Category Archives: Insurance

5 Big Myths about Clinical Transformation

5 Big Myths about Clinical Transformation

The seismic shift from volume to value that is currently spreading through the American health care landscape means big changes for care providers. And, as in any time of transition, while many people and institutions are feeling positive about these much-needed changes, there is also confusion, uncertainty, and many myths and misconceptions about what the new face of care will look like and how providers will make that vision a reality. A recent article from GE Healthcare Camden Group unpacks the facts behind some of the most common myths about the transforming world of health care and the keys to success in a value-based system. Read on to learn more.

Myth #1: All providers should be switching to value-based payment contracts.

Reality: Value-based payments, like bundled payments, can certainly be an important driver of clinical transformation, but that doesn’t mean that every organization needs to make the switch to value-based payments at the same time or the same pace. Organizations need to be aware of both the pace of their particular market and their own capabilities in deciding when and how to transition their payment models.

For some, the shift may have to be rapid if the market has adopted value-based payments on a widespread scale. But for others, who may still be maintaining success in a fee-for-service environment, taking the time to conduct a thorough analysis of clinical outcomes and cost of care is an important step in preparing for a more gradual transition.

Myth #2: IT systems interoperability results in clinical integration.

Reality: The lack of interoperability among different health IT systems is frequently cited as the number-one barrier to clinical integration (with clinical integration being necessary in a value-based care landscape in order to better allow different providers to coordinate efforts along the continuum of care and thus achieve desired health outcomes). But it’s important for organizations to understand that, while IT interoperability is a critical piece of clinical integration, it is not in and of itself the entire puzzle.

True clinical integration is the aligned vision, among all care team members, for improving health outcomes, and while IT systems enable this—through tools like evidence-based clinical pathways and historical and predictive data analytics—they do not cause it. In other words, interoperability is a means to an end, not the end itself.

Myth #3: Electronic medical records facilitate physicians’ work and ensure better patient care.

Reality: Just like the interoperability of IT systems, electronic medical records (EMRs) are merely a means to an end. There’s no question that advances in health care IT, including the development of EMRs, help provide the care team with a wealth of detailed knowledge about each individual patient—knowledge that does indeed facilitate the provision of high-quality, patient-centered care. However, the most important factor that has enhanced patient care is the creation of streamlined care processes and workflows that turn the information contained in EMRs into clear care protocols and actionable reports. Without such processes in place, the pure data contained in EMRs lacks clear meaning; in fact, too much unintegrated data can actually frustrate the efforts of physicians and lead to less coordinated delivery of services across care settings.

Myth #4: Clinical integration leads to mass layoffs of staff.

Reality: For many organizations, the idea of streamlined, integrated care conjures up the specter of mass layoffs. After all, if moving from volume- to value-based care is all about cutting out unnecessary and redundant services, then surely workforce reductions are an inevitable consequence? The reality, however, is more complex than this.

Reducing overall cost of care is certainly one of the three central tenets of value-based care, but the other two are improving health outcomes and improving the patient experience—components that a reduction in staff typically does little to help achieve. Instead, organizations should be ready to focus on staff redeployment rather than reduction. A clear assessment and redesign of clinical protocols can be very helpful in informing medical management staffing and in ensuring that staff are working to the top of their abilities and providing the right care at the right time to the right patients.

Myth #5: Higher patient satisfaction is the same as an improved patient experience.

Reality: Patient satisfaction is a complicated issue that, unfortunately, tends to get conflated with the “overall patient experience” in this new landscape of patient-centered care. However, the two concepts are not precisely the same, and care providers need to remember that.

For example, patients tend to rank their satisfaction with a care experience based primarily on factors like whether they received treatment in a timely manner and whether they got better as a result. However, patients typically do not take into account factors that are critical from a provider’s perspective, such as the cost and the appropriateness of the care that was provided.

Indeed, a recent prominent study revealed that those patients who reported the highest levels of satisfaction with their physicians also had higher care and prescription costs and were more likely to be hospitalized than patients reporting lower levels of satisfaction. Clearly, more research into this issue is required before care providers begin transforming their care models to cater to patient “satisfaction.”

What You Need to Know About Value-Based Care – 5 FAQs

What You Need to Know About Value-Based Care – 5 FAQs

According to most industry experts, our health care system’s move from volume to value is an inevitable transition. It’s happening slowly, but surely and irrevocably. In spite of this assessment, however, many organizations and individuals – from hospitals to insurance providers to patients – are still struggling to understand what value-based care really means, and…

What You Need to Know About Stop-Loss Insurance

What You Need to Know About Stop-Loss Insurance

With more employers opting for self-insurance over fully-funded health plans, the question of how to choose appropriate stop-loss insurance has become critically important. Designed to protect self-insured employers against sudden, catastrophic claims that could lead to unsupportable financial loss, stop-loss insurance is a necessity for most employers. However, deciphering the details of different stop-loss plans…

Why Are Payors and Providers Better Together?

Why Are Payors and Providers Better Together?

Given their rapid rise in popularity in recent years, payor-provider partnerships seem set to become one of the next big trends in the health care industry. In 2016, new product launches were announced at a steady pace, and the market also saw a much stronger focus on deeper, long-term collaborative partnerships with a high prevalence…

What Is Value-Based Insurance Design All About?

What Is Value-Based Insurance Design All About?

Value-based insurance design is becoming an increasingly popular approach with both public and private payors seeking to improve service quality and lower care costs. Read on for a helpful guide to the basics of this innovative insurance strategy. What exactly is value-based insurance design? Value-based insurance design (VBID) is a strategic approach to structuring health…

10 Important Benefits of Clinical Integration

10 Important Benefits of Clinical Integration

Clinical integration is becoming a top priority for all kinds of health care providers and entities as our health care system gradually shifts from a traditional fee-for-service model to the continuum of care framework, which focuses on coordinating care efforts across a range of services to provide better-quality, higher-value care to patients. Widely described by…

What You Need to Know before Your Company Chooses Self-Insurance

What You Need to Know before Your Company Chooses Self-Insurance

Self-insurance rates are surging as more and more companies decide that the benefits of a self-funded health plan outweigh the potential risks and disadvantages. But despite its growing popularity, self-insurance isn’t always the right choice for every company. If your business is thinking of moving to a self-funded health plan, here are some important points…

What Can ASCs Expect in the Year Ahead?

What Can ASCs Expect in the Year Ahead?

Given their rapidly evolving role in America’s ailing health care system, ambulatory surgery centers (ASCs) are facing a constantly changing array of challenges and opportunities. As a new year approaches, a recent article in Becker’s ASC Review outlines some predictions from leading industry experts as to what 2017 could have in store for the ASC…

Spotlight on Bundled Payments – A Look at the UCLA KTB

Spotlight on Bundled Payments – A Look at the UCLA KTB

The experiments with different payment models that have taken place over the last several years as part of the Bundled Payments for Care Improvement program, an initiative of the Centers for Medicare and Medicaid Services, have brought attention to the many potential benefits of bundled payments. Instead of receiving separate payments for each individual service…

A Look at the Debate over High-Deductible Health Plans

A Look at the Debate over High-Deductible Health Plans

With health care costs currently comprising 17 percent of America’s total GDP, there’s no question that action must be taken to slow the spiraling growth of health care spending. Over the past 25 years, a combination of factors—including technology, systemic inefficiencies, insurance coverage rates, and a changing population health status—has pushed costs up to their…