What You Should Know:

– A glimmer of hope shines through for hospitals, according to November data from Kaufman Hall’s National Hospital Flash Report points to ongoing stabilization and even growth.

– While the scars of the pandemic and economic challenges remain, key indicators suggest gradual recovery, with operating margins edging up and revenue streams climbing.

Margins on the Rise, Though Gap Between Performers Persists

The median calendar year-to-date operating margin index for hospitals in November 2023 reached 2.0%, marking a welcome improvement compared to the previous year. Inpatient and outpatient revenue experienced positive growth, rising 5% and 9% respectively. This trend is further bolstered by a decline in total expense per adjusted discharge and a simultaneous increase in revenue per adjusted discharge – both signs of financial progress.

Patient Acuity Normalizes, Value-Based Care Takes Center Stage

The average length of stay in hospitals dropped 6% year-over-year, indicating a return to more typical patient acuity levels. This shift presents significant opportunities for healthcare organizations embracing value-based and bundled payment models, as they can transition patients to the most appropriate care settings while optimizing financial performance.

Embracing Strategic Growth: The Key to Sustainable Success

“Hospitals should leverage this period of relative stability to re-ignite strategic growth initiatives if they aim to thrive in 2024 and beyond,” emphasizes Erik Swanson, senior vice president of Data and Analytics at Kaufman Hall. “Growth strategies will differ based on individual needs and market realities, but all leaders must prioritize goals beyond just profitability and scale. Business model transformation and diversification are equally essential for long-term success.”

Actionable Insights for Hospital Leaders in 2024

Now is the time for hospitals to re-embrace strategic growth to succeed in 2024 and beyond. Kaufman Hall outlines the following 4 key action steps for hospitals:

• Cutbacks won’t cut it: Rethink the “cut our way to viability” approach and shift focus towards strategic growth and reinvestment.
• Growth requires dedication: Achieving meaningful growth demands discipline, perseverance, and adaptability.
• Identify your growth vectors: Explore relevant options like market expansion, essentialization of services, and competitive repositioning.
• Ask the crucial questions: Evaluate your market size, market essentiality, and competitive position to craft an effective growth strategy.

The path to a brighter future for hospitals lies in actively pursuing strategic growth. By leveraging emerging opportunities and focusing on long-term goals beyond just financial metrics, healthcare organizations can pave the way for sustainable success in the evolving healthcare landscape.

The value-based care market is projected to grow to $174 billion by 2032, according to a MarketResearch.biz report released recently. As the march to VBC accelerates, there are operational, financial, data complexity/accessibility, and technology-related challenges that need to be overcome to implement value-based programs and to scale them for mass adoption.

Existing medical data is not fully exploited for analytics and risk score computation because of three main reasons:

1. Unstructured data – this requires multi-model processing with a combination of AI/ML plus amalgamation with the structured and semi-structured data sets.
2. Data gaps – many times, there are missing datasets that prevent creation of a good quantitative model.
3. It sits in data silos, and privacy concerns restrict access to this data.

The No. 1 issue mentioned above can be addressed using NLP and ML algorithms that digitize, plus train and process, data in conjunction with the data in the enterprise systems for an entity.  We can then share permissioned data with the granularity (full record or only sub-set attributes) between participants in a permissioned manner. 

The second issue can be addressed using Generative AI by creating synthetic datasets. Synthetic data is generated by using algorithms to create data that mimics real-world data, but with variations that allow for more extensive testing and analysis. 

The third issue (keeping the data privacy and security issues in mind) can be solved by replicating only the pertinent data. In addition, this issue also can benefit from a Federated Learning (FL) approach to machine learning.  FL enables gaining insights in a collaborative manner using a form of a consensus model, without moving patient data beyond the firewalls of the institutions in which they reside. Instead, the ML processes occur locally at each participating institution and only model characteristics like the parameters, gradients, etc., are transferred to participating entities.  Instead of gathering data on a single server in a centralized fashion, the data remains locked on their individual Enterprise infrastructures and the algorithms and only the predictive models travel between the servers of the participating entities – never the data.

When it comes to VBC, Gen AI can be utilized in a few critical areas:

• Intelligent contract builder process(es). The VBC contract process today is very time-consuming and manual to develop, review, and put into action. Gen AI processes can help streamline this approach.

Using past contracts against which we can build and run large language models (LLMs), Gen AI can generate new contract based on past patterns. Individual components of these contracts, such as different variables and their values, pricing information, attributes of different clauses, expiry dates, etc., can be extracted out of complex and lengthy contracts within seconds and presented to the user with a simple-to-use workflow in which users can finalize the contract within days.  

• Improvements in care management process(es). Care management strategies for patients center around the effective use of data, processes, and systems by a team usually comprised of physicians, nurses, CBOs (community-based organizations), care managers, and social workers. The basic concept is to have timely interventions for patients to reduce health risks and decrease the total cost of care.

Personalized care plans for patients broadly fall under four steps:

1. Population stratification, using risk-stratification methods
2. Alignment of care management services to the needs of the patient (i.e., created while interacting with the patient in a personalized manner to ensure buy-in into the plan)
3. Preparation of care plan and device monitoring for the patient for proactive care
4. Association of appropriate personnel to establish care plan team for execution, follow-ups, etc.

Gen AI isn’t needed for patient risk stratification, which can be achieved using simple data analytics, post-any data digitization (if needed for unstructured datasets), using a patient Longitudinal Health Record (LHR). The challenge starts with contacting and engaging the patient.  The communication protocols (emails, phone calls, SMS/MMS messages, snail mail) require persistent efforts to yield results. 

Gen AI can help personalize outgoing communication (conversational AI) based on past patient interactions, including any language translation preferences and level of education of the individual to keep the communication simple to understand. 

Once the patient has been engaged, a care team can prepare the care plan and put the device monitoring/data collection protocols in place. Non-clinical and administrative steps like medication reminders, scheduling appointments on time, scheduling check-ins for a telehealth conversation, creation of alerts and notifications when things do not go as planned, Rx refills, and prompting for daily exercise under the care plan – all can be personalized and automated using Gen AI.  

For the Internet of Medical Things (IoMT), Gen AI could help companies create more personalized and patient-centered devices – incorporating software that allows for preventive maintenance and repairs. 

The last part would be to help the care team navigate the complexity of the healthcare system – different workflows, assignment of the appropriate personnel based on their availability and expertise, and providing insights to the care team about patients who are not yet that sick but could be if meaningful interventions don’t happen on time.

Other Gen AI Successes

A good number of use cases are being worked on using Gen AI. Some are in research/concept stages, while a few are being deployed into production pilots, including automation of administrative tasks, prevention of costly medical errors, medical education, and clinical decision support. 

For VBC specifically, building solid VBC contract processes and improving care management workflows are just two of the ways the technology already is impacting the acceleration of new value-based payment models. 

About Rahul Sharma 

Rahul Sharma is the chief executive officer of HSBlox, an Atlanta-based technology company empowering healthcare organizations with the tools and support to deliver value-based care (VBC) successfully and sustainably.

Data has become the lifeblood of healthcare, making it possible to gain granular insights that enable more effective and precise patient-centric care. Yet, we have just scratched the surface of data analytics’ potential impact on optimizing segments of healthcare that need it most, such as the surging arena of consumer health. 

Of the four key types of data analytics – descriptive, diagnostic, predictive, and prescriptive – only the first two are effectively used in managing healthcare costs and member healthcare delivery. These two capabilities inform stakeholders about what has happened and why it happened. What might happen in the future, and determining the best course of action to take is often hard to assess at scale. Enter predictive and prescriptive analytics, which employ machine learning to analyze billions of possible scenarios and identify the optimal next step. Stakeholders today face an overwhelming amount of information to base decisions off of, but predictive and prescriptive analytics eliminate choice overload and prescribe the most impactful way forward.

Leveraging AI models to manage plan costs, identify potential emerging risks and high-cost claimants requires a proactive approach that focuses on prevention, early intervention, and the efficient allocation of resources to properly address the health needs of a population. In this context, predictive and prescriptive analytics – known as advanced analytics — play a pivotal role in overcoming the ever-growing challenges of managing healthcare spending and cost containment. By identifying high-risk populations, tailoring care plans, offering predictive modeling, optimizing resource allocation, and enabling continuous improvement, it empowers healthcare stakeholders and organizations to make data-driven decisions that result in better patient outcomes and a healthier community. 

Using Advanced Analytics with Risk Modeling  

Risk modeling is a crucial component of public health initiatives, helping policymakers and healthcare professionals better understand and address the health challenges facing communities. Traditionally, these models have relied on descriptive data and statistical analysis to identify health risks and historical trends. However, the integration of predictive and prescriptive insights into these models can significantly improve their effectiveness in mitigating health risks, particularly for the most vulnerable.

Advanced analytics leverages historical and real-time data to identify individuals or communities at high risk for specific health conditions or diseases. By analyzing various data sources, including claims history, demographics, and social determinants of health, advanced analytics can pinpoint actual high-cost claimants and emerging-risk individuals who are most likely to develop certain health issues. This enables healthcare stakeholders to implement recommended targeted interventions, such as early screenings and preventive measures, for these high-risk populations.

This advanced form of risk modeling will be especially important as the burden of chronic disease and an increasingly aging population intensifies over the next decade and beyond. By 2030, one out of every five Americans will be 65 or older. Additionally, an increasing number of people are living with one or more chronic conditions. These converging forces will put additional pressure on an already strained healthcare system and exacerbate continuously rising costs. However, the industry can begin to shift away from reactionary methods and towards a proactive approach with prescriptive insights.

These benefits can be broadly applied across patient populations and areas of care where patients are most vulnerable to adverse outcomes, such as obesity or heart disease, to improve the understanding of care needs and prevent expensive emergent care. With advanced analytics, healthcare stakeholders obtain real-time feedback and performance metrics. By constantly analyzing the effectiveness of interventions and care plans, it enables healthcare stakeholders to make ongoing improvements to population health management strategies. This dynamic process allows for the continuous enhancement of care and the adaptation to changing healthcare needs.

 Advanced Analytics in Value-Based Care  

A key aspect of value-based care is tailoring care plans to individual needs. Predictive and prescriptive analytics can create personalized care plans for individuals based on their health history, preferences, and risk factors. This individualized approach to care improves patient engagement and adherence to treatment regimens. For instance, it can recommend appropriate treatment options, medications, and lifestyle modifications tailored to a patient’s specific needs. In consumer health, this tailored approach results in better health outcomes and reduced healthcare costs, as it minimizes trial-and-error treatment and hospital readmissions.

To understand the value of applying advanced analytics in this context, consider how employers traditionally approach benefit planning. Benefit plan design is typically centered on the expertise of decision-makers. Given the complexity of these products and possible combinations, plan designers resort to last year’s choices to inform the next designs iteratively. Employers also often offer additional wellness and preventive benefits to their plans, but the extent of these benefits can be cut short or limited due to budgetary considerations. Prescriptive analytics can provide recommendations that enable employers to optimally tailor the benefits portfolio to a specific subgroup of employees who may have different needs, rather than relying on a one-size-fits-all approach to provide the best health outcomes. 

For example, members with musculoskeletal problems will be distinguished from those who require dietary support, and prescriptive methods would help employers best address those needs while maintaining budgets. Moreover, prescriptive analytics leverage past performance data to recommend the set of providers who would optimally improve health outcomes.

Healthcare organizations and members should look towards data science companies and payors who can combine an Area Under the Curve (AUC) methodology with large amounts of claims data to utilize historical data to accurately make predictions and provide patients and providers with actionable insights, mitigating risks and improving outcomes overall. 

Advanced analytics can revolutionize the consumer health experience. When deployed more broadly, this technology will be instrumental in moving the needle toward proactively minimizing disparities and optimizing outcomes for all communities.

About Sean Crandell

Sean Crandell is SVP of Healthcare Economics at MultiPlan, overseeing the company’s Healthcare Economics team and is responsible for strategic analytic advisory regarding the delivery and design of healthcare services to our clients, provider partners, and MultiPlan stakeholders.

What You Should Know:

– Arbital Health, a rising star in the value-based care space, announced a significant double play today, acquiring leading actuarial firm Santa Barbara Actuaries and securing $10 million in Series A funding led by Transformation Capital.

– This strategic move positions Arbital Health as a major player in accelerating the healthcare industry’s transition to a more outcome-driven model.

Building the Infrastructure for Value-Based Care

Founded in November 2023 by healthcare veterans Travis May and Brian Overstreet, Arbital Health is building technology to facilitate outcome-based contracts, a cornerstone of value-based care. By serving as a neutral third-party adjudicator, the company ensures fair assessments of contract fulfillment, fostering trust and collaboration across the healthcare ecosystem.

Fueling Growth and Impact

Transformation Capital’s $10M investment, joined by other prominent healthcare investors, underscores the immense potential Arbital Health holds. “We believe Arbital Health has the right team, technology, and vision to revolutionize how healthcare value is measured and rewarded,” stated Scott Rosen, Partner at Transformation Capital.

Arbital’s Initial Product Offerings

Arbital Health’s initial product offerings cater to diverse needs within the healthcare ecosystem:

Value Assessment for Point Solution Vendors: Quantify the economic value of healthcare interventions and optimize ROI through predictive analytics.

Value Analysis for Payers: Understand the true value employees and members are getting from deployed point solutions.

Actuarial Advisory: Leverage SBA’s expertise for a broad range of consulting services for risk-bearing organizations.

The acquisition of SBA brings a best-in-class actuarial team and established clientele to Arbital Health. “SBA’s expertise strengthens our mission to become the go-to utility for outcome-based contracts,” declared Brian Overstreet, CEO of Arbital Health. “Together, we’ll deliver unparalleled solutions for all stakeholders in the value-based care landscape.”

What You Should Know:

– Credo Health, a game-changer in value-based care technology, has secured $5.25M in Series Seed funding, led by FCA Venture Partners with strong participation from existing investors Hannah Grey VC, FirstMile Ventures, and SpringTime Ventures. This significant investment fuels Credo’s mission to become the definitive platform for value-based care providers, empowering them to thrive in the evolving healthcare landscape.

Bridging the Data Gap

Credo Health’s core platform, PreDx, stands out by uniquely combining both digital and manual medical record retrieval with cutting-edge AI analysis and human expertise. This powerful combination ensures providers have the complete clinical picture of every patient, eliminating information silos and fostering informed decision-making.

PreDx delivers

• Comprehensive Risk Adjustment: Accurately predict patient needs and optimize reimbursement.
• Enhanced Quality Measures: Achieve top HEDIS scores and drive better healthcare outcomes.
• Personalized Care: Tailor treatment plans to individual patient needs for improved satisfaction.

This funding will enable Credo to strengthen its technological infrastructure and enhance PreDx capabilities and explore new frontiers in AI-powered healthcare.

Credo Founder and CEO, Carm Huntress, is ecstatic about the growth: “This funding validates our commitment to providing value-based care providers with the technology they need to excel. Since launching PreDx at the Vive Conference just nine months ago, we’ve witnessed its transformative impact on organizations, and this investment fuels our expansion to empower even more providers.”

What You Should Know:

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

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

MHN’s Team-Based Care Model Drives Results

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

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

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

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

Significance for FQHCs

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

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

What You Should Know:

– Guidehealth, an AI-powered healthcare platform announced the acquisition of an industry-acclaimed managed services organization (MSO) and Value-Based Care Services division from Arcadia, a healthcare technology leader known for its powerful data platform.

– Additionally, Guidehealth secured a technology agreement to leverage Arcadia’s advanced analytics platform, further fueling its newly acquired offering.

Acquisition Impact

This acquisition and partnership signal Guidehealth’s commitment to empowering health systems and clinical networks in navigating the complex landscape of value-based care. Their existing platform already plays a crucial role in supporting physicians, with key features like:

– Strengthening network relationships: Fostering deeper connections between physicians and affiliated networks.

– Boosting financial performance: Optimizing value-based risk contracts for improved financial returns.

– Enhancing referral growth: Facilitating growth in high-value referrals for more efficient care delivery.

– Reducing administrative burden: Streamlining workflows to free up physicians’ time for patient care.

The acquired MSO brings additional expertise in managing critical aspects of value-based care, including:

• Streamlined visit access and referrals: Ensuring patients get timely access to necessary healthcare services.
• Efficient authorization and utilization management: Simplifying prior authorization processes and managing resource utilization effectively.
• Network administration and claims payment: Providing seamless network administration and prompt claims payment, particularly in two-sided risk arrangements.

“Arcadia is proud to have built a legacy of enhancing healthcare organizations’ abilities to improve clinical and financial outcomes,” said Arcadia President and Chief Executive Officer, Michael Meucci. “Partnering with Guidehealth will allow us to continue helping our customers succeed in value-based care and population health, while also empowering us to focus on our core business of providing a leading data platform for healthcare and further invest in our products that enable more complete and transparent decision making, ultimately leading to happier and healthier days for all.”

These capabilities address a major pain point for many health system networks. Current processes are often cumbersome and inefficient, hindering timely access to care and impacting overall quality. This is precisely where Guidehealth’s solutions come in, addressing a challenge that lies at the core of their mission.

While the terms of the deal remain undisclosed, it’s clear that Guidehealth is making a strategic play to become a dominant force in the value-based care arena. Their combined offering of AI-powered platform, MSO expertise, and advanced data analytics positions them to significantly improve care delivery and financial performance for health systems and ultimately, deliver better outcomes for patients.

What You Should Know:

– KAID Health, the AI-powered healthcare solutions pioneer, has secured a significant $9 million in funding led by Activate Venture Partners, Martinson Ventures, Boston Millennia Partners, and Brandon Hull, alongside KAID Health’s Board of Directors.

– With this new funding, KAID Health plans to expand its reach to more providers and their payer partners and develop new service offerings.

Unlocking the Power of Whole Chart Analysis

KAID Health’s flagship platform, Whole Chart Analysis, leverages cutting-edge natural language processing (NLP) to unlock the true potential of electronic medical records (EMRs). Unlike traditional NLP solutions that focus on specific data points, KAID Health goes beyond, analyzing every available piece of information within a patient’s chart, including notes, conditions, medications, and lab results. This comprehensive approach enables:

• Improved coding accuracy and capture: KAID Health demonstrably boosts coding accuracy, ensuring providers receive proper financial compensation while improving data-driven decision-making.
• Streamlined quality reporting: Effortlessly fulfilling complex quality reporting requirements, freeing up valuable time for clinicians.
• Enhanced care management: KAID Health identifies key patient needs, facilitating proactive care interventions and optimizing clinical outcomes.

Real-World Impact, Proven Results

KAID Health’s impact extends beyond theoretical promises. To date, the platform has already:

• Revolutionized Medicare Advantage coding for large provider groups nationwide.
• Simplified chart review for prior authorization and clinical trial enrollment.
• Outperformed physicians in identifying surgical risks at a major medical center.

“KAID Health continues to deploy technology that makes clinicians more efficient, translates that efficiency into more cost-effective care, and grows revenues,” explained Kevin Agatstein, CEO of KAID Health. “By combining best-in-class, scalable, flexible, secure technology with deep clinical workflow and market expertise, we can partner with each customer to meet their informatics needs while alleviating chronic staff shortages.”

What You Should Know:

– MedeAnalytics and HSBlox have announced a strategic partnership to offer healthcare organizations a comprehensive end-to-end value-based care solution.

– This collaboration combines MedeAnalytics’s best-in-class analytics platform with HSBlox’s technology platform for contract management and administration.

Maximizing Value-Based Care Performance

Integrating HSBlox into the MedeAnalytics ecosystem ensures coordinated and aligned activities supporting value-based care transformation. Maximizes performance and provides better patient outcomes at a lower cost of care delivery. The combined solution offers scalability and flexibility to meet the nuanced needs of various stakeholders, supporting providers, managed care organizations, commercial payers, and brokers.

“This partnership is powerful. The MedeAnalytics customer base represents the broadest reach of value-based care stakeholders in the industry and this combined solution will provide a level of support unmatched in the industry,” said Rahul Sharma, CEO of HSBlox.

What You Should Know:

– Arcadia (arcadia.io), a data platform for healthcare, today announced a partnership with WellSpan Health to improve the Pennsylvania health system’s performance in Medicare’s Shared Savings Program.

– This strategic partnership aims to leverage Arcadia’s data analytics platform to connect WellSpan Health’s 220 patient care locations and provide actionable insights that support the healthcare network’s value-based care journey.

Improving WellSpan Health’s Value-Based Care Performance

Benefits of the partnership for WellSpan Health include:

– Connect, normalize, and distribute data: Arcadia’s platform will integrate data from WellSpan’s 2,600 physicians and multiple EHR instances, providing a comprehensive view of patient data.

– Enhanced value-based care analytics: The platform will improve the accuracy and completeness of analytics across various contract types, including Medicare Advantage, commercial, and self-funded employer plans.

– Identify and close risk and quality gaps: Arcadia’s insights will help WellSpan identify and address gaps in care for its nearly 240,000 value-based patients.

– Improve care coordination: Risk stratification and modeling will enable WellSpan to improve the efficiency and effectiveness of care coordination.

– Manage referrals: Optimize quality while reducing unnecessary utilization and cost through better referral management.

“By leveraging data-driven insights and actions, healthcare organizations can meaningfully optimize performance in value-based care,” said Michael Meucci, President and CEO at Arcadia. “We’re thrilled to welcome WellSpan Health to our community of high performers who continue to lead the way in improving clinical and financial outcomes.”

What You Should Know:

– Anthem Blue Cross and Blue Shield in Virginia and Aledade, the nation’s largest network of independent primary care, today announced an expansion of their collaboration to provide more Virginians with access to high-quality primary care.

– The expanded strategic partnership will impact more than 80 practices, 15 health centers, and 25 rural health clinics across Virginia and covers Medicare Advantage, commercially insured, or Medicaid members.

– Aledade is particularly focused on bringing the benefits of value-based care to underserved communities and those receiving care through community health centers (CHCs). The company currently serves as a partner to 15 of Virginia’s 26 CHCs and supports the care of more than 90% of Anthem’s CHC members in Virginia.

Improved Outcomes for Diabetes and Breast Cancer Screening

Anthem and Aledade’s collaboration has already demonstrated positive results. In 2022, primary care practices and CHCs working with the two organizations improved their rates of hemoglobin A1c testing by 10% for patients with diabetes, reaching 9 out of every 10 eligible patients. They also achieved high levels of kidney health evaluation for patients with diabetes. Additionally, practices working with Anthem and Aledade ensured that 3 out of every 4 patients eligible for breast cancer screening received a mammogram.

Shared Savings and Reinvestment in Care Delivery

Shared savings generated through value-based care provide valuable revenue that can be reinvested in care delivery. In Virginia, this high-quality care led to substantial savings among Anthem’s commercially-insured patients, bringing more than $2M in shared savings payments back into community primary care.

“Putting our members and consumers at the center of what we do is our priority through partnerships with innovative companies like Aledade,” said Mark Schneider, Regional Vice President Medicare Market Performance. “Together, we can address the health of people and our healthcare system in the right way, improving health outcomes and lowering costs.”

The transformation of the healthcare landscape is undeniable. With the industry moving toward value-based care, the emphasis has shifted from volume of services to the actual value or outcome of care delivered. And while value-based care holds providers more accountable for results, it also grants resources and time to provide better, more patient-centric care. 

But even years into the shift, there remains no comprehensive guidebook for success. While providers are rewarded for higher quality care, determining how to get there is left to hospital leaders. But no matter what, a shift to value-based care means realigning every aspect of care and operations to serve the needs of the patient. 

When patients are actively involved in their own plan of care, they are better equipped to manage their health conditions, adhere to prescribed treatments, and reduce unnecessary healthcare utilization. However, achieving this level of involvement requires more than just surface-level interactions. It calls for a concerted, strategic effort to prioritize patient engagement in a way that genuinely prioritizes the patient’s needs and perspectives.

One thing remains clear: Without workflow efficiencies and enhanced communications, it will be an uphill battle. So what are the elements of an engagement strategy that’s built from the ground up to deliver on the promise of value-based care across the entire health continuum?

Pre-care patient empowerment

Patient engagement starts well before an actual care interaction. From the first contact, empowering patients with the right tools and information before they even enter a healthcare facility is an essential component of delivering value-based care.

Pre-care self-service capabilities are integral, granting patients agency over and access to their care journey and information. Giving patients the ability to access medical information, schedule appointments, or even consult with their healthcare providers through telehealth services is about more than just convenience—it’s about giving patients a greater degree of control over their own care.

When patients feel in charge, they are more likely to be proactive about their health, ask questions, seek clarity, and adhere to prescribed care regimens. They move from being passive recipients of care to active partners in their health journey.

Point-of-care active listening and action

An effective point-of-care rounding program that’s standardized and digitized gives health systems the opportunity to accurately understand in-the-moment issues and act on them. Both nurse-led and self-service digital rounding programs ease bandwidth issues for nurses and nursing leaders. Equally important, consistent rounding gives patients the opportunity to share positive feedback about their care team, voice concerns, ask questions, and feel heard, leading to a better overall hospital experience and higher patient satisfaction metrics, including HCAHPS. 

Rounding provides a consistent feedback loop. Real-time feedback from patients allows for timely service recovery and informs larger systemic changes, ensuring that the care provided is always evolving and improving. By regularly assessing patient needs, providers can ensure that resources—including staff members—are used efficiently and effectively toward patient-centered care. 

Post-discharge outreach and education

After a patient leaves the hospital, their journey to recovery isn’t over. In fact, in many cases, it’s just the beginning of the next phase. This transition is critical. Unfortunately, many patients, despite receiving quality in-patient care, often feel lost or unsupported after discharge.

Effective discharge management begins before the patient leaves the hospital through discharge readiness rounds that educate the patient on what they might expect after leaving the hospital. After discharge, by automating outreach in the medium most appropriate for each patient, providers can bridge the chasm between hospital care and at-home recovery. This comes through patient education and resources, but also through screening to ensure that patients understand and are adhering to discharge instructions and medication plans. Additionally, providers are able to identify any barriers to health care adherence, asking if patients have access to medications, have scheduled follow-up appointments, have reliable transportation, and more.  

When patients feel seen and remembered, it does more than boost satisfaction; it reinforces the trust that they are not just a number or a chart, but individuals deserving of continuous care and attention. This trust can lead to better adherence to care plans and, ultimately, better outcomes.

Conversational context to drive interactions

Patient outreach is about more than just sending reminders or scheduling follow-ups. It’s about building a continuous, meaningful relationship between the patient and healthcare provider, even outside the confines of a clinic or hospital. That comes through authentic, data-driven understanding that is synthesized and leveraged to improve every patient interaction. 

Every interaction, from pre-care to point-of-care to post-discharge outreach, presents a valuable opportunity to collect data and further optimize future interactions. Especially by leveraging AI functionality, providers can create a self-sustaining system that leverages machine learning to understand the health system’s strengths and opportunity areas. 

Every patient is unique, with different needs, concerns, and capacities for engagement. This means that a one-size-fits-all approach to patient communication will not suffice. Patient engagement strategies must be tailored to meet the individual where they are. But by creating patient engagement systems that are flexible, intelligent, and continuum-wide, providers can go beyond simply providing care to truly engaging and empowering each patient to become an active participant in their health journey. It’s time we put the patient at the center, where they rightfully belong.

About Joy Avery

Joy Avery, MSN, RN is SVP of Clinical Strategy at CipherHealth. She brings 37 years of expertise in clinical practice, healthcare operations, capacity management, and operationalizing enterprise command centers in dozens of healthcare systems across the US and UK. Prior to moving into the healthcare IT space, Joy had the opportunity to deliver patient care in a wide range of roles at North Mississippi Medical Center in Tupelo, MS, including Chief Flight Nurse, Trauma Program Manager, and Director of Specialized Clinical Services responsible for transfer center, patient throughput, bariatric services, and nursing leadership programs. In her role at CipherHealth, Joy serves as a clinical SME, assisting both her Cipher peers and customer partners in improving the patient, family, and staff experience. Joy is passionate about improving patient outcomes and access across the care continuum.

About Donna Pritchard

Donna Pritchard, DNP, FNP-BC, MSN, RN, is VP of Clinical Services at CipherHealth. Donna possesses over three decades of healthcare expertise, including over 25 years in high-level executive leadership roles. She dedicated 33 years to North Mississippi Medical Center, MMC, serving as Chief Nursing Executive for 17 of those years. In her current position at CipherHealth, she fulfills the role of Clinical Subject Matter Expert. Donna’s unwavering commitment lies in enhancing the health and safety of both patients and caregivers across the entire spectrum of care. Her enthusiasm is particularly evident in her relentless pursuit of elevating caregiver engagement and fostering long-term retention.

In the vast tapestry of the healthcare industry, certain years stand out as watershed moments. The year 2023 is shaping up to be one such pivotal year, marked by profound shifts and emerging trends.

Rise of the Physician Collectives

One significant transformation I’ve keenly observed is the enhanced stature and influence of small to medium-sized physician collectives. Historically relegated to the sidelines, these groups have now carved out a pivotal role for themselves. Why this sudden shift in the narrative? The reasoning is twofold. Firstly, there’s a growing realization among stakeholders that sidelining these collectives could inadvertently spur them to merge into larger entities. Such consolidations would bestow upon them a formidable negotiating prowess. Recognizing this potential shift, insurance providers in 2023 have displayed commendable adaptability, becoming more amenable to discussions, especially around the often contentious topic of reimbursement rates.

The Dance of Reimbursement Rates

Over the past year, reimbursement rates have resembled a pendulum, swinging between rises and falls. Factors like prevailing healthcare policies, remarkable technological innovations, and the broader economic milieu have all played their part in shaping these rates. However, as we transition into 2024, I anticipate a settling of sorts. Not a stagnation, but a move towards more stable, performance-driven rates. The emphasis? Quality over quantity. This aligns seamlessly with the rising clamor for value-based care, where patient outcomes are at the forefront.

For those in the industry contemplating bringing negotiation consultants onboard, a word of caution: diligence is key. The landscape is rife with entities that might overpromise, so thorough vetting is non-negotiable.

Regulatory Ripples: The CMS Proposals

The regulatory realm hasn’t been devoid of action either. The CMS’s proposed payment rules for 2024 have been a hot topic, eliciting a gamut of reactions. Established entities like the American Hospital Association (AHA) and the Federation of American Hospitals (FAH) have been vociferously vocal about their reservations. The crux of their concerns? Potential limitations in care accessibility, particularly for marginalized sections. Additionally, while the CMS’s ambitions to bolster price transparency are laudable, there’s a palpable skepticism surrounding the methods they’ve proposed.

However, it’s heartening to note that the CMS isn’t operating in a silo. They’ve been receptive to feedback, indicating a collaborative approach as they move towards finalizing their stance.

In Retrospect

To encapsulate, 2023 has been a year of significant recalibrations in the healthcare domain. As we look ahead, the ascendancy of physician collectives promises to be a narrative that will gain even more traction. Their role in shaping the future trajectory of healthcare is undeniable. In this dynamic milieu, one constant remains: the need to stay proactive, adaptive, and well-informed.

For anyone navigating this intricate landscape, whether a seasoned player or a newcomer, understanding these evolving dynamics is crucial. After all, in the world of healthcare, knowledge isn’t just power; it’s the very lifeblood of progress.

About Nathaniel Arana
Nathaniel Arana, owner of NGA Healthcare, combines extensive experience in healthcare and business management. With a management degree from the Eller College of Management, Nathaniel co-founded a successful out-of-network billing and consulting business, followed by the growth and management of a healthcare consulting firm. He founded NGA Healthcare to deliver results-driven consulting services to medical practices of all specialties. Nathaniel is a respected expert in practice management, regularly contributing to healthcare business publications. As a physician advocate, he works closely with clients to exceed their goals.

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

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

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

Applying Data Science to Healthcare Mobile Pay

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

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

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

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

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

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

Making the Right Moves for Mobile Pay

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

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

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

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

Establishing the Foundation for a Mobile-Smart Approach

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

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

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

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

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

About Janet Carbary

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

What You Should Know:

– Providence has become the first health system in the United States to develop a data-as-a-service (DaaS) product driven by HL7 Fast Healthcare Interoperability Resources (FHIR).

– This product facilitates the exchange of clinical data between providers and payers, aiming to standardize clinical data across the system.

Barriers to Data Exchange

Traditionally, one of the most significant barriers to seamless clinical data exchange has been the lack of standardization and automation. FHIR integration improves interoperability within value-based care, allowing health organizations to exchange comprehensive clinical data. This facilitates more accurate risk assessments, enhances care coordination, and captures outcomes more effectively. Standardized data exchange empowers stakeholders to make informed decisions, ultimately improving patient outcomes and the overall quality of care.

The DaaS product leverages the HL7 FHIR standard, which defines how healthcare information can be exchanged between different computer systems. FHIR provides a standardized and secure format for clinical and administrative data, reducing inefficiencies and enhancing the quality of care.

Providence’s DaaS Product

Providence’s DaaS product uses national data exchange standards, including the Member Attribution (ATR), Clinical Data Exchange (CDex), and Bulk Implementation Guides, developed through the HL7 Da Vinci Project. This project aims to enhance data sharing between payers and providers for a smoother transition to value-based care.

In September 2023, Providence piloted the DaaS product with Premera Blue Cross, one of the largest health plans in the Pacific Northwest. The product underwent thorough vetting and approval by internal quality teams and external Healthcare Effectiveness Data and Information Set (HEDIS) auditors.

Providence designed the DaaS solution to be scalable and adoptable by other providers. The goal is to ensure that payer partners have access to cutting-edge technology supporting growth and success in value-based care and beyond. The initiative is positioned to pave the way for industry-wide innovation in data exchange standards.

“Interoperability is critical within value-based care, and FHIR integration allows health care organizations to exchange comprehensive clinical data that enables more accurate risk assessments, enhances care coordination and captures outcomes more effectively,” said Michael Westover, vice president of population health informatics at Providence. “By using a national standard for contract gap closure and capturing the much-needed clinical data, we empower all stakeholders in their ecosystem to make more informed decisions, improve patient outcomes and enhance the overall quality of care to our patients – who are always at the center of all our efforts.”