Provider Manuals – Health Care Professionals | Aetna

auburn birthing centerbreastfeeding supportbreast healthchildbirth educationlet's talk women's health seriesurogynecology and pelvic floor medicineurogynecology and pelvic floor medicinethe christ hospital pelvic floor centerthe christ hospital pelvic floor centerthe christ hospital pelvic floor faqwomen's surgery centerwomen's surgery centerminimally invasive surgeryadditional servicesadditional servicesaudiologyclinical laboratoryendoscopyhealthcare business solutionshealthcare business solutionsbundled servicesbundled servicesdirectionshotel informationtravelcorporate wellness servicescritical connections e-icuproject heart restartdiagnostic telemedicineimagingimagingthe christ hospital imaging centerswomen's imaging centerpain managementspeech & voice servicestesting centerswellnesswellnesswellness programsworkforce wellnessexecutive healthupcoming eventsour locationsour locationsthe christ hospitalthe christ hospitalpatient guidepatient guideon-campus specialty centersretail pharmacyclassic cuisinepatient rights & responsibilitiesvisitor guidevisitor guideamenities and servicesdiningfamily loungesnearby hotels & accomodationsrequesting patient informationsending mail, packages or flowersvisiting hours & restrictionsdriving directionsparkingparkinghospital parkingmedical office building parkingimaging centersoutpatient centersoutpatient centersandersongreen townshipfort wright (ky. sum up all the costs across all the processes used during the patient’s complete cycle of care to produce the total cost of care for the patient. as providers improve their process flows and reduce redundancy, their patients will no longer have to be so “patient” as they receive a complete cycle of care. these cross-subsidies introduce major distortions in the supply and efficiency of care. kashuba served as senior director and associate counsel for health policy and government programs and also as assistant counsel to the insurance services division. for a start, the drivers of cost in health care had changed but the allocation methodology had not, with the result that our costing no longer reflected reality. equipment no longer needed can be retired or sold to other health care institutions that are expanding their capacity. as a result, clinical practice leaders are able to have more constructive and better informed discussions about how best to standardize care and treatment processes to reduce the costs of variability and limit the use of expensive approaches and materials that do not demonstrably lead to improved outcomes. their own reporting requirements but that may be unrelated to physician care. we increase the value of health care delivered to patients by improving outcomes at similar costs or by reducing the total costs involved in patients’ care while maintaining the quality of outcomes. page accordion 3 text​we currently offer bundled services in three areas: bariatric services, musculoskeletal (joint and spine) and women’s services, and have plans in place to develop more for future implementation. of care transformation—does work for maternity care, bulger says. we map those processes as we did in step 3 and then calculate and assign costs to patient-facing resources on the basis of their demands for the services of these departments, using the process that will be described in step 6. blackwell, md, chair and professor in the department of obstetrics,Gynecology and reproductive sciences at mcgovern medical school at uthealth in. of their care, they must be aligned with their physicians and have shared. their costs should and can be assigned on the basis of the patient processes that create demand for their services. czyzewski received the distinguished service and achievement award from carlow university alumnae in 2011 and was recognized as a 2015 leading lady from oakland catholic hs. effect of such arbitrary support-department allocations on the measured cost of services can be profound. the micromanagement of costs at the individual organizational unit level does little to reduce total cost or improve value—and may in fact destroy value by reducing the effectiveness of care and driving up administrative costs.. develop process maps of each activity in patient care delivery. measures, payment incentives, and care protocols to succeed in a. we created the institute for cancer care excellence in december 2008 to support this effort. come to agreement on what constitutes high-quality obstetrical care and. capitalizing on these value-creating opportunities—previously hidden by inadequate and siloed costing systems—is the key to solving the health care cost problem. care is also idiosyncratic; patients with the same condition often take different paths through the system. what’s more, md anderson routinely allocated more costs to services that were highly reimbursed.. cepullio provides the health plan's strategic direction for commercial products in the region. (the exhibit “new-patient process map” shows a process map for one segment of the patient care cycle at the md anderson head and neck center.. 27, 2017: upmc health plan earns prestigious stevie award® for customer service. they often allocate their costs to procedures, departments, and services based not on the actual resources used to deliver care but on how much they are reimbursed. upmc workpartners’ suite of services includes absence management services, commercial workers’ compensation, employee wellness and health coaching, employee assistance programs, employer on-site services (on-site health centers, near-site health centers, and mobile units), and health and productivity consulting and data analysis. the experiences of several major institutions currently implementing the new approach—the head and neck center at md anderson cancer center in houston, the cleft lip and palate program at children’s hospital in boston, and units performing knee replacements at schön klinik in germany and brigham & women’s hospital in boston—confirm our belief that bringing accurate cost and value measurement practices into health care delivery can have a transformative impact. gebbens’ previous positions include regional controller for humana, president and ceo for prevea health plan, and cfo for geisinger health plan. physicians and staff may shift more of their time and resources to the front end of the care cycle—to activities such as patient education and clinical team consultations—to reduce the likelihood of patients experiencing far more costly complications and readmissions later in the cycle.. for example, health plans tend to use quality measures that are relevant. gavin served as ceo of scranton counseling center, a comprehensive behavioral health program. holder is executive vice president, upmc; president, upmc insurance services division; and president and chief executive officer, upmc health plan. we prepare detailed process maps for each activity in the care delivery value chain.

Women's Health

in the value framework, the relevant cost is the total cost of all resources—clinical and administrative personnel, drugs and other supplies, devices, space, and equipment—used during a patient’s full cycle of care for a specific medical condition, including the treatment of associated complications and common comorbidities., one of the largest not-for-profit health systems in the country, does.’s explore the first component of the health care value equation: health outcomes. for chronic conditions, we choose a care cycle for a period of time, such as a year. biggest problem with health care isn’t with insurance or politics. in the past, schön klinik, like other hospitals in germany, had reduced the capacity of its total knee replacement rehabilitation units in part because the existing cost system portrayed them as less profitable than acute-care units. reductions that enable the quality of care to be maintained or improved need to be informed by accurate knowledge of the total costs required to achieve the desired outcomes when treating individual patients with a given medical condition. as providers improve their process flows and reduce redundancy, their patients will no longer have to be so “patient” as they receive a complete cycle of care. throughout her 25-year tenure with lancaster general, she held a number of roles with increasing responsibility, including president of acute care hospitals, president and ceo of a community health system, and an executive who was a founding member of the allspire health partners, a regional alliance between multiple, large healthcare systems in pennsylvania and new jersey. credit: ‘the new deal’ approach to healthcare collections is data-driven and consumer-focusedin this business profile, professional credit’s president scott purcell and chief marketing officer jeff johnson discuss the value of having a comprehensive and responsive collections partner. the cdvc focuses providers on the full care cycle rather than on individual processes, the typical unit of analysis for most process improvements and lean initiatives in health care. but this investment has yielded additional benefits by supporting process improvement opportunities and facilitating the standardization of care. through this work, we hope to provide convincing evidence of the health care value that md anderson’s integrative cancer treatment strategy actually delivers. she also oversees claims, customer service, enrollment, ancillary products, third party administration, systems configuration, business development and organizational performance. better measurement of outcomes will, by itself, lead to significant improvements in the value of health care delivered, as providers’ incentives shift away from performing highly reimbursed services and toward improving the health status of patients. with impending health care reform set to shift the industry away from fee-for-service reimbursement to bundled or global payments, we needed a costing system that could provide more accurate patient-level costs by medical condition. each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill., too many preterm births, and too many early elective inductions,All of which increase the need for neonatal intensive care services. much excess resource capacity, however, is due not to rare conditions or poor handoffs but to the prevailing tendency of many hospitals and clinics to provide care for almost every type of medical problem.’s degree in health policy and administration from penn state university. in addition, he oversees upmc health plan community health initiatives. proper implementation of healthcare information technology systems is crucial to an organization’s financial health. value in health care is measured in terms of the patient outcomes achieved per dollar expended. health system drives 10% up (patient payments) and 10% down (billing-related costs)., we specify the care delivery value chain (cdvc), which charts the principal activities involved in a patient’s care for a medical condition along with their locations. yet have a bundled-payment contract for maternity care, but it has spent. claro group: partnering for performance improvement in this business profile, larry volkmar, a managing director in the performance improvement. facilities management: working smarter to make organizations saferin this business profile, michael argir, ceo and president of medxcel facilities management, discusses the value and benefits of insourcing facilities-management services. the reimbursement for a total joint replacement care cycle in germany and sweden is approximately ,500, including all physician and technical services and excluding only outpatient rehabilitation. in that position, he provided strategic, clinical leadership, and medical oversight for the health plan’s medical management and line of business products. costing systems for physician services differ from those used by hospitals, they suffer from the same problems. kaplan is a senior fellow and the marvin bower professor of leadership development, emeritus, at harvard business school. schön klinik began to contemplate the expansion of its rehabilitation capacity—a complete reversal of its previous decision—and shifted its focus more intensively on reducing support costs incurred during the acute-care stay. perverse incentives also contribute: third-party payors (insurance companies and governments) reimburse for procedures performed rather than outcomes achieved, and patients bear little responsibility for the cost of the health care services they demand. chief of service for obstetrics and gynecology at children’s memorial. to estimate the total cost of jones’s care, we first identify the processes he undergoes and the resources used in each process. any true health care reform will require abandoning the current complex fee-for-service payment schedule altogether. instead we have zero-sum competition in which health care providers destroy value by focusing on highly reimbursed services, shifting costs to other entities, or pursuing piecemeal and ineffective line-item cost reductions.

Women's Preventive Care Services: Contraception Methods

the workload of these departments has expanded because of increased demand for the services and outputs they provide.. manolis oversees the pharmacy programs for the health plan's medicare, medical assistance, and commercial products. we map those processes as we did in step 3 and then calculate and assign costs to patient-facing resources on the basis of their demands for the services of these departments, using the process that will be described in step 6.. weinraub oversees the overall performance, strategic direction, and program development for upmc health plan’s medicare products. these health benefits companies manage benefits for commercial, medicaid, medicare, behavioral health, eap, health promotion, and workers’ compensation programs and other population health programs and services. to that we add the costs of all other associated resources that enable allen, white, and green to be available for patient care. more on processes of care—more on what they needed to do versus what they. capturing all the costs over the complete cycle of care for an individual patient’s medical condition, we allow providers and payors to address virtually any costing question. powerful driver of value in health care is that better outcomes often go hand in hand with lower total care cycle costs. page accordion 2 text  savingsreduce healthcare costs through a contracted price for procedures streamlined administrative processes efficiencyhealthcare navigatorpriority schedulingconsistent, coordinated care teams providing world class techniquessimplified billing processreporting on outcomes, productivity, and personal goals accountability customized scorecards showing outcomes and volumecontrolled physician panel selection criteria includes volumes, outcomes, complication rates among others​. but imposing arbitrary spending limits on discrete components of care, or on specific line-item expense categories, achieves only marginal savings that often lead to higher total systems costs and poorer outcomes. costing systems, which measure the costs of individual departments, services, or support activities, often encourage the shifting of costs from one type of service or provider to another, or to the payor or consumer. accurate costing also unlocks a whole cascade of opportunities, such as process improvement, better organization of care, and new reimbursement approaches that will accelerate the pace of innovation and value creation. are now completing the analysis of our pilot project data and will be extending the methodology to all our other integrated cancer care units. launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available.. gavin works collaboratively with state and county officials, as well as other behavioral health stakeholders, to ensure the delivery of clinically effective, accessible, and cost-efficient behavioral health services. our approach makes patients and their conditions—not departmental units, procedures, or services—the fundamental unit of analysis for measuring costs and outcomes. to put it bluntly, there is an almost complete lack of understanding of how much it costs to deliver patient care, much less how those costs compare with the outcomes achieved. instead, payors should introduce value-based reimbursement, such as bundled payments, that covers the full care cycle and includes care for complications and common comorbidities. for primary and preventive care, the unit of value measurement is a particular patient population—that is, a group with similar primary care needs, such as healthy children or the frail and elderly with multiple chronic conditions.) this overall view of the patient care cycle helps to identify the relevant dimensions along which to measure outcomes and is also the starting point for mapping the processes that make up each activity. is a managed care expert with more than 30 years of executive and consulting experience spanning commercial, medicare, medicaid, program of all-inclusive care for the elderly (pace), and managed long term services and supports (mltss). seeing more than 30,000 new patients every year, md anderson accounts for approximately 20% of cancer care within the houston region and 1% of cancer care nationally. lean six sigma green belt and certified business coach (wabc)., which we have found straightforward to implement, requires a significant time investment to develop process maps for all care areas. with health care administration emphasis from the university of illinois. of science degree in health services from the university of california at los angeles. client was a nine-hospital health system with 14 clinics serving communities in a multi-state market with very limited access to care, poor economic conditions, high unemployment, and a heavy medicare/medicaid/uninsured payer mix. he also was the recipient of the robert wood johnson pioneer award to evaluate the effect of innovative prescription label design on adherence to chronic medication and health outcomes. accurate measurement of costs and outcomes is the previously hidden secret for solving the health care cost crisis. woodcock, mba, facmpe, cpc, to: discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management. new approach actively engages physicians, clinical teams, administrative staff, and finance professionals in creating the process maps and estimating the resource costs involved in treating patients over their care cycle.’s degree in business administration accounting from grand valley state university. the pilot year,Women served in the pregnancy care package model had a cesarean rate of just. christ hospital is among only 6 percent of hospitals in the nation awarded magnet recognition for demonstrating the highest-quality patient care, nursing excellence and innovation in nursing. care decisions that affect maternal and newborn outcomes but also. and directing maternity care and for dividing the payment among. she serves on the board of directors for several nonprofit organizations and she is recognized nationally as an expert on service excellence and claims optimization.

Centers of Excellence - Bundled Services

tdabc analysis showed, however, that the demand for many support-unit services, such as medical billing, is far higher during the days a patient spends in the acute-care facility than during rehab days. in 2005, she joined heritage health systems of houston, texas, where she served as senior vice president for national hmo operations. she is also a faculty member at the university of pittsburgh in the department of psychiatry and the graduate school of public health. among the most complex in geisinger’s suite of provencare episode-of-care. process maps encompass the paths patients may follow as they move through their care cycle. told, we estimate that upwards of 95% of what health care managers think of as fixed costs are actually under their control and therefore not really fixed.. turan is responsible for overseeing and leading the cross-organizational compliance; ethics; privacy; enterprise risk management (erm); fraud, waste, abuse and recoveries; quality assurance and operational integrity; and data governance programs for upmc insurance services. cincinnati residents have ranked the christ hospital the most preferred for all healthcare services and the “consumer’s choice” for healthcare in our region for 19 consecutive years (1996 – 2014). for each condition, we define the beginning and end of the patient care cycle.’s degree in public management/healthcare administration from carnegie-mellon university. it starts with the full compensation of each person, including salary, payroll taxes, and fringe benefits such as health insurance and pensions. outcomes for any medical condition or patient population should be measured along multiple dimensions, including survival, ability to function, duration of care, discomfort and complications, and the sustainability of recovery.: using video monitoring to improve patient safety and achieve cost efficienciesin this business profile, brad w. services staff are always looking for ways to improve the verification, billing and collections processes, and munson healthcare is no different. initially, upmc will offer government products: medicare advantage and d-snp, pa healthchoices, and pa community healthchoices. addition to his service on local, regional, and national organization boards of directors, he serves as board chair for the association of community affiliated plans (acap), a trade association comprised of 60 provider-affiliated regional health plans enrolling medicaid and other low-income beneficiaries. that approach jeopardizes both the quality and the supply of care. but reimbursement itself is based on arbitrary and inaccurate assumptions about the intensity of care. in addition, she has served as chief executive of mercy life and keystone health plan west. space costs are a function of occupancy area and rental rates; it costs are based on an individual’s use of computers and communications products and services. (the exhibit “the care delivery value chain” shows the cdvc developed with the brigham & women’s pilot site for patients with severe knee osteoarthritis. health care leaders will eventually accept the idea that the direct costs of patient care, such as nurses, physicians, and consumable supplies (drugs, bandages, and syringes), ought to be assigned more accurately to individual patients.. kashuba joined the insurance services division’s legal services department in january 2005., which we have found straightforward to implement, requires a significant time investment to develop process maps for all care areas. long has consulted with health plans, local and state governments, hospitals and health systems, and professional associations along with other health and social service providers. the cdvc focuses providers on the full care cycle rather than on individual processes, the typical unit of analysis for most process improvements and lean initiatives in health care. accurate costing gives managers a valuable tool for consolidating patient care for low-volume procedures in fewer institutions, which would both reduce the high costs of unused capacity and improve outcomes. widespread confusion between what a provider charges, what it is actually reimbursed, and its costs is a major barrier to reducing the cost of health care. for example, in total knee replacement, surgeons use different implants, surgical kits, surgeons’ hoods, and supplies, thereby introducing substantial cost variation in treating patients with the same condition at the same site.—is in a two-year pilot with a medicaid managed care plan that covers. in most of these communities, the system was the sole source of care. its “pregnancy care package” in a single clinic in portland.. peele brings 13 years of patient care experience along with 12 years of academic research experience to her position as the leader of health care analytics at the health plan.. develop process maps of each activity in patient care delivery. from many major health plans, although payers thus far have been.. weir leads upmc workpartners, which provides health and productivity solutions for high-performing companies throughout the united states.. lammie has worked for upmc since september 1990, holding key business, financial, and operational leadership positions that have supported the health system's development into one of the nation's leading integrated delivery and financing health systems. perkins served as vice president of medical affairs for upmc health plan.

The Big Idea: How to Solve the Cost Crisis in Health Care

, and chief medical officer-population health, geisinger health system,Danville, pa. in these roles, she helped to establish a new company for innovative solutions responsible for service ideation, development of enterprise services, new innovative care delivery and business models and related ventures. albright is the director of the institute for cancer care excellence at md anderson cancer center. we are to stop the escalation of total health care costs, the level of reimbursement must be reduced. to put it bluntly, there is an almost complete lack of understanding of how much it costs to deliver patient care, much less how those costs compare with the outcomes achieved. matters worse, participants in the health care system do not even agree on what they mean by costs.) - future developmentphysical & occupational therapysleep centerssurgery centerstesting centersurgent carewound & ostomy careoutpatient clinicsnews & communitynews & communitynewsroomnewsroomfor the mediafor the mediaawardscalendar of eventscommunity health needs assessmentvolunteer servicessocial feedpatient & visitor resourcespatient & visitor resourcesonline bill payinsurance & pricingmedical recordspatient & family-centered carenotice of privacy practicespatient rights & responsibilitiespatient guideresidency programsvisitor guideadvanced practice providersnotice of nondiscrimination and accessibility requirements. we increase the value of health care delivered to patients by improving outcomes at similar costs or by reducing the total costs involved in patients’ care while maintaining the quality of outcomes. half of all medicare beneficiaries treated in the hospital will need post-acute care services after discharge. since providers in all three countries report, in aggregate, similar margins on joint replacement care, u. the pregnancy care package model, some health plans do not cover doula. lovelace is chief program officer at community care behavioral health organization, a behavioral health managed care organization that is part of the upmc insurance services division. as a result, clinical practice leaders are able to have more constructive and better informed discussions about how best to standardize care and treatment processes to reduce the costs of variability and limit the use of expensive approaches and materials that do not demonstrably lead to improved outcomes. early,” says john bulger, do, chief medical officer of geisinger health. tdabc builds a common information platform that will unleash innovation based on a shared understanding of the actual processes of care. with a rising tide of bad debt, a large southeastern healthcare system was seeing a sharp decline in net patient revenues. cutting payor reimbursement does reduce the bill paid by insurers and lowers providers’ revenues, but it does nothing to reduce the actual costs of delivering care. shrank began his career as a practicing physician with brigham internal medicine associates at brigham and women’s hospital in boston, as well as an assistant professor at harvard medical school.. shrank joined upmc’s health plan division in june 2016 as the company’s new chief medical officer. transform maternity care initiative at pacific business group on health., we identify the support resources necessary to supply the primary resources providing patient care.. jacobs provides strategic business development and planning for upmc health plan’s non-insurance products and commercial business segment, and consumer technology innovations that support the member experience. the cost of patient care is the top strategic priority of most hospital cfos today. (the exhibit “the care delivery value chain” shows the cdvc developed with the brigham & women’s pilot site for patients with severe knee osteoarthritis. at mcgovern medical school at uthealth, and chief of service for obstetrics. perverse incentives also contribute: third-party payors (insurance companies and governments) reimburse for procedures performed rather than outcomes achieved, and patients bear little responsibility for the cost of the health care services they demand. learn more about navigant's work with university of michigan health system. effect of such arbitrary support-department allocations on the measured cost of services can be profound., she serves as chief clinical officer and senior vice president of population health for the upmc insurance services division (isd). across-the-board cuts in reimbursement will jeopardize the quality of care and likely lead to severe rationing. but this investment has yielded additional benefits by supporting process improvement opportunities and facilitating the standardization of care. shrank received is the 2015 healthcare executive transformation award from the los angeles county medical association. see how tdabc works in the health care context, we first explore a simplified example. a complete picture of the time and resources involved, providers can optimize across the entire care cycle, not just the parts. underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.’s degree in public health from university of michigan school of public health. electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access ehrs. other countries spend less of their gdp on health care but have the same increasing trend.

Leadership Team | UPMC Health Plan

for example, as payors introduce high copayments to limit the use of expensive drugs, costs may balloon elsewhere in the system should patients’ overall health deteriorate and they subsequently require more services. cost measurement has also led to huge cross-subsidies across services. calculate the total cost of jones’s visit to the facility by simply multiplying the capacity cost rate of each resource by the time (in hours) jones spent using the resource, and then adding up the components:As this example demonstrates, accurately calculating the cost of delivering health care is quite straightforward under the tdabc system., we identify the support resources necessary to supply the primary resources providing patient care. cutting payor reimbursement does reduce the bill paid by insurers and lowers providers’ revenues, but it does nothing to reduce the actual costs of delivering care. health care system participants, including economists and accountants, believe that most costs in health care are fixed because so much care is delivered using shared staff, space, and equipment. a complete picture of the time and resources involved, providers can optimize across the entire care cycle, not just the parts. it is not the number of different services provided or the volume of services delivered that matters but the value. understand why most health care costs are not fixed, start with personnel costs, which are generally at least 50% of the total costs of health care providers, according to american hospital association statistics. any true health care reform will require abandoning the current complex fee-for-service payment schedule altogether. kaplan, of “how to solve the cost crisis in health care” (hbr, september 2011). we have done this through a collaborative effort between highly-respected physicians, health navigators, hospital leaders, nursing and other clinical experts as well as hospital business experts. since providers in all three countries report, in aggregate, similar margins on joint replacement care, u. for example, as payors introduce high copayments to limit the use of expensive drugs, costs may balloon elsewhere in the system should patients’ overall health deteriorate and they subsequently require more services. has 36 years of experience in the area of health care. without proper measurement, the healthy dynamic of competition—in which the highest-value providers expand and prosper—breaks down. md anderson is a medical condition–focused center that provides integrated, interdisciplinary care across the care cycle. the cost of treating a patient with diabetes, for example, must include not only the costs associated with endocrinological care but also the costs of managing and treating associated conditions such as vascular disease, retinal disease, and renal disease. as we merge ongoing measurement of clinical outcomes in each of our care centers with patient-level costs for a full care cycle, we will be better positioned to drive value improvement and develop bundled prices for clinical care. reducing diagnostic and treatment delays limits deterioration of health and also lowers costs by reducing the resources required for care. accurate costing also unlocks a whole cascade of opportunities, such as process improvement, better organization of care, and new reimbursement approaches that will accelerate the pace of innovation and value creation. as providers start to understand the total costs of treating patients over their complete cycle of care, they will also be able to contemplate innovative reimbursement approaches without fear of sacrificing their financial sustainability.: a patient-centered financial experiencein this business profile, sheila schweitzer, founder and ceo of patientmatters, offers insights.. haas has more than 20 years of experience in health care and health care technology fields. weinraub has taught strategic management at the university of pittsburgh and held senior leadership positions at highmark blue cross blue shield and metropolitan jewish geriatric health system in brooklyn, ny. how orlando health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce a/r days. we validated all the process steps, time estimates, and branching points with the help of frontline health personnel who were actually performing the tasks—not just departmental managers and senior leaders.’s concerns about physician compensation are the result of the changing healthcare environment. by integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. the actual capacity utilization of much health care equipment is sometimes lower because equipment capacity is supplied in large lumps. spending more on early detection and better diagnosis of disease, for example, spares patients suffering and often leads to less complex and less expensive care later. care providers have multiple opportunities to reduce cycle times for treating patients, which in turn will reduce demand for resource capacity. team works together to implement the latest best-practices in patient care to ensure a continuum of care that extends from the very first phone call to the final visit. for transform maternity care, pacific business group on health, san. version of this article appeared in the september 2011 issue of harvard business review. having begun his career as a family therapist and crisis clinician, mr. than in the traditional care model, while patient satisfaction scores were. services may only represent 10 percent of the total cost of maternity.

Prepping for Maternity Care Bundles | HFMA

if most costs were fixed, growth in demand for health care would increase only that small fraction of costs that are variable, leading to lower average costs in the system, not the dramatically higher share of gdp now being devoted to health care. with these powerful tools in place, health care providers can utilize medical staff, equipment, facilities, and administrative resources far more efficiently, streamline the path of patients through the system, and select treatment approaches that improve outcomes while eliminating services that do not. the experiences of several major institutions currently implementing the new approach—the head and neck center at md anderson cancer center in houston, the cleft lip and palate program at children’s hospital in boston, and units performing knee replacements at schön klinik in germany and brigham & women’s hospital in boston—confirm our belief that bringing accurate cost and value measurement practices into health care delivery can have a transformative impact. big idea: how to solve the cost crisis in health care.. gebbens is responsible for accounting, finance, regulatory reporting, claims payable, accounts receivable, actuarial services, underwriting, and clinical analysis for the division’s 12 companies. by comparing process maps and resource costs for the same medical condition across multiple sites, we can determine how much of the cost difference is attributable to variations in processes, protocols, and productivity and how much is attributable to differences in resource or supply costs such as wages and implant prices. proper goal for any health care delivery system is to improve the value delivered to patients. such fragmentation of service lines introduces costly redundancy throughout the health care system. in turn, the cost accounting function in healthcare provider organizations is becoming an increasingly important and strategic function. the reimbursement for a total joint replacement care cycle in germany and sweden is approximately ,500, including all physician and technical services and excluding only outpatient rehabilitation. measured outcomes and cost must encompass the entire cycle of care for the patient’s particular medical condition, which often involves a team with multiple specialties performing multiple interventions from diagnosis to treatment to ongoing management. the infrastructure many providers would need to manage a bundled. they often allocate their costs to procedures, departments, and services based not on the actual resources used to deliver care but on how much they are reimbursed. to that we add the costs of all other associated resources that enable allen, white, and green to be available for patient care.“and we could have a team-based model of care that allows everyone to work at. page accordion 4 text​we have been serving the tristate for more than 125 years and we have a comprehensive health network with more than 1,000 physicians caring for residents in more than 100 locations throughout greater cincinnati and northern kentucky. gavin has more than 40 years of training and experience in behavioral health care, from clinical service delivery through executive management. value-based reimbursement rewards providers who deliver the best overall care at the lowest cost and who minimize complications rather than create them. the cost of treating a patient with diabetes, for example, must include not only the costs associated with endocrinological care but also the costs of managing and treating associated conditions such as vascular disease, retinal disease, and renal disease. measuring costs and outcomes is the single most powerful lever we have today for transforming the economics of health care. the process maps developed for tdabc often reveal opportunities for appropriately skilled but lower-cost health care professionals to perform some of the processes currently performed by physicians without adversely affecting outcomes. in operational terms, you might describe health care today as a highly customized job shop. what’s more, md anderson routinely allocated more costs to services that were highly reimbursed. lovelace oversees medicare products, medicaid, and the children's health insurance program (chip) of upmc health plan, known as upmc for kids. proper goal for any health care delivery system is to improve the value delivered to patients. for every patient; if a mother begins her care with geisinger in the. current health care reform initiatives will exacerbate the situation by increasing access to an inefficient system without addressing the fundamental value problem: how to deliver improved outcomes at a lower total cost. these cross-subsidies introduce major distortions in the supply and efficiency of care. albright is the director of the institute for cancer care excellence at md anderson cancer center. cost measurement has also led to huge cross-subsidies across services. if most health care costs were truly fixed, we would not have the health care cost problem we do today. providers are generously reimbursed for some services and incur losses on others. more care and more expensive care is not necessarily better care. with impending health care reform set to shift the industry away from fee-for-service reimbursement to bundled or global payments, we needed a costing system that could provide more accurate patient-level costs by medical condition. cost measurement in health care is challenging, first because of the complexity of health care delivery itself. actual duration should be calculated for time-consuming, less predictable processes, especially those that involve multiple physicians and nurses performing complex care activities such as major surgery or examination of patients with complicated medical circumstances. but how this is done will have profound implications for the quality and supply of health care. accurate measurement of costs and outcomes is the previously hidden secret for solving the health care cost crisis.

Equally Insured? What You Need to Know About Women and Health

these activities—such as nurse counseling time, physician phone calls to patients, and multidisciplinary care team meetings—can often make major contributions to efficiency and favorable outcomes. vice president and chief financial officer,Upmc insurance services division. of pregnancy care, and it will be challenging for this to spread rapidly. success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. we are struck by the sheer size of the opportunity to reduce the cost of health care delivery with no sacrifice in outcomes., we calculate the capacity cost rate for each resource—that is, how much it costs, per hour or per minute, for a resource to be available for patient-related work—using the following equation:The numerator aggregates all the costs associated with supplying a health care resource, such as allen, white, or green. he is also responsible for compliance, finance, and operations for individual products on and off the healthcare exchange. instead, providers (and payors) turn to simplistic actions such as across-the-board cuts in expensive services, staff compensation, and head count. haas spent 13 years with bluecross blueshield of illinois as part of healthcare services corporation (hcsc), serving in several roles to connect and advance it and business strategies across hcsc’s participating blues plans. in the value framework, the relevant cost is the total cost of all resources—clinical and administrative personnel, drugs and other supplies, devices, space, and equipment—used during a patient’s full cycle of care for a specific medical condition, including the treatment of associated complications and common comorbidities. she first joined the health plan in 1996 and was part of the start-up team that established the health plan as a major health insurer in western pennsylvania. already complex path of care is further complicated by the highly fragmented way in which health care is delivered today. pilot study also sought to evaluate whether the new costing approach would allow us to measure the cost consequences of changes in care processes. maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. more care and more expensive care is not necessarily better care. in the future, we expect providers will use electronic handheld, bar-code, and rfid devices to capture actual times, especially if tdabc becomes the generally accepted standard for measuring the cost of patient care. md anderson is a medical condition–focused center that provides integrated, interdisciplinary care across the care cycle. but reimbursement itself is based on arbitrary and inaccurate assumptions about the intensity of care. resource utilization data also reveal where increasing the supply of certain resources to ease bottlenecked processes would enable more timely care and serve more patients with only modestly higher expenditures. two-year pilot, blackwell’s group did not make substantial changes to care. one opportunity to decrease costs of maternity care and improve. as we merge ongoing measurement of clinical outcomes in each of our care centers with patient-level costs for a full care cycle, we will be better positioned to drive value improvement and develop bundled prices for clinical care. indirect costs have been accurately assigned, managers and physicians can look for ways to reduce demand for support-department services and improve the efficiency with which they are delivered. others who were involved in the care, it becomes really complicated from a logistical. she has also served on the governor’s intergovernmental council on long term care. weir served for six years as vice president of network development and claim services for the university of pittsburgh medical center. what it doesn’t do is detail how hospitals and providers can participate in the value-based care environment during the development process. to estimate the total cost of jones’s care, we first identify the processes he undergoes and the resources used in each process. actual duration should be calculated for time-consuming, less predictable processes, especially those that involve multiple physicians and nurses performing complex care activities such as major surgery or examination of patients with complicated medical circumstances. other countries spend less of their gdp on health care but have the same increasing trend. space costs are a function of occupancy area and rental rates; it costs are based on an individual’s use of computers and communications products and services. this whitepaper includes five strategies for efficient and accurate cost accounting and service line analytics and keys to overcoming the associated challenges. turan has an extensive and highly successful track record of building, implementing and leading world-class and award-winning grc programs across a number of the most dynamic and heavily regulated industries, including health care, banking and financial services, insurance, and technology. convened by the department of health and human services to advance. health care system participants, including economists and accountants, believe that most costs in health care are fixed because so much care is delivered using shared staff, space, and equipment. currently holds faculty appointments in health policy and management and in psychiatry in the school of medicine at the university of pittsburgh. group, representing walmart,Boeing, and many of the nation’s other largest healthcare purchasers, hopes. the tdabc model makes visible the high costs of these redundant administrative and clinical processes, motivating professionals from different departments to work together to integrate care across departments and specialties.

Reimbursement Policies - Commercial

he previously held management positions with medco health solutions and stadtlanders specialty pharmacy services. we are struck by the sheer size of the opportunity to reduce the cost of health care delivery with no sacrifice in outcomes. through this work, we hope to provide convincing evidence of the health care value that md anderson’s integrative cancer treatment strategy actually delivers. instead we have zero-sum competition in which health care providers destroy value by focusing on highly reimbursed services, shifting costs to other entities, or pursuing piecemeal and ineffective line-item cost reductions. indeed, institutions may be penalized when the improvements they make in treatments and processes reduce the need for highly reimbursed services. facing revenue pressure due to lower reimbursements—particularly from government programs such as medicare and medicaid—providers today use a hatchet approach to cost reduction by mandating arbitrary cuts across departments. discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy. for 12 years he worked for highmark blue cross blue shield in pittsburgh, where he held a variety of management positions in business and in information technology.. point of service, customer service, patient statements) and analyzed regularly for maximized results. instead of focusing on the costs of treating individual patients with specific medical conditions over their full cycle of care, providers aggregate and analyze costs at the specialty or service department level. understand why most health care costs are not fixed, start with personnel costs, which are generally at least 50% of the total costs of health care providers, according to american hospital association statistics. care is also idiosyncratic; patients with the same condition often take different paths through the system. page accordion 1 text​bundled services are packages that companies purchase to reimburse health care providers for a complete episode of medical treatment or care. new approach actively engages physicians, clinical teams, administrative staff, and finance professionals in creating the process maps and estimating the resource costs involved in treating patients over their care cycle. facing revenue pressure due to lower reimbursements—particularly from government programs such as medicare and medicaid—providers today use a hatchet approach to cost reduction by mandating arbitrary cuts across departments. as health care providers begin to reorganize into units focused on conditions, standardize their protocols and treatment processes, and improve their information systems, using the tdabc system will become much simpler. costing systems for physician services differ from those used by hospitals, they suffer from the same problems. capitalizing on these value-creating opportunities—previously hidden by inadequate and siloed costing systems—is the key to solving the health care cost problem. it is not the number of different services provided or the volume of services delivered that matters but the value. shrank served as senior vice president, chief scientific officer, and chief medical officer of provider innovation for cvs health. health gains insight into denials, reduces a/r days with relayanalytics acuity., the pregnancy care package, which gives women options for pain management. for example, in total knee replacement, surgeons use different implants, surgical kits, surgeons’ hoods, and supplies, thereby introducing substantial cost variation in treating patients with the same condition at the same site. she is an expert on the affordable care act (aca) and its impact on health care delivery. cost of services provided through the pregnancy care package was 15 percent. porter, of “how to solve the cost crisis in health care” (hbr, september 2011). the networkabout the 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surgerygynecologic surgeryheart & vascular surgeryjoint replacement surgeryneurosurgeryplastic surgeryrobotic-assisted surgeryrobotic-assisted surgeryda vinci surgical systembenefits to patientsbenefits of surgeonthoracic surgerytransplant surgerytransplant surgerykidney transplantkidney transplantkidney transplant faqkidney transplant teamtissue transplanturology surgerypain managementtesting centersvisitor informationwomen's healthwomen's healthbirthing centersbirthing centersliberty family birthing centermt. project team then estimated how much time it takes to perform each task and the capacity cost of each health care provider. “accountable entity” that accepts a bundled payment for maternity care,Durham thinks that function can be handled by a health system, with ob.. manolis has more than 30 years of experience in the pharmacy and managed care industry. by comparing process maps and resource costs for the same medical condition across multiple sites, we can determine how much of the cost difference is attributable to variations in processes, protocols, and productivity and how much is attributable to differences in resource or supply costs such as wages and implant prices. business profilesxtend healthcare: helping organizations optimize their revenue cycle in this business profile, mike morris, president of xtend healthcare, discusses the value of partnering with a revenue cycle management vendor that has deep experience in delivering strong roi. because existing systems hide these costs in overhead (see myth #1), such important elements of care are prone to be minimized or left unmanaged.. manning is a senior executive and marketing professional with over 25 years of demonstrated achievement across multiple industries: telecommunications, financial services, and health care. mobile health care (emhc) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today emhc serves a population of more than a million people in and around memphis, answering 75,000 calls each year. shrank served as the inaugural director of research and rapid-cycle evaluation for the center for medicare & medicaid innovation at the centers for medicare & medicaid services (cms) where he helped design and led the evaluation of new payment reform models tested by the center such as pioneer acos, bundled payments and progressive primary care models. for these patients, a stay in an inpatient rehabilitation facility, skilled nursing facility or other post-acute care setting comes between hospital and home.., this is partly a historical artifact of the medicare cost-plus reimbursement system, which requires hospital departments to prepare an annual medicare cost report (mcr), detailing costs and charges by department.

sum up all the costs across all the processes used during the patient’s complete cycle of care to produce the total cost of care for the patient. if most health care costs were truly fixed, we would not have the health care cost problem we do today. without proper measurement, the healthy dynamic of competition—in which the highest-value providers expand and prosper—breaks down. perkins served as senior medical director of commercial business and workpartners’ suite of products. even at our pilot site schön klinik, which already had an excellent departmental cost-control system, introducing tdabc revealed powerful new ways to improve its processes and restructure care delivery. within each segment of care—the outpatient clinic, diagnostic imaging, the operating room, inpatient care, radiation therapy, and chemotherapy administration—we created process maps that also included all the resources involved. our bundled services focus on providing high-quality packages with experienced care team members in one convenient and central location. how gwinnett medical center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process. the payment can include physician visits, testing, procedures, hospital stays, recovery time and follow-up care such as: rehabilitation and post-procedure physician visits. matters worse, participants in the health care system do not even agree on what they mean by costs. are now completing the analysis of our pilot project data and will be extending the methodology to all our other integrated cancer care units. providers can aggregate and analyze patients’ cost of care by age, gender, and comorbidity, or by treatment facility, physician, employer, and payor. she leads marketing intelligence, segmentation, marketing automation, brand strategy and management, creative services and design along with all aspects of sales support — group and individual. we created the institute for cancer care excellence in december 2008 to support this effort. care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. in the typical care delivery process, for example, patients see multiple providers in multiple locations and undergo a separate scheduling interaction, check-in, medical consultation, and diagnostic workup for each one. instead, providers (and payors) turn to simplistic actions such as across-the-board cuts in expensive services, staff compensation, and head count. kashuba was director of the northern erie clinical services, an outpatient alcohol and substance abuse clinic located in buffalo, n. better measurement of outcomes will, by itself, lead to significant improvements in the value of health care delivered, as providers’ incentives shift away from performing highly reimbursed services and toward improving the health status of patients. care organizations today, like all other firms, conduct arduous and time-consuming budgeting and capacity planning processes, often accompanied by heated arguments, power negotiations, and frustration. from several commercial payers and the centers for medicare and medicaid services (cms) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. the upmc insurance services division includes upmc health plan, upmc for you, upmc for life, upmc for kids, askesis development group, community care behavioral health, and upmc workpartners. cost depends on how much of a resource’s available capacity (time) is used in the care for a particular patient, not on the charge or reimbursement for the service, or whether it is reimbursed at all. our pilots, we have documented significant variation in the processes, tools, equipment, and materials used by physicians performing the same service within the same unit in the same facility. big idea: how to solve the cost crisis in health care. value-based reimbursement rewards providers who deliver the best overall care at the lowest cost and who minimize complications rather than create them. she is core faculty at the center for research on health care at the university of pittsburgh medical center and an elected fellow of the centre for interuniversity research and analysis on organizations in montreal, canada. process maps encompass the paths patients may follow as they move through their care cycle. cost depends on how much of a resource’s available capacity (time) is used in the care for a particular patient, not on the charge or reimbursement for the service, or whether it is reimbursed at all.. lovelace is president of upmc for you, a managed care organization that serves medical assistance and medicare advantage special needs plan recipients in 40 counties in pennsylvania. approaches for measuring health care outcomes have been described previously, notably in michael porter’s 2010 new england journal of medicine article, “what is value in health care? measuring costs and outcomes is the single most powerful lever we have today for transforming the economics of health care. in the typical care delivery process, for example, patients see multiple providers in multiple locations and undergo a separate scheduling interaction, check-in, medical consultation, and diagnostic workup for each one. in that role, she leads cross-function initiatives that impact the financing and delivery of health care and assists in the ongoing clinical transformation of the isd. the care and the payment model so those things are appropriately. we prepare detailed process maps for each activity in the care delivery value chain. in 2010, with robert kaplan, we launched a pilot project, also within the head and neck center, to assess the feasibility of applying modern cost accounting to health care delivery. community care provides behavioral health coverage for more than 900,000 medicaid beneficiaries in 36 pennsylvania counties as well as care coordination services in new york.

. mccallister helped develop and implement the core technological solutions that saw the health plan become one of the nation's fastest-growing hmos. the workload of these departments has expanded because of increased demand for the services and outputs they provide. it starts with the full compensation of each person, including salary, payroll taxes, and fringe benefits such as health insurance and pensions. the inability to properly measure cost and compare cost with outcomes is at the root of the incentive problem in health care and has severely retarded the shift to more effective reimbursement approaches. (pictured at right) gained access to data about the actual cost of care for a given. watch: providers adapt as value-based care moves from hype to reality. in 2010, with robert kaplan, we launched a pilot project, also within the head and neck center, to assess the feasibility of applying modern cost accounting to health care delivery. although the example is admittedly simplified, it captures almost all the fundamental concepts any health care provider needs to apply to estimate the cost of treating patients over their full cycles of care. such realignment of care delivery, already under way at children’s hospital boston, improves the value and convenience of more routine services for both patients and caregivers while allowing tertiary facilities to concentrate their specialized resources on truly complex care. schön klinik began to contemplate the expansion of its rehabilitation capacity—a complete reversal of its previous decision—and shifted its focus more intensively on reducing support costs incurred during the acute-care stay., we calculate the capacity cost rate for each resource—that is, how much it costs, per hour or per minute, for a resource to be available for patient-related work—using the following equation:The numerator aggregates all the costs associated with supplying a health care resource, such as allen, white, or green. cost measurement in health care is challenging, first because of the complexity of health care delivery itself. their costs should and can be assigned on the basis of the patient processes that create demand for their services. providers can aggregate and analyze patients’ cost of care by age, gender, and comorbidity, or by treatment facility, physician, employer, and payor. at the christ hospital, what center of excellence means to us is a hospital program that has been thoughtfully and specifically designed to provide exceptional care to our patients by providing exceptional outcomes, the best value and an outstanding patient experience. the actual capacity utilization of much health care equipment is sometimes lower because equipment capacity is supplied in large lumps. see how tdabc works in the health care context, we first explore a simplified example. for example, some underutilization of expensive space, equipment, and personnel is caused by poor coordination and delays when a patient is handed off from one specialty or service to the next. by accurately measuring the cost of delivering the same services at different facilities, rather than using figures based on averaged direct costs and inaccurate overhead allocations, providers are able to see opportunities to perform particular services at properly resourced and lower-cost locations. each segment of the process map took approximately 40 hours to complete, with a team consisting of a project manager, a project coordinator, a process mapping expert, financial staff, clinical and business managers, and staff members from each function being mapped. calculate the total cost of jones’s visit to the facility by simply multiplying the capacity cost rate of each resource by the time (in hours) jones spent using the resource, and then adding up the components:As this example demonstrates, accurately calculating the cost of delivering health care is quite straightforward under the tdabc system. assume that we find nurse white’s total cost to be as follows:We next calculate nurse white’s availability for patient care—the denominator of our capacity cost rate equation. her most recent position before joining the isd, marion served as executive vice president and chief population health officer for lancaster general health in lancaster, pa. the lack of accurate cost data covering the full cycle of care for a patient has been the major barrier to adopting alternative reimbursement approaches, such as bundled reimbursement, that are more aligned with value. in reality, the cost of using a resource—a physician, nurse, case manager, piece of equipment, or square meter of space—is the same whether the resource is performing a poorly or a highly reimbursed service. tdabc analysis showed, however, that the demand for many support-unit services, such as medical billing, is far higher during the days a patient spends in the acute-care facility than during rehab days. across-the-board cuts in reimbursement will jeopardize the quality of care and likely lead to severe rationing. this article, written by apex founder and ceo brian kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (ehr) software to realize a high roi in speed to payment, patient satisfaction and portal adoption for meaningful use. the hcplan workgroup and others recommend designating ob providers as. for primary and preventive care, the unit of value measurement is a particular patient population—that is, a group with similar primary care needs, such as healthy children or the frail and elderly with multiple chronic conditions. care providers today are typically organized around specialties and services, which complicates coordination, interrupts the seamless, integrated flow of patients from one process to the next, and leads to the duplication of many processes. with these powerful tools in place, health care providers can utilize medical staff, equipment, facilities, and administrative resources far more efficiently, streamline the path of patients through the system, and select treatment approaches that improve outcomes while eliminating services that do not., this resource- and process-based approach gives providers visibility into valuable nonbilled events in the cycle of care. the process maps developed for tdabc often reveal opportunities for appropriately skilled but lower-cost health care professionals to perform some of the processes currently performed by physicians without adversely affecting outcomes. resource utilization data also reveal where increasing the supply of certain resources to ease bottlenecked processes would enable more timely care and serve more patients with only modestly higher expenditures.) this overall view of the patient care cycle helps to identify the relevant dimensions along which to measure outcomes and is also the starting point for mapping the processes that make up each activity. in the past, schön klinik, like other hospitals in germany, had reduced the capacity of its total knee replacement rehabilitation units in part because the existing cost system portrayed them as less profitable than acute-care units. told, we estimate that upwards of 95% of what health care managers think of as fixed costs are actually under their control and therefore not really fixed.

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report focuses on the three big questions hsg receives about adding value to physician compensation; why are organizations redesigning their provider compensation plans? begin by specifying the medical condition (or patient population) to be costed, including the associated complications and comorbidities that affect processes and resources used during the patient’s care. porter is a university professor at harvard, based at harvard business school in boston. when politicians and policy makers talk about cost reduction and “bending the cost curve,” they are typically referring to how much the government or insurers pay to providers—not to the costs incurred by providers to deliver health care services. for chronic conditions, we choose a care cycle for a period of time, such as a year. he has also worked for electronic data systems (eds) of plano, texas. methodology to bring the triple aim goals to maternity care. healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. previous positions include corporate vice president, finance; executive vice president and chief financial officer, upmc diversified services; managing director, upmc health ventures; and vice president, upmc patient business services. porter is a university professor at harvard, based at harvard business school in boston. spending more on early detection and better diagnosis of disease, for example, spares patients suffering and often leads to less complex and less expensive care later. these resources are used in processes that start with a patient’s first contact with the organization and continue through a set of clinical consultations, treatments, and administrative processes until the patient’s care is completed.. czyzewski provides leadership, direction, and support for all human resource functions for upmc insurance services division. seeing more than 30,000 new patients every year, md anderson accounts for approximately 20% of cancer care within the houston region and 1% of cancer care nationally. health care leaders will eventually accept the idea that the direct costs of patient care, such as nurses, physicians, and consumable supplies (drugs, bandages, and syringes), ought to be assigned more accurately to individual patients., this resource- and process-based approach gives providers visibility into valuable nonbilled events in the cycle of care. indeed, the potential to improve outcomes while driving down costs is greater in health care than in any other field we have encountered. providers understand the total costs of treating patients over their complete cycle of care, they can contemplate innovative reimbursement approaches without fear of sacrificing their financial sustainability. instead of focusing on the costs of treating individual patients with specific medical conditions over their full cycle of care, providers aggregate and analyze costs at the specialty or service department level. lesson learned:The actual spend on physician services may need to increase for avoidable—and. providers are generously reimbursed for some services and incur losses on others. reimbursing physicians on the basis of highly aggregate and likely inaccurate estimates of their costs introduces major incentive problems into the health care system. the team began by developing a care delivery value chain that mapped out the full treatment of a patient. equipment no longer needed can be retired or sold to other health care institutions that are expanding their capacity. upmc is one of the nation’s leading integrated delivery systems and through its health plans and affiliates provides health care coverage and benefits management for more than 2. this myth also motivates some health care organizations to expand through mergers, acquisitions, and organic growth in order to reap economies of scale by spreading their fixed costs over an increased volume of business. capturing all the costs over the complete cycle of care for an individual patient’s medical condition, we allow providers and payors to address virtually any costing question. indirect costs have been accurately assigned, managers and physicians can look for ways to reduce demand for support-department services and improve the efficiency with which they are delivered. such fragmentation of service lines introduces costly redundancy throughout the health care system. current areas of focus for the health plan include payment reform, advancement of patient-centered medical home, a primary care practice transformation, and initiatives with upmc as an integrated delivery and financing system. the tdabc model makes visible the high costs of these redundant administrative and clinical processes, motivating professionals from different departments to work together to integrate care across departments and specialties. writes about healthcare business and policy topics for several hfma. widespread confusion between what a provider charges, what it is actually reimbursed, and its costs is a major barrier to reducing the cost of health care. provides leadership, direction, and administration for the services provided by upmc for you, which offers coverage to eligible medical assistance recipients through its contracts with the pennsylvania department of public welfare as well as coverage options for medicare beneficiaries who are also enrolled in the pennsylvania medical assistance program. rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.. mccallister has more than 20 years of experience in the technology and information services industry.., this is partly a historical artifact of the medicare cost-plus reimbursement system, which requires hospital departments to prepare an annual medicare cost report (mcr), detailing costs and charges by department. this 5-minute white paper briefing explains how providers can improve vital measures of technical and business performance to accelerate cash flow.

begin by specifying the medical condition (or patient population) to be costed, including the associated complications and comorbidities that affect processes and resources used during the patient’s care. haas is vice president of payer applications at upmc health plan. peele was the first person chosen by ibm as an ibm big data hero and was voted the 2014 it news men & women of the year as a top innovator in health care analytics.. holder has held a number of leadership positions in health care, including ceo of western psychiatric institute and clinic of upmc and founding ceo of community care behavioral health. costing systems, which measure the costs of individual departments, services, or support activities, often encourage the shifting of costs from one type of service or provider to another, or to the payor or consumer. in operational terms, you might describe health care today as a highly customized job shop. prior to joining upmc, she led a national consulting firm, w squared health, specializing in medicare advantage and dual products.“a strategy for health care reform: towards a value-based system” by m. those that deliver desired health outcomes faster and more efficiently, without unnecessary services, and with proven, simpler treatment models will not be penalized by lower revenues. that approach has introduced massive cross subsidies that reimburse some services generously and pay far below costs for others, leading to excess supply for well-reimbursed services and inadequate delivery and innovation for poorly reimbursed ones.“calculating the return on investment of performance improvement has been missing from most of the quality improvement discussions in health care,” dr. the inability to properly measure cost and compare cost with outcomes is at the root of the incentive problem in health care and has severely retarded the shift to more effective reimbursement approaches.: taking data analytics to the next level in this business profile, christine santos, chief of strategic business analytics for. he also oversees a group of medicare advantage special needs plans for people who are dually eligible for medicare and medicaid, and for individuals who are eligible for long-term care services. these activities—such as nurse counseling time, physician phone calls to patients, and multidisciplinary care team meetings—can often make major contributions to efficiency and favorable outcomes. for each condition, we define the beginning and end of the patient care cycle. there he led the development of solutions to support providers manage risk and deliver better care for the populations they serve. each segment of the process map took approximately 40 hours to complete, with a team consisting of a project manager, a project coordinator, a process mapping expert, financial staff, clinical and business managers, and staff members from each function being mapped. our approach makes patients and their conditions—not departmental units, procedures, or services—the fundamental unit of analysis for measuring costs and outcomes. for a start, the drivers of cost in health care had changed but the allocation methodology had not, with the result that our costing no longer reflected reality. in that capacity, he is responsible for the stabilization and advancement of the health plan’s entire technology footprint. much excess resource capacity, however, is due not to rare conditions or poor handoffs but to the prevailing tendency of many hospitals and clinics to provide care for almost every type of medical problem. health care costs currently exceed 17% of gdp and continue to rise. he has more than 40 years of experience at various executive levels in both private and public health care services. reimbursing physicians on the basis of highly aggregate and likely inaccurate estimates of their costs introduces major incentive problems into the health care system., we specify the care delivery value chain (cdvc), which charts the principal activities involved in a patient’s care for a medical condition along with their locations. payment is in the form of a fixed sum and is based on anticipated costs for different episodes of care or services. the team began by developing a care delivery value chain that mapped out the full treatment of a patient. biggest problem with health care isn’t with insurance or politics. read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than million in additional upfront annual revenue in one year.“calculating the return on investment of performance improvement has been missing from most of the quality improvement discussions in health care,” dr. came to community care in 1999 with an extensive history of progressive management experience. as providers start to understand the total costs of treating patients over their complete cycle of care, they will also be able to contemplate innovative reimbursement approaches without fear of sacrificing their financial sustainability.. mcanallen is responsible for strategic plan development and implementation of network management and provider relations for all of the insurance services division’s lines of business. indeed, the potential to improve outcomes while driving down costs is greater in health care than in any other field we have encountered. version of this article appeared in the september 2011 issue of harvard business review. those that deliver desired health outcomes faster and more efficiently, without unnecessary services, and with proven, simpler treatment models will not be penalized by lower revenues. and national pilots to test episode payment for maternity care will start.

powerful driver of value in health care is that better outcomes often go hand in hand with lower total care cycle costs. that approach has introduced massive cross subsidies that reimburse some services generously and pay far below costs for others, leading to excess supply for well-reimbursed services and inadequate delivery and innovation for poorly reimbursed ones. with accurate costing, providers can target their cost reductions in areas where real improvements in resource utilization and process efficiencies enable providers to spend less without having to ration care or compromise its quality. indeed, institutions may be penalized when the improvements they make in treatments and processes reduce the need for highly reimbursed services. care delivery model, providence leaders see the barriers facing payment. already complex path of care is further complicated by the highly fragmented way in which health care is delivered today. his 30 years in the health care field also include 13 years as a family physician in south charleston, w. cycle management has become an even more complex issue with declining reimbursements, implementation of electronic health records, evolving local carrier determinations (lcd), and payer credentialing [the emphasis on healthcare fraud, abuse and compliance has increased the importance of accuracy of data reporting and claims filing). if most costs were fixed, growth in demand for health care would increase only that small fraction of costs that are variable, leading to lower average costs in the system, not the dramatically higher share of gdp now being devoted to health care. what elements and parameters must be part of successful compensation plans?’s explore the first component of the health care value equation: health outcomes. of business administration from the wharton school, university of pennsylvania. pilot study also sought to evaluate whether the new costing approach would allow us to measure the cost consequences of changes in care processes. the overall costs associated with maternity and newborn care so that. assume that we find nurse white’s total cost to be as follows:We next calculate nurse white’s availability for patient care—the denominator of our capacity cost rate equation. her role as vice president, she drives marketing strategies and execution for all product lines and business units. white paper, written by apex vice president of solutions and services, carrie romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. he implemented new solutions by using emerging technologies and leveraging the health plan's relationship with providers to help it become one of the nation's leading integrated delivery systems. for example, some underutilization of expensive space, equipment, and personnel is caused by poor coordination and delays when a patient is handed off from one specialty or service to the next. as health care leaders obtain more accurate and appropriate costing numbers, they can make bold and politically difficult decisions to lower costs while sustaining or improving outcomes. in the future, we expect providers will use electronic handheld, bar-code, and rfid devices to capture actual times, especially if tdabc becomes the generally accepted standard for measuring the cost of patient care. our pilots, we have documented significant variation in the processes, tools, equipment, and materials used by physicians performing the same service within the same unit in the same facility.​we have established several centers of excellence for many services inluding joint, spine and obstetrics. prior to citibank, she was with at&t in a variety of roles supporting call center services, financial services, and telecom products all in a marketing and branding capacity. kaplan is a senior fellow and the marvin bower professor of leadership development, emeritus, at harvard business school. accurate costing gives managers a valuable tool for consolidating patient care for low-volume procedures in fewer institutions, which would both reduce the high costs of unused capacity and improve outcomes. (the exhibit “new-patient process map” shows a process map for one segment of the patient care cycle at the md anderson head and neck center. in reality, the cost of using a resource—a physician, nurse, case manager, piece of equipment, or square meter of space—is the same whether the resource is performing a poorly or a highly reimbursed service. physicians and staff may shift more of their time and resources to the front end of the care cycle—to activities such as patient education and clinical team consultations—to reduce the likelihood of patients experiencing far more costly complications and readmissions later in the cycle. when politicians and policy makers talk about cost reduction and “bending the cost curve,” they are typically referring to how much the government or insurers pay to providers—not to the costs incurred by providers to deliver health care services. with accurate costing, providers can target their cost reductions in areas where real improvements in resource utilization and process efficiencies enable providers to spend less without having to ration care or compromise its quality. the critical link between patient care and reimbursement, health information enables more complete and accurate revenue capture. services today are delivered in over-resourced facilities or facilities designed for the most complex patient rather than the typical patient. services today are delivered in over-resourced facilities or facilities designed for the most complex patient rather than the typical patient. although the example is admittedly simplified, it captures almost all the fundamental concepts any health care provider needs to apply to estimate the cost of treating patients over their full cycles of care. that approach jeopardizes both the quality and the supply of care.                                          coverage typically includes pre-treatment care through a follow-up period immediately after the care. within each segment of care—the outpatient clinic, diagnostic imaging, the operating room, inpatient care, radiation therapy, and chemotherapy administration—we created process maps that also included all the resources involved.

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  • health care costs currently exceed 17% of gdp and continue to rise. as health care leaders obtain more accurate and appropriate costing numbers, they can make bold and politically difficult decisions to lower costs while sustaining or improving outcomes. measured outcomes and cost must encompass the entire cycle of care for the patient’s particular medical condition, which often involves a team with multiple specialties performing multiple interventions from diagnosis to treatment to ongoing management. the micromanagement of costs at the individual organizational unit level does little to reduce total cost or improve value—and may in fact destroy value by reducing the effectiveness of care and driving up administrative costs. but how this is done will have profound implications for the quality and supply of health care. approaches for measuring health care outcomes have been described previously, notably in michael porter’s 2010 new england journal of medicine article, “what is value in health care? even at our pilot site schön klinik, which already had an excellent departmental cost-control system, introducing tdabc revealed powerful new ways to improve its processes and restructure care delivery. porter, of “how to solve the cost crisis in health care” (hbr, september 2011). care providers today are typically organized around specialties and services, which complicates coordination, interrupts the seamless, integrated flow of patients from one process to the next, and leads to the duplication of many processes. prior to joining upmc health plan, she worked in the pittsburgh office of morgan lewis & bockius as a labor and employment associate. instead, payors should introduce value-based reimbursement, such as bundled payments, that covers the full care cycle and includes care for complications and common comorbidities. we are to stop the escalation of total health care costs, the level of reimbursement must be reduced. we continue to receive national recognition for our outstanding care and medical excellence-- year after year. jenkins is a strong supporter of upmc health plan’s process improvement efforts and has a green belt certification in six sigma. puts it bluntly: the resources spent on maternity care services are not. is also president of government programs and individual advantage for the upmc insurance services division. providers understand the total costs of treating patients over their complete cycle of care, they can contemplate innovative reimbursement approaches without fear of sacrificing their financial sustainability. care providers have multiple opportunities to reduce cycle times for treating patients, which in turn will reduce demand for resource capacity. kaplan, of “how to solve the cost crisis in health care” (hbr, september 2011). this whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks. peele was the vice chair of the department of health policy and management at the university of pittsburgh graduate school of public health. we validated all the process steps, time estimates, and branching points with the help of frontline health personnel who were actually performing the tasks—not just departmental managers and senior leaders. these resources are used in processes that start with a patient’s first contact with the organization and continue through a set of clinical consultations, treatments, and administrative processes until the patient’s care is completed. reducing diagnostic and treatment delays limits deterioration of health and also lowers costs by reducing the resources required for care. tdabc builds a common information platform that will unleash innovation based on a shared understanding of the actual processes of care.“a strategy for health care reform: towards a value-based system” by m. and the employer to kind of pound the table and let plans know that. a very challenging aspect of moving toward bundled payment,” says laurel. as healthcare shifts to more data-driven decision making, having clear visibility into key volume, cost and profitability measures across clinical service lines is becoming increasingly important for both long-range and tactical planning activities. current health care reform initiatives will exacerbate the situation by increasing access to an inefficient system without addressing the fundamental value problem: how to deliver improved outcomes at a lower total cost. by accurately measuring the cost of delivering the same services at different facilities, rather than using figures based on averaged direct costs and inaccurate overhead allocations, providers are able to see opportunities to perform particular services at properly resourced and lower-cost locations. such realignment of care delivery, already under way at children’s hospital boston, improves the value and convenience of more routine services for both patients and caregivers while allowing tertiary facilities to concentrate their specialized resources on truly complex care. but imposing arbitrary spending limits on discrete components of care, or on specific line-item expense categories, achieves only marginal savings that often lead to higher total systems costs and poorer outcomes. the lack of accurate cost data covering the full cycle of care for a patient has been the major barrier to adopting alternative reimbursement approaches, such as bundled reimbursement, that are more aligned with value. is designed to coordinate care from prenatal services through labor and. care organizations today, like all other firms, conduct arduous and time-consuming budgeting and capacity planning processes, often accompanied by heated arguments, power negotiations, and frustration. in this role, he focuses on the design and implementation of new payment and delivery models to promote improved population health and further advance upmc’s integrated clinical business strategies. perkins served for 12 years as corporate medical director for blue cross blue shield of vermont, the largest vermont-based health coverage carrier.

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