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Engage Front-Line Clinicians to Drive Down the Costs of Care

September 7, 2016


The Centers for Medicare and Medicaid Services’ 2018 target date for having 50 percent of all Medicare fee-for-service payments made through a value-based model is not far away. The transition to value requires hospitals, physicians and post-acute care providers to unite in delivering a high quality and cost-effective patient experience. Indeed, providers must do so or suffer penalties.


Quantros Study Finds No Correlation Between CMS Star Ratings and Quality

August 31, 2016


As we reported in an earlier briefing, the Centers for Medicare and Medicaid Services (CMS) published hospital quality star ratings on July 27th, despite pressure from industry stakeholders and Congress to delay their release.


Three Research Studies Indicate Early Discharge Puts Patient Lives at Risk

August 24, 2016


Today hospitals operate under a microscope. Consumerism has motivated healthcare leaders to become more transparent in publically sharing their pricing, quality and performance data. In addition, they must comply with a barrage of new reporting requirements thrust upon them by governmental mandates. These trends along with other operational challenges have forced providers to operate in a financial pressure cooker.


How Hospitals Can Avoid the Risks of Moving to the Cloud

August 17, 2016


Eighty-three percent of healthcare organizations have systems in a cloud environment, and an additional nine percent are in the planning phase, according to a 2014 survey by the Health Information Management Systems Society (HIMSS). Other research shows that 55 percent of hospitals have already migrated mission-critical and sensitive data to a cloud, and that 77 percent plan to move more of their information technology (IT) systems there in 2016.


Improving the Patient Experience Drives Superior Patient Satisfaction

August 10, 2016


Anyone who has followed the healthcare industry over the past few years understands the transition that is underway moving from the traditional fee-for-service (FFS) model of reimbursing providers for delivering care where physicians and organizations are incentivized to do more and provide more services. Under this economic model, a provider can make more money by ordering more tests, see more patients and perform more procedures.


MiraMed Global Services' Subsidiary Company, Plexus Technology Group’s Anesthesia Touch Becomes First Mobile AIMS Solution to Achieve Full KLAS Rating

August 9, 2016


MiraMed Global Services' subsidiary company and trusted Anesthesia Information Management Systems (AIMS) partner, Plexus Technology Group, LLC (Plexus TG), is pleased to announce Anesthesia Touch™ is now a fully-rated AIMS solution as scored by providers and recorded by KLAS research with a score of 891.


Where the Rubber Meets the Road – Correcting Improper Payments

August 3, 2016


Health plans and care providers need to open the lines of communication with each other in ways that they have never done before.  In order to maintain compliance and receive accurate payment from the Centers for Medicare and Medicaid Services (CMS) that reflects the severity of illness, utilization of resources and the increasing number of chronic conditions requires ongoing management of care documentation by providers.  The silos that exist between payers, providers and other enterprises must play ball together, or they will become their own besetting evil.  Frankly, this decision to communicate and collaborate will be the very process that will separate the “Men from the Boys; and the Women from the Girls.”  This article will delve into four areas that affect improper payments and will offer strategies to mitigate them.  They are:


Overall Hospital Quality Star Ratings

July 27, 2016

As part of their continuing efforts to make quality of care information more readily available, the Centers for Medicare & Medicaid Services (CMS) has developed a rating system that reflects comprehensive quality information about the care provided at our nation’s hospitals.  The ratings are intended to convey a hospital's overall quality with a single, composite metric of one to five stars, with five being the best.  The CMS originally planned to publish those ratings on its Hospital Compare website in April but delayed doing so after 60 senators and 225 representatives wrote letters urging it to hold off.  The CMS already publishes hospital star ratings based on patient experience; however, the Overall Hospital Quality Star Rating (Star Rating), which was developed through a public and transparent process, takes 62 existing quality measures already reported on the Hospital Compare website and summarizes them into a unified rating of one to five stars.  The rating includes quality measures for the routine care an individual receives when being treated for heart attacks and pneumonia to quality measures that focus on hospital-acquired infections, such as catheter-associated urinary tract infections.  Key measures included in the Star Rating ask questions such as:


The Hospital’s Role in the Opioid Epidemic

July 20, 2016

According to the U.S. Centers for Disease Control, 44 people die every day in the United States from overdose of prescription painkillers.1 In order to combat the devastating effects of the growing epidemic, the American Hospital Association (AHA) and the Centers for Disease Control (CDC) have joined forces to educate the public about the issue. With the help of various experts from within the healthcare industry, the organizations formed a document entitled, Prescription Opioids: What You Need to Know, detailing the risks and side effects of opioids. In light of this release and the current national focus on opioid prescription use and abuse, it is important to understand what facilities and hospital systems can do to assist in curtailing this rapidly growing epidemic.


Changes Proposed to Medicare Appeals Process

July 13, 2016


Every year, Medicare Administrative Contractors process an estimated 1.2 billion fee-for-service claims on behalf of the Centers for Medicare & Medicaid Services (CMS) for more than 33.9 million Medicare beneficiaries.  When beneficiaries or providers disagree with a coverage or payment decision made by Medicare, they have the right to appeal and the Social Security Act established five levels to the Medicare appeals process:


CMS-HCC Risk Adjustment Auditing—A Necessary Evil

July 6, 2016


The Centers for Medicare and Medicaid Service’s (CMS) Hierarchical Condition Category (HCC) risk adjustment model is used to calculate risk scores, which will adjust capitated payments made for aged and disabled beneficiaries enrolled in Medicare Advantage (MA) and other plans.


Understanding Risk Adjustment and the Hierarchical Condition Categories Methodology

June 30, 2016


Risk Adjustment (RA) and Hierarchical Condition Category (HCC) coding is a payment model mandated by the Balanced Budget Act of 1997 (BBA) and implemented by the Centers for Medicare and Medicaid Services (CMS).  The RA program allows CMS to pay plans for the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries.  By risk adjusting plan payments, CMS is able to make appropriate and accurate payments for enrollees with differences in expected costs.  RA is used to make payments based on the health status and demographic characteristics of an enrollee.  Risk scores measure individual beneficiaries’ relative risk and they are used to adjust payments for each beneficiary’s expected expenditures.  By risk adjusting plan bids, CMS is able to use standardized bids as base payments to plans.


DOJ and NC Attorney General File Antitrust Suit Challenging Anti-Steering Restrictions

June 22, 2016


Healthcare costs in the United States (U.S.) are rising faster than the rate of inflation.  Since 2009, healthcare inflation has outpaced the Consumer Price Index by as much as 3.5 percent in a single year.1  The cost of providing care is skyrocketing.  Providers and payers need to look for ways to reduce costs so our healthcare system can continue to provide quality care.


OIG Views Favorably Arrangements Aimed at Assisting Patients with Financial Obligations

June 15, 2016


The Office of the Inspector General (OIG) has issued a pair of Advisory Opinions that could impact non-profit organizations that want to help patients pay for treatment.  In the Opinions, 15-16 and 15-17, the OIG views favorably non-profit organizations seeking to financially assist patients with their out-of-pocket expenses associated with the prescription drugs required to treat certain diseases.  At a time when all healthcare arrangements are heavily scrutinized by government regulators, the positions the OIG takes in these Advisory Opinions are consistent with previous positions taken by the OIG on such arrangements, though nonetheless welcomed positions allowing organizations to provide patients with the financial assistance they need.


Boomer Healthcare 101

June 8, 2016


By 2030, one in five Americans will be a senior citizen, nearly double the 12 percent in 2000, according to The State of Aging and Health in America, a 2013 special report from the U.S. Centers for Disease Control and Prevention (CDC).  By 2029, when the last round of boomers reaches retirement age, the number of Americans 65 or older will climb to more than 71 million, up from about 41 million in 2011, a 73 percent increase, according to Census Bureau estimates.  Not only are there more seniors, they’re also living longer.  In the past century, life expectancy has increased by nearly 30 years.


Patients’ Ability to Shop for Services Has a Modest Effect on Healthcare Spending

June 1, 2016


If patients know the prices that various providers of healthcare services will charge, they will shop for the best value and in the process drive prices down.  That assumption underlies the numerous governmental and health system efforts to deliver price transparency seen over the last few years.  Is the assumption valid?


Buy Versus Build or Both?

May 25, 2016

Lately, technology security has taken center stage as health organizations face increased challenges of maintaining the security of patient health information.  While securing data is of concern, determining the most applicable and cost-efficient technology is the most important priority.


Addressing Hospital Readmissions with Diverse Patient Populations

The Centers for Medicare and Medicaid Services (CMS) recently released guidance to assist hospitals in decreasing the number of avoidable readmissions among racially and ethnically diverse Medicare beneficiaries.


HIPAA Audit Program—Phase 2

May 11, 2016


The Health Information Technology for Economic and Clinical Health Act (HITECH) requires the HHS Office for Civil Rights (OCR) to conduct periodic audits of covered entity and business associate compliance with the HIPAA Privacy, Security and Breach Notification Rules. In 2011 and 2012, OCR implemented a pilot audit program (Phase 1) to assess the controls and processes implemented by 115 covered entities to comply with HIPAA’s requirements.


MACRA and the Medicare Payment Reform Juggernaut

April 27, 2016

More Changes Coming to Healthcare Delivery


Healthcare Price Variation is Alive and Well

May 4, 2016


It is no secret that the cost of healthcare services varies greatly between geographic regions.  A major new study from the Health Care Cost Institute (HCCI),  National Chartbook of Health Care Prices, examined price variation for 242 common medical services across 41 states and the District of Columbia and found a two- to threefold difference.  The graph below, from the accompanying article by David Newman et al. (Prices for Common Medical Services Vary Substantially among the Commercially Insured) in the April 2016 issue of Health Affairs, shows the variation among average prices in the 41 states and D.C. when each is compared to a national index figure of 1.00:


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