University of Colorado Hospital ED developed over 50 Care Pathways to guide care and use of its resources. The measurable results included:

• Use of high-cost CT scan and MRI scans dropped by 15%
• Avoidable hospital admissions decreased by 20%
• Patients with major heart attacks are in the cardiac catheterization lab in less than 90 minutes 100% of the time
• Total cost of care per patient is down 18%

The Importance of Electronic Health Records
When Pathways were first introduced, few hospitals implemented them because care-givers found it difficult to track progress, share information and capture data on paper. The advent of electronic health records (EHRs) eliminated that barrier, creating the ability to automate practice guidelines with a way to quickly monitor progress through electronic methods. The emergence of EHRs, combined with the increasing arrival of big data in medicine, has cleared the way for the medical community to be more receptive to evidenced-based medicine in general, and Pathways in particular.
Are Care Pathways Compatible With Precision Medicine?
At first glance, these standardized care protocols may appear to contradict the push toward precision medicine (PM), where treatment is individualized based upon the patient’s genetic make-up. Physicians, even within the same hospital, often vary in their treatment approaches for patients with the same diagnosis.
There is currently a shift toward PM which appears, on the surface, to make Pathways look out-of-date. Breakthroughs in next-generation sequencing and bioinformatics are paving the way for physicians to tailor treatments to a patient’s specific genotype. As such, Pathways may seem to limit the physician’s ability to tailor the treatment around the patient’s genetic make-up. Upon closer look, however, there are critical similarities between the procedures and processes of Pathways and PM. Both rely on identifying the variables involved in the treatment of individual patients and combining that with historical evidence to determine which treatment options are more effective than others. Hospitals rely on this information as they take the time to create individual Pathways to help their patients. These same processes of discovery and best practices are used in PM to ensure treatment options are focused to match a specific patient’s gene with the appropriate treatment protocol. In many ways, PM can be viewed as an enhanced version of Pathways.
Creating Pathways With Best Practices
While physicians understand the importance of following best practices, Pathways cannot dictate medical care. Physicians still must make the decision about what is best for the patient, with the flexibility to tailor the plan as necessary.
The key is to use evidence-based, confirmed-care Pathways and algorithms that are fully standardized. To ensure safety, these Pathways should be vetted by a nationwide quality team of medical professionals and experts.
As Pathways are created, hospitals must ensure that compensation is not linked to the protocol. Physicians will, from time to time, have to deviate from the plan in the interest of the patient. When this happens, the provider should not be penalized.
Going forward, the Pathway protocol may extend to care coordination among long-term care facilities, rehabilitation centers and home care. Further, as both providers and payers utilize Pathways, it is essential that they serve as a resource for clinicians, and not be a restriction on the care a patient receives. Hospitals still must see their patients as individuals and adapt the guidelines to meet their needs. The Pathway should provide the foundation and instructions to care.

Our chapter will help with education fees related to obtaining the CHFP designation for members. 
Contact the certification committee for more information.

​

​
By: Frazer Buntin, President, Value Based Services, and Kate Rollins, Vice President, Clinical Programs and Performance, - Evolent Health
​
The new skills required to operate a value-based care business successfully are vast, and the financial return becomes viable only if a provider can go at-risk for enough lives to scale their investment. This reality is a major inhibitor to providers who want to move up the risk continuum and for those who tried and failed. Unfortunately, many value-based care (VBC) initiatives fall at the lower end of a spectrum of accountability, amounting to little more than glorified pay-for-performance tasks that check the box for bonus dollars. This doesn’t drive accountability into the care delivery system in the same way that taking on both upside and downside risk does. To effect lasting change, providers are moving up this continuum of risk-taking through mechanisms that allow them to capture more of their generated savings, but also hold them financially accountable for losses—such as Next Generation ACO or Medicare Advantage for Medicare populations. 
 
Providers making the move toward risk are balancing the in-sourcing of new skillsets with outsourcing to third parties. Those who are seriously committed to VBC as their path forward are looking for partners that can help them rethink and redeploy their clinical model for effective population health, get technology in place to enable clinicians and administrators to operate effectively, and, for the most sophisticated, run the back-office administrative components that are culprit cost drivers, but which providers must own if they want to capture the maximum financial gain from the value they’re creating.
 
The way the industry is evolving, and where providers are innovating in the space, is bridging the clinical, administrative and financial:
 
1.       Clinical:

• CARE TEAM PERFORMANCE: Using a care team to support high-risk patients is not a new concept, but has traditionally been challenging to directly measure impact/ROI. Having a concrete process and key performance indicators for care managers helps providers identify exactly what tasks correlate to improved health outcomes and lower costs. It also helps identify high and low performers so teams can replicate the best practices of the highest performers and deploy skills training for those who need coaching. Getting smarter on how to orient expensive clinical resources and directing that attention where the care team can make the biggest impact is a different construct than yesterday’s disease management programs.

 

• COMMUNITY HEALTH WORKERS: In one program, a provider deployed Community Health Workers as part of an extended care team for Medicaid populations. In a preliminary analysis of the impact on the care team’s workload and productivity, early data suggest that care managers can nearly double their case loads after successful introduction of Community Health Worker support. This could have major implications for how the industry thinks about creating capacity for both doctors and nurses, what roles are needed in the healthcare workforce at large, and the benefits of a community-centric approach to operationalize and deliver care. It also has implications for avoiding physician burnout. The more productive the care team is that supports that primary care practitioner (PCP), the more that PCP can trust that patients are followed and continually engaged outside of the point-of-care office visit. This helps them succeed at population health without taking essential time away from other practice areas, and sets them up for a better relationship with the patient when they’re face-to-face.

 

• CLINICAL PROGRAM INNOVATION: The same provider is also engaged in a partnership with in which some of their partners are piloting new clincial programs for targeted populations. One in particular is a pilot to prevent chronic kidney disease from escalating to end-stage renal disease. What’s interesting about this partnership is that the provider is helping their partners take the best academic models and determine how to operationalize them on the front lines. The provider is working to iterate, test and titrate at the population- and disease-specific level to drive better patient experience and health outcomes. The goal is to refine the approach and then scale it  to the provider’s numerous national partners nationwide.

 
2.       Administrative:

• THIRD-PARTY ADMINISTRATOR (TPA) CAPABILITY: To capture the value that providers can create through clinical impact and savings, they need to be able to administrate claims, run effective utilization management and pharmacy benefits management, and in some cases support member services with call centers and staff. These aren’t traditional areas of expertise for a provider, but helping them take on these administrative services is beneficial.

 

• POWER OF CLAIMS PLUS CLINICAL: One provider successfully integrated its claims administration platform into Identifi℠, its core population health data analytics technology, last year. This means that their partner now has claims processing and data operating on the same scalable platform as their clinical and financial workflow tools. Claims traditionally have months of lagtime before they can be used to help identify patients who may need care management support. With the stratified clinical platform, knowledge about which patients may be high risk for an acute event can be quickly spread across the care contiuum, and lead to accelerated conversations with the patient and her PCP. This helps achieve the ultimate goal of interevening before a medical event occurs.

 
3.       Financial:

• FINANCIAL METRICS ARE DIFFERENT FOR VBC: When providers effectively learn the new clinical and administrative skills they need to be successful in risk, it drives financial performance, as well. Providers benefit from having reporting and analytics on the same infrastructure as their clinical and administrative tools. In the value-based care world, they need to be able to track, report and manage based on contract terms that work differently than fee-for-service.

 

• FINANCIAL PERFORMANCE READINESS: Providers participating in Next Generation ACO are faced with a complex financial situation. They need to monitor performance on clinical outcomes for a specific group of Medicare benficiaries throughout the year to know if they’re on track to achieve savings or not. Knowing the financial trend of the value business early on creates opportunity to change approaches mid-year for a better chance at achieving savings targets. However, to do this effectively, providers need to get started before their performance year begins with CMS. They can deploy tools several months prior to the performance year to start analyzing and assessing the probable risk of their Medicare panel, get people in early for preventive care, and jump start the clinical program design process so that the entire care team can make a difference on day one of the performance year. 

 
KEY TAKEAWAY: Any given provider could pull all of these levers and still not see an ideal return if they’re only doing it for a few thousand patients. Once infrastructure and process is in place and there’s a roadmap for success via a smaller population test case, providers are then ready to place more risk lives under management. How they accomplish this depends uniquely on the dynamics of their local markets, which drives the wide variety of business strategies across the country. For instance, some take their PSHP to new geographies to get more membership; some create alliances with other provider groups to get more patients attributed to a successful ACO; some have immediate scale if they’re granted the opportunity to manage hundreds of thousands of Medicaid beneficiaries. Regardless of which strategy providers choose to naviagte the shift to value-based care, it’s clear that they’re on the right track to serving a common goal of improving health.