Sometimes complex communication in a large practice mimics the Tower of Babel. When that happens, a solution may be adopting some enterprise architecture (EA) strategies of hospitals.
EA is strategic business planning used by an organization to uniformly align business and IT goals across the entire organization. It includes all aspects of implementing a technical strategy to reach a set goal typically related to new technology. Scaled down and adapted to the mid-sized or large physician group or practice, EA can prove a valuable tool during the chaos of implementation.
The process is often used to maximize the return of an investment and prevent waste within larger health care organizations such as hospitals, but is also an excellent tool for practice management. EA—required by the Office of Management and Budget (OMB) across all federal agencies—considers:
- Business Goals
- Business Processes
- IT Hardware
- Software Applications
- Data Management
The process of EA requires goal setting and project planning. It often incorporates the use of technical roadmaps, reference models, design patterns and blueprints, and change management systems. It is used by health care organizations migrating away from one or more systems to meet new goals or adopt newer technologies. Many large health care organizations have outdated “legacy systems” that are the result of the evolution of their business (e.g., technology added over many years, company mergers, etc.). EA is used to connect systems, primarily through interfaces, to achieve system interoperability. EA often is used to consider:
- Provision of Services
- Operational Management
- Billing and Other Business Management
- Human Factors (eg, training and certification)
- ANSI X.12
- Health Level 7 (most popular in medical clinics)
- Data Repositories
- Security Mechanisms
- Infrastructure Services
The goal is to enable the organization’s disparate software to communicate by using phases requiring dual systems, implement bridges to connect systems, or decide to replace systems altogether. Whichever process is defined by the EA, the ability to communicate across an organization provides timely access to accurate clinical, financial, and related information needed for operations. This allows practices and other health care systems to improve the quality and efficiency of the care they provide. It also allows them to more easily interact with outside entities, such as a Health Information Exchanges (HIE) or Affordable Care Organizations (ACOs).
There are different frameworks, methods, techniques, and tools used to achieve EA. The majority of large health care enterprises utilize the HL7 standards for communication of data between internal applications and other facilities. Whichever EA is used, the goal is to provide a comprehensive framework to manage and align an organization’s Information Technology (IT) assets, people, operations and projects with its operational characteristics. EA defines how information and technology will support the business operations and provide benefit for the business.
November 26th, 2012
With the Centers for Medicare & Medicaid Services (CMS) predicting the number of affordable care organizations (ACOs) will double to 300 by the end of 2012, it is time to start thinking about what you and your providers need to do to become Medicare ACO partners.
How does a Medicare ACO function and how will it potentially affect your office?
Born of the Affordable Care Act, Medicare ACOs are made up of a group of Medicare providers and suppliers. Under the ACO, the providers and suppliers agree to band together, coordinating care, documentation, and billing for patients, improving quality and cost savings in the process. Providers, payers, and newly established groups have applied to CMS for approval to start an ACO, which if approved must operate for at least three years.
An ACO’s quality performance is evaluated in five areas: care coordination, patient safety, preventive health, patient/caregiver experience, and at-risk population/frail elderly health.
CMS’ Medicare Shared Savings Program (MSSP) bases financial incentives to ACOs on successful cost reduction via care coordination. Under the MSSP, ACOs serve a minimum of 5,000 beneficiaries and must provide enough primary care physicians to easily serve the population. Before applying for MSSP status, an ACO must establish legal and governance structures, cooperative clinical and administrative systems and a shared savings distribution protocol.
Incentive payments are based on comparing an ACO’s annual incurred costs relative to CMS determined benchmarks and ACOs can choose to be reimbursed based on a “one sided” or “two sided” model. The one sided model allows the ACO to share a maximum of 50 percent for the first two years and savings or losses the third year. The two sided model allows a maximum of 60 percent sharing of savings and losses for all three years. Shared loss grows from 5 percent to 10 percent over the three year period.
A key to success is the communication of patient information, which adds a new perspective on current, interoperative electronic health record (EHR) systems. ACOs were ideated to encourage seamless treatment of patients by teams of providers from different entities and disciplines. Universally reliable documentation and classification of each patient may help providers meet incentives while providing improved quality of care.
If you are updating your EHR, investigate its ability to capture and communicate the information needed by other practices, physicians, and providers who may be joining your practice in a future ACO.
Want to keep your reimbursement costs for services down? Buy or affiliate with the service providers. Payers pressured by the Affordable Care Act (ACA) to keep costs low are looking to ambulatory surgery centers (ASCs)—already low-cost providers—as acquisitions.
While this trend has grown over the past few years with payers like Kaiser Permanente and Geisinger, other payers have been showing recent signs of interest, too. Highmark, for example, recently announced its plan to construct 10 ASCs in Pennsylvania.
In a Healthcare Payer News article, author Joan Dentler said, “Since ASCs have argued for years that they are the lower cost surgery model, payers will look to identify how low the reimbursement for surgery centers can go. But when the ASC uses this argument, it does not want to receive the lowest reimbursement possible. It is looking to receive reimbursement just low enough to make it worthwhile for the payer to reward the surgery center with the contract.”
Challenges for payers include understanding how to keep owners and providers active and engaged, as their motivation is generally outside of reimbursement, case scheduling, supplies and equipment, and other areas of management payers are not used to organizing. “It’s important to remember that one of the biggest concerns for physicians and third-party management companies, and hospitals investing in ASCs, is the need to maximize the revenue cycle and maintain their profit margins. For payers, procedure coding, billing and reimbursement are not the center’s primary business focus, but rather operational efficiency and cost savings. Potential partners need to discuss these differences very candidly and find ways to bridge any gaps in their ownership objectives,” Dentler said.
September 18th, 2012
Healthcare Payer News reports a new accountable care health plan from Aetna and Aurora Health Care will offer a price guarantee to employers, many of whom may see an average reduction of 10 percent based on their past claims expenses. The Aurora Accountable Care Network’s price guarantee may be the first offering of its kind, and is designed primarily to meet the insurance needs of small- and mid-sized employers in Wisconsin.
August 9th, 2012
Physicians were busier than they’ve been in a long time in the second quarter of 2012, American Medical News reports, with visits increasing almost 5 percent on average. This reverses a downward trend starting in 2008; providers saw a nearly 9 percent decline the same quarter of 2011. This points to an improving economy for both patients and their caregivers, some experts say.