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Overwhelming Majority of Payments to Doctors and Hospitals in New York State Are Still Made Using Fee-for-Service

New Scorecards Show One-Third of Payments in the Empire State Now Tied to Value

April 30, 2015 (New York) – An independent review of health care payments to doctors and hospitals reveals that the vast majority of payments in New York State continue to flow through a fee-for-service mechanism in both the commercial (94%) and Medicaid (73%) sectors. However, a significant proportion of payments are “value-oriented”—that is, designed to boost the quality of care patients receive. Approximately one-third of health care payments to doctors and hospitals in New York State are value-oriented.

Catalyst for Payment Reform (CPR) released the findings today in two Scorecards, commissioned by the New York State Health Foundation.

New York State is currently organizing an ambitious reform effort through its Delivery System Reform Incentive Payment (DSRIP) program and the State Health Innovation Plan (SHIP). DSRIP’s primary purpose is to restructure the health care delivery and payment systems through reinvesting in the Medicaid program. Similarly, a key goal of the SHIP is to ensure that, within five years, 80% of New Yorkers are cared for under value-based payment arrangements, rewarding providers who help patients stay healthy and achieve quality health care outcomes at an efficient cost.

“The shift toward value-oriented payments is critical for improving the quality and affordability of care in New York State,” said James R. Knickman, President and CEO of the New York State Health Foundation. “While we clearly have some work to do to move away from our antiquated fee-for-service system, it’s encouraging that a large proportion of payments are tied to quality and value. New York State is on the right path.”

The Scorecards, based on comprehensive surveys of commercial health plans and Medicaid health plans that collectively insure 16.3 million New Yorkers, found that:

  • Among commercial health plans, 34% of payments are tied to value; similarly, among Medicaid plans, 33% of payments are tied to value.
  • In the commercial sector, less than 15% of payments place health care providers at financial risk for their performance (that is, they stand to lose financially if they overspend or do not meet quality targets); in Medicaid this grows to 46%.
  • In the commercial sector, the most common form of value-oriented payment is pay-for–performance, which is typically traditional fee-for service payment with a bonus for meeting quality or efficiency goals (23%).
  • In Medicaid, the most common form of payment reform is a combination of some kind of non-fee-for-service base payment along with a shared savings agreement (13%). These arrangements are most often put into place to support patient-centered medical homes, or accountable care organizations (ACOs) for which providers may receive a care coordination fee or other per-member per-month payment and have an agreement with payers that they will share in any savings they produce.
  • In the commercial sector, less than 3% of payment arrangements contain “shared risk,” which means providers are financially responsible for any financial losses and have the opportunity to gain financially if there are any savings. In Medicaid this jumps to nearly 13%, likely because Medicaid health plans that are provider-owned are in a better position to hold providers financially responsible for exceeding cost targets.

In 2013 and 2014, Catalyst for Payment Reform produced National Scorecards on Payment Reform, measuring value-oriented payment in the commercial sector across the United States.

“These New York Scorecards released today are groundbreaking because it is the first time we have looked at payment reform by Medicaid in contrast to the commercial sector,” said CPR’s Executive Director Suzanne Delbanco. “We know health care providers need stronger and more consistent signals from payers. These Scorecards help public and private payers identify where there are opportunities for further alignment in their approach to payment.”

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About the New York State Health Foundation

The New York State Health Foundation (NYSHealth) is a private, statewide foundation dedicated to improving the health of all New Yorkers, especially the most vulnerable. Today, NYSHealth concentrates its work in three strategic priority areas: expanding health care coverage, building healthy communities, and advancing primary care. The Foundation is committed to making grants, informing health care policy and practice, spreading effective programs to improve the health system, serving as a neutral convener of health leaders across the State, and providing technical assistance to its grantees and partners.

About Catalyst for Payment Reform

Catalyst for Payment Reform is an independent, non‐profit corporation working on behalf of large health care purchasers to catalyze improvements to how we pay for health services and to promote better and higher-value care in the U.S.

About the New York Scorecard on Commercial Payment Reform and the New York Scorecard on Medicaid Payment Reform

All data in the New York Scorecard on Commercial Payment Reform and the New York Scorecard on Medicaid Payment Reform come from commercial and Medicaid health plans, respectively. CPR collaborated with the New York State Department of Financial Services (DFS) to collect data from health plans. DFS issued a request for information pursuant to Section 308 of the New York Insurance Law to ensure participation by all health plans within the scope of the project. Ten commercial health plans and fifteen Medicaid plans completed a survey, from which CPR aggregated results. For additional information, please see the relatedMethodology documents.

April 30, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Large Pioneer ACO Outlines Role of Clinical & Business Intelligence in Value-Based Care

CHICAGO (November 15, 2012) – As patient care models evolve to value-based care, clinical and business intelligence (C&BI) tools are playing a central role for organizations operating under new payment models. HIMSS Analytics published a new white paper titled “Banner Health Network Pioneer ACO Clinical Intelligence & Business Intelligence Approaches” that looks at how Banner Health Network is designing and implementing C&BI to effectively operate in a value-based care model.

Headquartered in Phoenix, Ariz., Banner Health Network (BHN) is one of 32 organizations selected in 2011 by the Centers for Medicare and Medicaid Services for its Pioneer Accountable Care Organization program. BHN stood out as a Pioneer candidate since it had experience coordinating care across multiple patient care settings. BHN expanded an existing ACO relationship with Aetna to include full technology and analytics support for its ACO patient populations. The report covers the results of in-depth interviews with BHN executive staff to explore the organization’s progress and multi-layered approach to C&BI.

Banner Health Network – the Organization: With the overall mission to provide excellent patient care, BHN followed three key drivers, identified as the “triple aim,” from the Institute for Healthcare Improvement. BHN had an existing infrastructure to support claims payment, medical management, customer service and other health-plan-like activities, which gave it several critical components needed to support the Pioneer ACO model. In addition, senior leadership viewed existing healthcare fee-for-service payment models as unsustainable. As noted in the white paper, “We are moving from an acute care system to a more comprehensive delivery system that is more viable and stable,” says Dr. Tricia Nguyen, Chief Medical Officer.

Clinical & Business Intelligence in Action: Because BHN is transitioning from fee-for-service payment and incentive methodology to a value-based methodology, physicians must receive the right information at the right time to drive more efficient patient care that results in higher quality outcomes.  Adhering to this philosophy, BHN used C&BI to:

  • Implement payment codes that encourage and reward physicians to spend more time reviewing patient risk scores and profiles based on data gathered from BHN information systems that inform physicians about the status of their patients.
  • Manage and refine communication with specialists to help motivate them to follow processes that align and coordinate patient care with BHN standards.
  • Leverage business intelligence to track gaps in care, healthcare risks, communication plan effectiveness, and to benchmark progress toward the desired change in physician and patient engagement.
  • Establish executive level support and leadership through a Business Intelligence Data Governance program, managed by the Executive Steering Committee, with clearly defined roles and responsibilities for each level of data governance to avoid information silos.

“Our research with Banner Health Network provides valuable insights into how this health system leverages clinical and business intelligence in transitioning to a new model of accountable care.  The BHN executive team supports the use of C&BI tools to better understand patient populations and offer patient-level care coordination with high-quality, standardized information,” says James E. Gaston, Senior Director, Clinical and Business Intelligence, HIMSS Analytics.

Collaboration for a Technology Solution:  At Banner Health Network, the distinction between clinical and business intelligence often overlaps, impacting business performance and optimizing patient care.  To better manage C&BI efforts, BHN expanded its existing ACO relationship with Aetna to include technology to better support its value-based care models and patient populations. This support covers population health management and patient services for more than 200,000 Banner Health Network patients, including more than 50,000 Medicare fee-for-service patients who are part of the Pioneer ACO savings program.

The Aetna Accountable Care Solutions (ACS) technology helps physicians see patient data at the individual and population level, and predict risk and opportunities for health and wellness programs. It also enables them to track, monitor, coordinate and report on patient health outcomes.  BHN provides physicians a comprehensive care management model supporting Pioneer ACO efforts so that patient engagement happens in a more meaningful way, including nursing home and palliative care. Using the Aetna ActiveHealth technology care management programs and outreach, BHN is at the early stage, but leading edge, of building and designing true population-based health management tools.

“Value-based care requires physicians to understand and impact the health of individuals and populations of patients, particularly those with chronic disease where intervention and management is key to better health outcomes and cost. The range of technologies from our Aetna companies complements Banner Health Network’s technology to empower full clinical integration and intelligence,” said Charles D. Kennedy, chief executive officer, Accountable Care Solutions from Aetna.

Read “Banner Health Network Pioneer ACO Clinical Intelligence & Business Intelligence Approaches” at www.HIMSSAnalytics.org/research on the HIMSS Analytics website. Contact James E. Gaston at James.Gaston@HIMSSAnalytics.org for more information on this research.

About Aetna

Aetna is one of the nation’s leading diversified health care benefits companies, serving approximately 37.3 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional, voluntary and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities, Medicaid health care management services and health information technology services. Our customers include employer groups, individuals, college students, part-time and hourly workers, health plans, health care providers, governmental units, government-sponsored plans, labor groups and expatriates. For more information, see www.aetna.com.

About HIMSS Analytics 

HIMSS Analytics is a wholly owned not-for-profit subsidiary of the Healthcare Information and Management Systems Society (HIMSS).  The company collects and analyzes healthcare information related to IT processes and environments, products, IS department composition and costs, IS department management metrics, healthcare trends and purchase-related decisions.  HIMSS Analytics delivers high quality products, services and analytical expertise to healthcare delivery organizations, healthcare IT companies, state governments, financial companies, pharmaceutical companies, and consulting firms.  Visit www.himssanalytics.org for more information.

November 18, 2012 I Written By

New Consulting Company Exsede Brings Unparalleled Expertise to Meet Critical Demand for Healthcare IT

Announces Partner Network of technology providers that share vision for patient-centric, value-based care

AUSTIN, TX. – October 3, 2012 Exsede today announced its launch as a recently formed healthcare IT consulting company providing technical and business development services to facilitate successful adoption of technologies for improved quality of patient care. Founded by healthcare IT experts Emma Cartmell, Phillip LaJoie and Erin Scales, who have more than 30 years combined experience, Exsede’s mission is to become the leading facilitator of innovation within the healthcare domain, enabling adoption of transformative technologies by healthcare delivery organizations and providers.

Healthcare IT growth is skyrocketing. A report from KLAS, “Shifting Demand for Consultants: Who’s Hot, Who’s Not, and Why,” found that demand for healthcare IT consulting is also booming, with 70 percent of healthcare providers surveyed expecting to hire a firm to help implement meaningful use, the qualification for federal funding. Much of this is to meet federal mandates for electronic health records (EHR) and data interoperability. In Texas alone, according to the Texas Medical Association Electronic Health Records Report 2012, 60 percent of state physicians are using EHR, up from 43 percent in 2009, and 22 percent more plan to implement EHR, the majority within the next year.

“The healthcare industry is at a tipping point, and technology is paramount to getting costs under control while improving quality of care. As healthcare organizations plan their strategies, Exsede strives to be the company they rely on to bring forth the right technologies in the right ways to meet their goals and facilitate growth,” said Cartmell, co-founder of Exsede, and co-founder and vice president of the Austin chapter of the Healthcare Information Management and Systems Society (HIMSS).

“We have the knowledge, experience and passion to help them select the most advantageous technologies for their missions and, in turn, manage implementation to comply with mandates, or to make them more competitive,” she added.

Industry veterans Cartmell, LaJoie and Scales founded Exsede on the belief that technologies can enable healthcare industry transformation, improve patient service and facilitate value-based care. Their experience spans management of technology selection and implementation for leading global healthcare organizations; design and development of interoperability strategies and architectures between health systems; business development and sales management for health IT enterprises; and contributions with HIMSS to health IT legislation.

“As people are entering healthcare consulting, few have the breadth of experience to make informed decisions on project management execution, as well as the knowledge base of what technologies to bring forward at a time when there’s a lot of noise and confusion,” said Nora Belcher executive director, Texas eHealth Alliance. “Exsede’s level of expertise is a welcome addition to the space and to the state of Texas with its booming healthcare industry of $103.6 billion.”

Technical Services

According to Gartner analyst Thomas J. Handler, M.D., in “Agenda For Healthcare, 2012” published February 29, 2012, “If healthcare organizations are to manage, evaluate and transform healthcare delivery under radically evolving market conditions, IT is more essential than ever before. The goal is to have all stakeholders work to better coordinate care for patients, making it easier to deliver high-quality care, while spending healthcare money more wisely.”

Exsede technical services assist healthcare organizations in developing their plan for future technology investments and integration with existing assets, and provide project management through implementation. Backed by Exsede, organizations are able to make effective decisions regarding IT compliance and for attraction, education and retention of patients.

Business Development Service

Exsede business development services enable existing and emerging technologies to successfully enter the healthcare marketplace. The company leverages its years of business development and sales experience in commercial and federal healthcare, in addition to industry knowledge and relationships, to help technology companies by assisting with strategy, advising on technical roadmap and generating a tactical pipeline.

Exsede Partner Network

Exsede works with only best-of-breed technology service providers that meet the highest industry standards and support the vision of patient-centric, value-based care. Partners include Austin-based OnRamp, which provides highly secure HIPAA compliant hosting services for healthcare businesses, as well as “social patient acquisition” platform company BrightWhistle and enterprise master patient index (EMPI) company NextGate, which identifies, matches, links and coordinates patient data across healthcare platforms, among other emerging technology companies.

“Exsede is aligning itself with companies meeting growing industry needs, and we are pleased to be a part of the network,” said Chad Kissinger, founder, OnRamp. “Healthcare IT is cluttered with vendors, making it hard for organizations to know what technologies will truly benefit them and their patients. Exsede cuts through the noise to what’s next and most important, and is the perfect partner as we continue to grow our business.”

About Exsede

Exsede is a new healthcare IT consulting company that provides technical and business development services to facilitate successful adoption of technologies for improved quality of patient care. Located in Austin, TX, and founded by healthcare IT experts with more than 30 years combined experience, Exsede aims to be the leading facilitator of innovation within the healthcare domain, enabling adoption of transformative technologies by healthcare delivery organizations and providers.

November 6, 2012 I Written By