Readers Write: The Interoperability Revolution Continues

The Interoperability Revolution Continues
By Mark Gingrich

Mark Gingrich, MS is chief information officer of Surescripts of Arlington, VA.

Remember when you would leave your doctor’s office with a handwritten paper prescription, and then need to bring it to the local pharmacy to be filled? Hard to believe that was the norm just two decades ago.

The height of innovation was swapping out this piece of paper for an electronic transaction. It was a simple enough concept, but the impacts have turned out to be profound. Electronic prescribing helped revolutionize how care providers and patients shared information, making prescribing safer and faster and connecting prescribers and pharmacists like never before.

Now, 60,000 pharmacies are connected and 2 billion prescriptions were filled using this technology in 2022 alone. E-prescribing serves as the basis for what we now consider healthcare interoperability, but the scale of healthcare interoperability advances every day. Our company, through subsidiary Surescripts Health Information Network LLC, has submitted its application to become a Qualified Health Information Network (QHIN) under the Trusted Exchange Framework and Common Agreement.

But what does healthcare interoperability mean for patients and clinicians? The definition can be something different depending on the stakeholder, yet the definition is far less important than the impact that healthcare interoperability has had and will continue to have in transforming patient care.

The impact is seen when clinicians have the right patient information, such as medication history and clinical documents, at their fingertips, at the right time, and can provide safer, better informed, and less-costly care for their patients. This means stronger, trusted relationships between patients and care providers.

Our company’s master patient index makes it possible for health information for nearly every patient to be accessible by 2 million care providers. Interoperability means connecting 250,000 clinicians across all 50 states and Washington, DC to access 100 million clinical documents each month in 2022, delivering the information they need to care for their patients in the most meaningful way possible. Applying to become a QHIN is the next step towards amplifying our impact in ensuring that care providers can quickly and easily access the information that they need to provide safe, quality, and lower-cost care for their patients.

Readers Write: Five Takeaways from The Sequoia Project’s Annual Meeting

Five Takeaways from The Sequoia Project’s Annual Meeting
By John Blair, MD

John Blair, MD is CEO of MedAllies of Fishkill, NY.

I recently attended the annual meeting in San Diego of The Sequoia Project, a non-profit that advocates for health IT interoperability, and was impressed with the spirit of collaboration and optimism as stakeholders look forward to taking the next steps toward making interoperability a reality.

Without a doubt, interoperability has been a top-of-mind subject for many years for many of us in attendance, but the issue has gained renewed focus recently, as Qualified Health Information Networks (QHINs) are poised to launch.

QHINs are an essential component of The Trusted Exchange Framework and Common Agreement (TEFCA), a new regulation backed by the federal government and intended to improve interoperability. TEFCA’s goal is to establish a universal floor for interoperability across the country by developing the infrastructure model and governing approach for users in different networks to securely share basic clinical information with each other.

In addition to QHINs, other key issues discussed included: interoperability use cases, the benefits of Fast Healthcare Interoperability Resources (FHIR), the unique challenges to health information exchange for public health, and how today’s patient experience can be improved leveraging existing technology and investments.

My five biggest takeaways include:

1. QHINs will be quickly migrating customers from their current networks to the new QHIN networks.
2. Although QHINs will be competing for customers, they plan to cooperate with each other as the networks become operational. They understand that a network of networks is only as good as the weakest network, and it’s essential that they help and support one another in day-to-day operations. Without cooperation, customer support will suffer and the overall success of QHINs will be at risk.
3. Interoperability stakeholders are anxious to get the current uses up and running. These use cases include treatment, individual access services, payment, health care operations, public health, and government benefits determination.
4. Although the treatment use case has been active for many years, there is still work to be done around data quality, quantity, and end-user workflow.
5. Data usability is set to take center stage. A plethora of health data is already being exchanged, but its value is often limited due to issues with normalization, fragmentation, and usability. QHINs will help solve these limitations by driving greater accuracy and completeness of patient health data.

Open questions remain regarding the ultimate effect that TEFCA and QHINs will have and their ability to generate nationwide interoperability improvements. However, the energy and enthusiasm that were palpable at the Sequioa Project’s annual meeting will likely fuel efforts to overcome inevitable roadblocks as stakeholders work to address current and future regulations and advance efforts to increase the volume and utility of health information exchange.

Readers Write: Navigating the Telehealth Regulatory Labyrinth

Navigating the Telehealth Regulatory Labyrinth
By Sheeza Hussain

Sheeza Hussain is chief growth officer of SteadyMD of St. Louis, MO.

Telehealth has the potential to amplify its impact on healthcare access while further reducing costs, but a web of state regulations is hindering that promise.

Telehealth became a household term for millions of Americans in 2020, emerging as a vital component of healthcare delivery. It helped bridge the gap caused by clinician shortages, tackled certain social determinants of health, and facilitated care for rural patients who otherwise struggle to access it.

However, the rapid expansion of telehealth has exposed a glaring issue – a labyrinth of regulatory and legal obstacles. State licensure variability, reimbursement policies, telehealth parity laws, cross-state regulations, and other hurdles continue to impede adoption.

Licensure is just one complicating factor in the telehealth regulatory maze. Many states have differing regulations on nurse practitioner scope of practice, with variance in whether NPs can operate independently, require physician oversight, or are restricted entirely. This patchwork hinders multi-state advanced practice clinician telehealth.

Additionally, certain modes of virtual care like asynchronous visits face ambiguity, as some states allow reimbursement while others prohibit or fail to address it. Like licensure, these state-by-state discrepancies in nurse practitioner and asynchronous visit policies make scaling telehealth availability and minimizing legal risk complex for providers. Overcoming the regulatory headaches requires close tracking of each state’s evolving rules.

Among the three primary challenges, the perplexing variations in state licensing rules are the most significant.

Healthcare providers are required to be licensed to practice in the state in which their patient resides. In some cases, patients are forced to cross state borders to receive telehealth services from their chosen physicians.

The disparities in telehealth policy between states are glaring. For instance, North and South Dakota, as well as Virginia and West Virginia, don’t see eye to eye on telehealth regulations. This patchwork of policies is emblematic of the broader problem – 50 states, each with its own set of laws, medical communities, and stakeholders, all contributing to the complexity of telehealth regulation.

The existing state-by-state licensure processes are antiquated, leaving telehealth companies that operate in multiple states grappling with a complex and ever-changing regulatory landscape. A common requirement is that telehealth providers must hold licenses in the state where their patients are located. However, this doesn’t simplify telehealth; it complicates it further. Most providers are licensed only in one or two states, limiting their usefulness to telehealth companies operating across several states.

Obtaining licenses in additional states is a costly and time-consuming endeavor for telehealth companies. They must build a roster of multi-state providers, carefully manage supply and demand, and ensure compliance with the laws of each state they serve.

Calls for modernizing licensure portability have gained momentum, with some advocating for a standardized federal system akin to driver’s licenses. However, this transformation won’t occur overnight. As telehealth becomes increasingly integrated into healthcare, state regulations may eventually become more uniform, but this change is unlikely to happen soon. The healthcare industry can advocate for greater licensure portability, such as the implementation of a standardized federal licensing system, but providers need relief now.

In the meantime, telehealth providers are seeking alternative solutions. Many are opting to partner with telehealth infrastructure providers that guarantee compliance with state laws, recruit and manage providers, and stay current with shifting regulations. By entrusting an external partner to navigate the intricate regulatory landscape, telehealth providers can focus on what truly matters – providing the best care to their patients.

Readers Write: Surviving the Blizzard: How Technology Can Ease Specialty Medication Re-Enrollment Season

Surviving the Blizzard: How Technology Can Ease Specialty Medication Re-Enrollment Season
By Julia Regan

Julia Regan, MBA is founder and CEO of RxLightning of New Albany, IN.

One of the most challenging times of the year for providers, medication access staff, biologics coordinators, and other team members who support specialty medication onboarding is re-verification and re-enrollment season, which is aptly known as Blizzard Season.

While insurance selections are finalized and patients are counting down the days until the new year, coverage modifications on the back end can cause significant challenges in medication access. Most common adjustments include updates to a coverage policy and a new prior authorization requirement, reset deductibles, the end of co-pay assistance and patient assistance programs (PAP), or the selection of an entirely new insurance provider.

Some of these changes can wholly prevent the continuation of medication fulfillment, while others – like deductible and financial assistance resets – may surprise patients enough to forego the unexpected costs and immediate adherence to their meds.

Manufacturers, hubs, and patient support groups often hire small armies of workers to meet the influx of benefits verification demands, but this model is inefficient and expensive. While much of the work cannot be started until updated forms and insurance details are finalized, a robust Blizzard Season plan is a necessity.

To accelerate the benefits verification process and reduce the resources and costs required, providers should understand which plans, manufacturers, FRMs, and hubs they may be working with, and proactively collect as much information about coverage changes and patient health changes so that re-submitting paperwork can be more nearly seamless. Additionally, teams should communicate with patients early to understand who may be changing plans, alert them of potential upcoming requests such as signatures required and plan details, and support them through this confusing time.

While many programs transition on January 1, enrollment or PAP forms are often available 1-2 months ahead of time, enabling teams to get a head start on the re-enrollment process. With the right plan of attack, as well as the right technology, Blizzard Season can be more efficient and straightforward.

There will always be a need for real people to manage some of the more complex patient cases, wherein new coverage restrictions, financial assistance, or prior authorization is required to continue a patient’s care regimen. However, a significant portion of re-enrollments and re-verifications can be streamlined by using technology.

In many cases, the first step for re-enrollment is finding the appropriate medication or PAP paperwork and completing the paper form correctly. While this may seem simple, completing thousands of paper forms is a tedious and error-prone task. With new digital enrollment technologies, providers and care teams can be assured that they are completing the most up-to-date form with no missing information, greatly reducing the risk of a downstream issue in the application.

Another important step that can be streamlined with technology is (re)confirming the patient’s insurance and completing an eligibility and benefits check. Instead of manually scrolling through documents on a plan’s website or calling a representative to confirm coverage, real-time connectivity can accurately display a patient’s plan details while providing insight into cost and restrictions required, reducing time spent confirming details and allowing stakeholders to move on to more complex steps of the process.

Next, collecting consent. While patient and provider signatures are necessary to re-enroll for a specialty medication or PAP, with the click of a button, email and SMS notifications can be sent to appropriate stakeholders to securely sign documents from wherever they might be. No waiting until the next in-person visit or stop by the desk to collect a signature. Instead, consent can be collected remotely in a matter of seconds.

As mentioned, with deductibles, co-pay, and PAP all resetting, it is essential for technology to surface affordability options that can support patients, whether through long-term PAP enrollment, foundation or grant support, or short-term, low-cost options that a patient can receive in the interim while their specialty medication enrollment is being finalized. With an interconnected network of coupon and discount providers, care teams can easily identify and communicate with patients about affordable options that are available to them.

One of the most time-consuming tasks of the re-enrollment process is filtering which patients are qualified for PAP or financial assistance programs. Major credit check companies now allow technology vendors to connect into their systems to provide real-time insight into income and credit score, enabling an initial verification of assistance eligibility. Using this technology can greatly fast-track certain patient cases over others.

The unfortunate truth is that manufacturers, hubs, patients, and providers all have work to do to complete a specialty medication re-enrollment successfully. However, from digitized forms to automated eligibility checks, and digital consent collection to real-time notifications, the process to re-enroll a patient is more streamlined, personalized, and error-free than ever before.

With a thoughtful plan, innovative technologies, a robust ecosystem, and proficient staff, Blizzard Season can require less resources and time, enabling what matters most, consistent care with no lapse in medication access.

Readers Write: Bracing for the Silver Wave: How to Design a Healthcare Technology Stack Built for the Future

Bracing for the Silver Wave: How to Design a Healthcare Technology Stack Built for the Future
By Amanda Hansen

Amanda Hansen is president of AdvancedMD of South Jordan, UT.

For some time now, the healthcare industry has been focused on preparations for the coming Silver Wave, the first time in our nation’s history that adults over the age of 65 will outnumber children 18 years old and younger. This dramatic shift in age demographics has major implications for healthcare providers and the patients they serve. As patient populations age, physicians and their staff will need to reconsider everything from the services they provide and the ways they deliver care to the technology solutions that underpin their systems.

Private medical practices are especially vulnerable to the coming changes. Without the resources and budgets of large healthcare networks, many private practices will face a number of challenges associated with the Silver Wave, some of which have already taken root. Chief among these challenges is ineffective technology solutions that fail to meet the needs of an aging patient population. Few private practices have a crystal ball to help them plan for the future, but there are definite steps healthcare providers can take now to prepare for transitions ahead.

As we enter the beginning stages of the Silver Wave, EHR systems will be even more critical to the patient experience. The increased demand for healthcare services that come with caring for older patient populations translates to increased EHR use and greater need for truly interoperable systems.

The impending shifts associated with the Silver Wave require technology solutions that can effectively manage multiple components of care, from basic patient demographics and healthcare records to complex healthcare services often related to elderly patients. Private practices will need EHR systems that can accommodate and support patient records with multiple healthcare providers, complex treatment plans for chronic illnesses, and increased prescriptions, all dynamics connected to elderly care.

EHR platforms are a crucial component of every healthcare technology stack, now and even more so in the future. Without the right solution in place, interoperability becomes a major obstacle that can significantly impair patient outcomes, the financial health of the private practice, and the overall patient experience, a challenge that will be more difficult to overcome as we near the massive shift in patient ages.

During the pandemic, telehealth became an essential healthcare delivery model. It also opened the door to all new opportunities for underserved patient populations, giving rural areas access to a broader selection of healthcare services and providers. In the last few years, telehealth adoption rates have continued to skyrocket. Now, as the healthcare industry faces a future with more patients over the age of 65 than under the age of 18, telehealth and other alternative healthcare delivery models will become integral to the healthcare experience.

Fortunately, many private practices have already tapped into the potential of telehealth, offering virtual visits to patients who desire more flexibility and convenience when scheduling doctor appointments. For aging patient populations, telehealth is no longer a “nice to have,” instead, it becomes a critical need for people unable to leave their homes. Telehealth, combined with at-home care services and remote patient monitoring (RPM) devices, enable healthcare providers to deliver comprehensive treatment to those most in need.

Similar to effective EHR platforms, alternative healthcare delivery models demand technology solutions that enable seamless processes. Telehealth platforms that are safe and secure, but also offer intuitive user-interfaces ensure physicians can care for all of their patients. At-home care requires technology that allows healthcare providers to update patient records in real-time outside of their office. Same with RPM devices: physicians need technology platforms that effectively integrate with RPM solutions to monitor things like blood pressure, heart rate data, and other medical details for at-risk patients managing chronic illnesses.

Many of the technology solutions that will help bolster healthcare services for the coming silver wave are primarily implemented and managed by the healthcare provider, but it’s important to acknowledge how they will impact the patient. While some may assume that an elderly patient population may be tech-averse, recent reports have revealed just the opposite.

After surveying more than 21,000 adults over the age of 55, McKinsey Health Institute discovered the smartphone was the preferred technology device for the vast majority of respondents ages 55 to 64. Nearly 50% of this same age group listed a tablet or laptop as their preferred device. In fact, when it came to barriers around embracing technology, survey participants cited cost and lack of knowledge. In other words, cost-effective technology paired with effective training that teaches patients how to use various tech devices and apps could mitigate many of the technological challenges facing older patients.

It’s worth noting that the silver wave will include a segment of Generation X, the first generation to use email, search the internet, and download songs to their iPod. If ever there was a generation primed for digital healthcare services, Gen X is it. In the same way an early diagnosis allows for improved patient outcomes, early investments in highly effective technology will enable private practices to establish a robust foundation that not only delivers immediate gains but will sustain their practice during the coming silver wave and all the challenges it will bring.

Readers Write: Easing HCC Coding Adoption by Using Insights and Assessment for More Accurate Data

Easing HCC Coding Adoption by Using Insights and Assessment for More Accurate Data
By Shahyan Currimbhoy

Shahyan Currimbhoy, MS is vice president of product of Edifecs of Bellevue, WA.

Healthcare provider organizations that are participating in Medicare Advantage plans are acutely focused on the adoption and execution of Hierarchical Condition Category (HCC) coding. HCC is a healthcare risk adjustment model that is used to predict the healthcare costs of individuals or populations based on medical conditions. Adoption requires disciplined and accurate documentation and coding of all relevant medical conditions to properly reflect the health status of patients. Accuracy is critical. Even the slightest inconsistency or error can impact risk scores and subsequent reimbursements to providers.

HCC coding is an important model for healthcare reimbursement risk adjustment because it offers the benefit of accurately predicting healthcare costs. Unfortunately, as it has been put into practice, it has elevated some operational challenges. It’s no secret that coding has long-been an administrative burden on the healthcare system. Over time, we’ve learned that automated, integrated, and system-wide technology can help reduce these burdens. In the present evolution of our healthcare system, we also know the viability of value-based care (VBC) desperately depends on alignment between documentation, provider engagement, and claims coding.

The implementation of HCC coding requires a thoughtful approach. If done right, organizations could quickly see opportunities to refine and improve the encounter documentation process and care delivery.

Your HCC Coding Approach: Collaborate with Clinicians

As care teams recognize HHC coding as a critical component of an organization’s business model, identifying the right deployment approach is an important early step. Each health system will take a different approach, but change must be met with ease and collaboration. Organizations that attempt to move into alternative payment models (APM) by flipping the switch overnight on new processes or technologies will encounter pushback from care teams and coding staff. Value-based payment participants will have a better outcome if they ease into the transition, including starting with tools that are made for VBC, and weaving them into the existing team structure and processes.

Care teams and coding staff will have questions. Will HCC coding be addressed before, during, or after the visit? Will coders and clinicians collaborate in person or electronically? Consult your clinicians before determining the best approach. Excluding them will undoubtedly result in a missed opportunity to best understand how strategy could impact their day-to-day workflows, which can lead to a more challenging implementation process.

A collaborative approach will result in more accurate coding in the long run, playing a huge role in reducing the time providers are spending confirming or rejecting a suspected condition.

Coding Insights and Provider Education Support Entering High-Risk Sharing Arrangements with Confidence

Even with automation and collaboration tools, care teams that have incorporated HCC can still find themselves coding inconsistently. For leadership to understand where education and resources are needed, there needs to be provider-level visibility of coding efficacy. Without data-driven insights into provider quality risk operations, this can prove challenging.

With the proper sources, providers can build patient registries, identify where the patients are, and build standard care pathways to ensure that patients are getting proper care. Leadership can gather the clinicians to share knowledge and identify variations in care. Treating HCC coding as a discipline, rather than as an administrative or financial function, helps ensure alignment between providers and the coding team, which drives improved patient outcomes.

Organizations with confidence to move into high-risk sharing arrangements can use automation and natural language processing (NLP) to drive scalability, collaborative tools that allow care teams to work in unison, and performance analytics to help the whole care team continue to improve.

Using “MEAT” to Fully Assess New Conditions Against Patient History

VBC payment models often require a comprehensive understanding of a patient’s medical history, always culled from various sources and locations. Consolidating diagnostic codes linked to HCCs becomes difficult when a patient is treated at multiple departments within a clinically integrated network (CIN) with separate EMRs. In today’s state of financial resources, the right integrations and automation tools are key.

Organizations are empowering clinical review specialists by giving them a comprehensive view of each patient’s medical history, as well as the tools needed to help identify the gaps in care. If medical history is reviewed prior to an encounter, it can reduce some of the burden on clinicians during the patient visit. With the comprehensive view and additional time, providers can better assess new potential conditions using the acronym “MEAT” as suggested by the AAPC (monitoring, evaluating, assessing/addressing, and treating).

MEAT serves as the connective tissue between documentation, provider intervention, and claims coding, and is essential for any reliable risk adjustment program. VBC relies on this alignment, confirming that money is flowing to organizations that are most at risk, and ensuring that patients with chronic conditions are served efficiently. Combined with tools that simplify HCC recapture, such as artificial intelligence and machine learning, these approaches can save time across the care team and ensure care continuity and revenue capture for chronic disease management.

Stop Using Old Solutions for New Practices

Automation tools and assessments like MEAT help care teams, providers, and coders ensure that HCC coding accurately reflects the true burden of patient populations. Without the necessary systems and technology infrastructure in place, following the guidelines in practice can be challenging. Health systems that are incorporating VBC arrangements often expect to solve new problems with old solutions, and that is just simply not realistic. Organizational efficiencies leading to increased clinician satisfaction, improved financial performance, and better clinical outcomes can be realized with the right operational components to support automation, visibility, and collaboration for both provider organizations and health plans.

Readers Write: It’s Time to Hold Payers Accountable For Their Games

It’s Time to Hold Payers Accountable For Their Games
By Matt Seefeld

Matt Seefeld is EVP of MedEvolve of Little Rock, AR.

Payer, provider, and patient alignment — it’s the holy grail of healthcare’s focus on value to ensure the best care is delivered at the lowest cost. And while industry stakeholders have the best intentions to achieve this critical big-picture goal, the average healthcare organization sinking in denials management knows that we still have a long way to go.

A report issued by the Kaiser Family Foundation in 2022 reveals the continuation of year-over-year trends of high rates of claims denials. The report found that approximately 18% of in-network claims were denied on average during the reporting period, but some plans reached as high as 80%. This reality equates to increased burdens on revenue cycle teams and delayed reimbursements, two challenges today’s healthcare organizations must mitigate amid burnout, staffing challenges, and tight operational margins.

While provider organizations are wise to implement infrastructures and automation to ensure clean claims are delivered to payers on the first try, they should also consider how to improve reimbursement through the lens of payer accountability. For instance, understanding payer mix and where an organization is getting the most bang for its buck can provide a foundation for better negotiating power.

Jumpstarting a payer accountability strategy starts with visibility into key payer trends and data, or the ability to maintain a payer scorecard.

Payer Scorecard: Laying the Foundation for Payer Accountability

Improving operational margin is imperative for today’s physician practices. As shifting reimbursement models place more financial responsibility on patients, healthcare organizations must have a holistic strategy that proactively addresses the full lifecycle of billing processes to maximize use of limited and expensive internal resources.

Effectively negotiating with payers is a key part of this strategy, yet few provider organizations understand where they are getting the most ROI against work effort with their health plan partners. For example, can your executive team answer the following questions?

• How many claims touches did it take to get paid from Payer A compared to Payer B?
• What is the ratio of zero-touch rate (claims paid without humans getting involved), denials, and work effort between Payer A and Payer B?
• How does at-risk AR, collection effectiveness, and work effort stack up between payers?
• What is your denial overturn rate and associated work effort to achieve this result?
• Which health plans are having the greatest impact on gross collection rate (GCR) and net collection rate (NCR)?

When providers can identify payers that are creating the most internal revenue cycle havoc or have poor ROI when compared to work effort, they are empowered to confront issues head on. For example, it’s fair to ask why reimbursement from Payer A appears in 14 days while Payer B takes 28 days on average. Or why my organization is getting 60 cents on the dollar from one managed care contract and 70 cents on the dollar for another. In either case, maybe it’s time to stop seeing a particular carrier’s patients and opt for better contracts and partnerships.

Increasing Zero-Touch Rates Through Payer Accountability

The goal for any healthcare organization’s revenue cycle is to achieve the highest zero-touch rate possible. Not surprisingly, this measure reflects claims that are processed and paid without any human involvement. When that happens, work effort and cost to collect automatically goes down, and revenue cycle teams operate more efficiently.

A 26-location, 75-provider orthopedics and neurosurgery group set a course to improve its zero-touch rate with payer accountability as a key part of the strategy. To do this, they needed visibility into the daily work of every staff member and a way to track payer interactions. Because EMR and practice management systems do not have the analytics capabilities to produce the level of granularity and visibility to answer key questions, the organization deployed a framework of effective intelligence to identify where breakdowns were occurring along the revenue cycle that required human intervention.

They created a dashboard to measure zero touch visits against claims edits, refiles, denials, and actions required by the billing team to get paid. This strategy complemented other payer accountability use cases that compared work effort against at-risk AR as well as how each payer was impacting net collection rates (NCR). In essence, the team developed and maintained an ongoing payer scorecard.

Since implementing this dashboard, the organization has been able to improve its payer contract negotiations and refocus efforts around the greatest ROI. Early results have been promising:

• 98% NCR, above industry benchmark of 97%.
• 77% increase in production from redesigned processes.
• 62% zero-touch rate.

At a time when insurance companies are reporting billion-dollar profit margins and providers are finding it increasingly difficult to stay independent (or in business), it’s important that healthcare organizations have proactive visibility into payer insights. Payer accountability must become a strategic part of broader revenue cycle processes to maximize bottom-line impact and position for a viable future.

Readers Write: Accelerating Redetermination: Social Drivers of Health and 1115 Waivers

Accelerating Redetermination: Social Drivers of Health and 1115 Waivers
By Jaffer Traish

Jaffer Traish is COO of Findhelp of Austin, TX.

Medicaid Redetermination

Medicaid continues to be the largest healthcare funding vehicle in the United States. From February 2020 to April 2023, Medicaid and the Children’s Health Insurance Plan (CHIP) enrollees increased 33% to 94 million individuals.

The declaration of the public health emergency (PHE) by Congress in March 2020 enacted a “continuous coverage” requirement, where Medicaid agencies couldn’t disenroll anyone unless they asked, moved out of state, or passed away. Traditionally, there is a churn or loss of enrollees due to non-responsiveness to forms requests, regular eligibility reviews, income changes, and so forth. When the PHE ended on May 11, 2023, state Medicaid agencies were given 12 months to initiate renewals and 14 months to complete them. For many states, unwinding from the PHE will last well into 2024.

Redetermination processing is an enormous undertaking. States are under pressure from the Centers for Medicare and Medicaid Services (CMS) which can track call center metrics and procedural terminations (for example, if the person couldn’t be reached). CMS could even request corrective action plans and implement financial penalties in the event of missed unwinding reporting as required by the Consolidated Appropriations Act.

Being a Medicaid director is a critical yet unenviable position for PHE unwinding, and some states have requested waivers to use simplified criteria to process redeterminations. It has been estimated by Kaiser Family Foundation that a staggering eight to 24 million enrollees may lose Medicaid coverage.

Innovating with CMS Waivers

One approach available to states, and growing in popularity, is the 1115 Waiver. The Secretary of Health and Human Services (HHS) can approve a waiver for a pilot or demonstration project that federal rules would normally not allow, including changes to eligibility, benefits, and provider payments.

As of August 2023, there are 68 approved 1115 waivers across 48 states. Interestingly, 19 of these have social drivers of health provisions. There are 33 more waivers pending approval, and 12 of these also include social drivers of health provisions.

Beneficiary Stability

By investing in non-traditional case management, housing, and nutrition, states are adding stability for enrollees with specific health-related social needs and anticipate a positive impact on redetermination. New York, for example, is awaiting approval on a several billion dollar waiver proposal to invest in creating major social care network structures.

Amanda Lothrop, COO of Medicaid for New York State, shared the significant role social care networks will play in the 3.5 year demonstration waiver to a large group of NY stakeholders on September 27.

Centene, UnitedHealth Group, Elevance Health, Molina, and Aetna control about half of the Medicaid Managed Care market across 40 states. They receive requests from states for both updated enrollee contact information to better process redetermination and to meet requirements for social care provider networks and claim processing as part of their benefit administration.

Three Themes: Understanding the Evolving Medicaid Population

In discussing these challenges with managed care organizations, government, schools, hospital systems, and community organizations, we hear three consistent themes:

• States are in the dark about the non-medical risks of enrollees and how this is impacting churn and cost. In particular, MCOs need early notification about the clinical and social risks of both adults and children. Not only to work to address them, but to conduct benefit eligibility determinations and proactive engagement.
• Hospital systems need to adapt to new Medicaid-led financial incentives to assess needs and initiate interventions. States may take for granted the community engagement (trust-building), network contracting, and technology implementation that is required for successful non-medical services delivery.
• A single care coordination technology mandate does not substitute for community interoperability. Care coordination is cross-sector and collaboration goes far beyond traditional healthcare. All industries should look to United States Core Data for Interoperability (USCDI) standards and follow rules such as the Michigan Health Information Network (MiHIN) interoperability pledge.

The Future of Redetermination

To stay rooted in reality, waivers come and go, as do the officials that approve them. In the long term, states should invest in enhancing their member engagement channels to reduce procedural termination, updating their public health analytics to include social risk, and reducing paper friction in the state benefit eligibility processing.

The Kaiser Family Foundation estimates that more than 4 million people have lost Medicaid coverage so far. States do not have to make redetermination data public, so the full scope is unknown until federal numbers are published later this year.

Imagine if:

• The MCO could retrieve current member contact information and social risk through hospital electronic health record (EHR) connectivity to contact members for redetermination and support. Epic Payer Platform and SchoolCare are two examples of vendors supporting these efforts.
• The acute and post-acute care providers could order waiver-approved social services based on automatic benefit authorization. CalAIM is an example of this enhanced care management.
• The community social service provider could document services and reimbursement codes would automatically associate in the system for claims. MassHealth supports codified services in this approach.
• States aggregate anonymized social risk, supply, and demand to inform future capacity investments and waiver services to expand or retract. CRISP HIE in Washington, DC is leading efforts in aggregated social services management.

The large redetermination effort nationwide and the requests by states to fund social services for beneficiary stability are fueling a renewed look at antiquated state benefit eligibility systems and processing. One prediction – we will start seeing API-based application submissions that enable fast determination and financial disbursements for state benefits.

We will be watching (and supporting) waiver implementations closely along with private sector investments in social drivers of health to better understand public benefit needs, direct service delivery, and accelerated redetermination.

Readers Write: Navigating the Early Days of Healthcare AI Integration

Navigating the Early Days of Healthcare AI Integration
By Michael Burke

Michael Burke, MBA is founder and CEO of Copient Health of Atlanta, GA.

Have you tried using any of the AI tools that have taken the world by storm recently? This article will probably be more helpful if you have some knowledge or experience with ChatGPT, Google Bard, Anthropic Claude, or any other LLM/chat model tool.

If you haven’t already, try asking one of these tools a specific question or give it an assignment to produce a specific document and see where it leads. You may be surprised at just how useful the results can be.

If you’ve used these tools to answer questions or generate content (e.g., a legal document, a policy document, an email, or an article like this one), you have some sense of their potential. Imagine what could be done with a tool that leveraged an LLM like ChatGPT on your hospital’s data. The software vendors you use are all either investigating or actively releasing tools powered by LLMs to leverage your data. At Copient Health, we are, too.

It’s my belief that these tools will fundamentally change the way you interact with those vendor systems and ultimately, in both the way that you do your work and the results that you get.

A comprehensive list of all use cases is impossible because we’re so early in the process, but here are a few obvious low-hanging fruit uses that are relevant for software vendors:

• LLMs are already powering chart notes that are built in real time from patient conversations.
• Dashboards and reports will become unnecessary, because you will always have the specific data or chart that you need just a query away. The LLM can even proactively push the appropriate information in the appropriate format for the appropriate context.
• You can forget about manuals, indexed help systems, or frustrating first-generation chat bots that perform poorly. LLM-powered solutions are better at finding what you’re looking for using a similarity search of a vector database.
• You might even abandon memorizing complex commands or menu hierarchies and ask the LLM to accomplish the task instead.

But ChatGPT and other public-facing LLMS were trained on public data. How can they be leveraged for use cases that require knowledge of private data?

The answer to that question used to take a lot of time, money, and a team of data scientists to train your own LLM, or at least fine tune an existing open source model. That has changed dramatically, mostly in the last 6-8 months, based primarily on a term that you may have heard: “prompt engineering,” and one that you probably haven’t: “in-context learning.” Here’s a quick summary:

LLM models are text-in, text-out black boxes. But the text-in doesn’t have to be limited to a simple question. It can include prompts of background information, examples of questions and answers to similar scenarios, chunks of data, or simply directing the LLM to “think step-by-step.”

These are all basic forms of prompt engineering. The LLM temporarily “learns” from this prompt data, at least enough for your current conversation. LLMs can be used as an inwardly-directed service to decide what data or tool to use based on the prompts that it receives. This design pattern has demonstrated better results than the more cumbersome fine-tuning approach for the smaller data sets that we’re talking about.

An entire ecosystem of software tools has emerged to support the use of these pre-trained LLMs on private data. These tools convert the challenge from what was once an arcane AI data science problem to a data engineering problem, primarily built around prompt engineering and in-context learning.

Here’s an illustration of how quickly these tools have evolved and been adopted. One of the most widely used tools in the ecosystem, LangChain, was first introduced in October last year as an open source project from two college students. In a few months, its use expanded globally. The founders incorporated and raised $20 million in venture funding from Sequoia Capital. Since last October, they have garnered 60,000 GitHub stars, which is a measure of its popularity among software developers. For context, Python, the language the LangChain toolset is written in, has fewer stars over a significantly longer time period: 51,500 stars over six years. ChatGPT itself captured one million users in just five days.

This head-spinning rate of change gives an advantage to startups, given their rapid iteration and integration of new tools and ideas. Some large healthcare software vendors that are infamous for relying almost exclusively on internally developed tools find themselves in a challenging situation. It’s impractical for them to build their own LLMs, as they would likely never rival the performance of commercially available options, and it would take forever. And since they are not used to relying on third-party software as part of their solution, they aren’t prepared for the rate of change at which these solutions are evolving.

For instance, just yesterday, LangChain had 18 separate commits (i.e., changes) to their codebase. That’s fast! Adapting to rapid changes and advancements requires a new level of agility.

We’ve recently heard announcements and partnerships from big tech and big healthcare IT. It will be interesting to see if these announcements produce real value in the near term, or if they are just a way to buy time for the vendor to figure out this rapidly evolving space.

Readers Write: It’s Time for a National Patient Identifier

It’s Time for a National Patient Identifier
By Gregg Church

Gregg Church is president of 4medica of Marina del Rey, CA.

Congress has the power to make healthcare safer and less expensive for patients, payers, and providers. It can do this by removing the ban that prohibits using federal funds for the development of a unique national patient identifier.

The patient identifier system would give each patient a single ID that would follow them through their healthcare journey, regardless of provider or payer, while still protecting their private information. It would reduce medical and billing errors and denied claims, while eliminating countless hours insurers and hospital systems spend resolving patient matching errors. It would also aid medical research and make it easier for our healthcare system to respond effectively during national emergencies, like the COVID-19 pandemic.

The federal ban on a national patient identifier was born from good intentions. Former US Rep. Ron Paul in 1998 added the provision to the Labor-HHS appropriations bill. The physician and libertarian cited concerns about patient privacy and the dangers of the federal government collecting and centralizing medical records. His son, Sen. Ron Paul, also a physician and libertarian, now leads the opposition with the help of the ACLU and other groups.

Congress has come close to ending the ban. For the past four fiscal years, the House has removed it from its version of the appropriations bill; the Senate did likewise the past two years. Each year, however, it has been reinstated in the final budget.

In 2021, Patient ID Now, a coalition of more than 40 healthcare organizations, including the American College of Surgeons, American Heart Association, American College of Cardiology, The Joint Commission, and American Health Information Management Association, was formed to push for a nationwide strategy to address patient identification.

The group noted that the ban was put in place 25 years ago at a time when patient records were still largely kept in manila folders. It’s now a hindrance to the necessary digitization of healthcare. While concerns over patient privacy are real, a national patient identifier could be implemented in such a way that it protects patients.

I like to believe that much of the opposition to a universal patient identifier is due to a lack of awareness of the volume of incomplete, duplicate, missing, and overlaid medical records and the problems they cause.

Imagine if your personal finance records had a roughly one in five chance of being duplicated or mixed up with someone else’s accounts by financial institutions. Think of the chaos and damage and the ensuing demands to fix the problem.

Duplication of patient records is one of the most serious problems with healthcare data quality, and it’s more common than many think. Duplication rates are as high as 30% in some healthcare organizations, and a 10% rate is common. Up to half of patient records are not matched in transfers between healthcare systems. 

Patients are endangered by low-quality records, particularly duplicate and overlaid records, in which the data for two patients is mixed.

Approximately 70% of care decisions are based on lab tests, which are performed by techs working in relative isolation from the care team. Labs frequently create duplicate records while entering patient information into computers. That bad data can then be multiplied and disseminated throughout a hospital system and between systems.

Clinicians working from bad data can misdiagnose, prescribe the wrong course of treatment, and order duplicate tests, which delay necessary treatment.

Black Book in 2018 surveyed health technology managers about problems with patient identification processes. It found that the cost of medical care due to duplicate records averaged $1,950 per patient per inpatient stay and more than $800 per ED visit.

Those surveyed also estimated that 33% of denied claims were due to inaccurate patient identification or information. That cost the average hospital $1.5 million in 2017 and the US healthcare system more than $6 billion annually.

That unnecessary expense could be eliminated with a standard patient identification system.

True interoperability among patients, providers, and payers is a goal of the healthcare industry, one that could be made more achievable through a patient identifier system that allows for the disruption-free exchange of patient records.

While recent improvements in patient identification processes, such as hospitals adopting Enterprise Master Patient Indexes and the use of machine learning, have improved record matching, it’s barely keeping pace with the explosion in medical records and the sharing of data among different healthcare organizations.

Adopting a national patient identifier would be a significant step toward building a safer, and more effective and affordable healthcare system. It’s time for Congress to listen to the experts and remove the ban. We’ll all be better off for it.

Readers Write: Tell Me Again Why Fax is Superior?

Tell Me Again Why Fax is Superior?
By Dan Wilson

Dan Wilson is founder and CEO of Moxe Health of Madison, WI.

The “inherent security” provider argument in a recent KLAS report on digital fax is unfounded and a remnant of another era. User error is inherently possible when a process involves manual steps, and fax isn’t secure relative to more modern ways to encrypt and transact data between multiple parties. It’s also unlikely that faxing remains analog (using only a phone line), as groups are using Efax or VOIP lines with transactions going over the Internet and the fax isn’t actually encrypted. 

“Ease of use” sounds like the person who used to say that “no one will text, because it’s easier to just pick up the phone and call someone.” Faxing is easy only because finding a directory of where to send files electronically is so hard. If we solve the directory issue, the “ease of faxing” benefit is reduced.

Another way to think about ease of use is that it’s actually a tradeoff for security. Fax is easy because you send a document to a clinic’s single number. That means that the message isn’t specific to a patient or recipient. Anyone who has access to the fax machine can see the information. Rarely do you get both ease of use and security, but there’s a better set of options with digital exchange to select the right tradeoffs based on the sensitivity of the information versus just having a blunt tool.

Fax is hopelessly outdated. It creates enormous manual effort and adds cost on both ends of the transaction. A CAQH study estimates that faxing or mailing instead of using digital transfer costs $25 billion per year.

For the love of God, can we stop making doctors do a ton of work to digitize records and paying people to print them and fax them, taking those records from digital to analog and then to an even worse version of analog (an image)? And then consuming massive resources on the recipient’s end to try to reconstitute a digital copy of what started its life as a digital record? And along the way, losing fidelity of information in addition to people and compute time.

Tell me again why fax is superior?

Readers Write: What’s Needed to Resolve the Medicaid Redetermination Crisis

What’s Needed to Resolve the Medicaid Redetermination Crisis
By Carrie Kozlowski

Carrie Kozlowski, OT, MBA is co-founder and COO of Upfront Healthcare of Chicago, IL.

More than 90 million Americans, including children, the elderly, people with disabilities, and veterans rely on Medicaid for their health coverage. Many of them are now losing that coverage with the expiration of the COVID-19 relief laws this spring.

According to the Kaiser Family Foundation (KFF), as of mid-July, more than two million people have lost Medicaid coverage since April 1, 2023, with most of them removed from state rolls for technicalities, such as missing the deadline to complete their forms or to file certain required documents. The Centers for Medicare and Medicaid Services’ (CMS) also found that 31% of renewals resulted in someone dropping Medicaid or Children’s Health Insurance Program (CHIP) benefits, with an alarming 79% of the beneficiaries losing coverage due to procedural reasons, not because they no longer qualified due to income or changes in family arrangements.

In total, KFF estimates that 15 million people will be dropped from Medicaid over the course of the year under this “Medicaid unwinding” process. The result? Healthcare enterprises will experience a gap in compensation for care, operational efficiency will suffer, and patients will get sicker during this post-pandemic Medicaid redetermination period.

The federal government is stepping in to try to stem the crisis. On July 19, CMS reported that it has intervened with several states, requiring them to pause procedural terminations and reinstate individuals. Moving forward, the CMS will be closely tracking state data and fielding complaints to identify problems early with renewals and take corrective action, according to the fact sheet “Returning to Regular Medicaid Renewals: Monitoring, Oversight, and Requiring States to Meet Federal Requirements” released by the agency.

More efforts are needed, however. Basic lack of awareness about the changes in the laws is a key part of why the Medicaid unwinding process is turning into a crisis in many states. A Robert Wood Johnson Foundation survey, “Awareness of the Resumption of Medicaid Renewal Processes Remained Low in December 2022,” revealed that approximately 64% of Medicaid members had heard nothing at all about the enrollment requirements, leaving them vulnerable to losing their coverage.

All this is a significant concern, not only from a population health and health equity perspective, but it also because it has far-reaching financial implications for health systems and medical group that are already facing slim to negative operating margins. With declining enrollees, they risk further negative financial impacts and may need to increase staffing to facilitate point-of-care enrollment, adding to the costs and inefficiencies.

It is crucial for health systems to keep patients enrolled in Medicaid, not just for the sake of their health, but for the financial stability of their own operations. Keeping them enrolled ensures that they can continue to receive preventative care, which leads to improved health outcomes, protected reimbursement, and reduced overall healthcare costs.

From an operational standpoint for health systems, it is also in their best interest to keep Medicaid patients covered so they do not lose access to primary care providers, causing delayed time to treatment and sicker patients admitted to hospitals, flooding intensive care units, and causing backlogs in emergency departments that can reverberate through the hospital and can delay elective surgery schedules.

Alarmed by the numbers of people losing insurance, some states are taking a more proactive approach to notifying and educating people about the new verification process for maintaining coverage. But a one-size-fits-all approach will not be effective in communicating with this diverse audience. Connecting with these different populations requires understanding their unique needs and preferences and delivering culturally sensitive content in multiple languages. Digital health solutions are well positioned to help states and providers achieve their shared goal of engaging Medicaid patients.

Combining digital communications with human efforts is critical to achieving this daunting task. Trust plays a role as well, as more people with Medicaid express wariness about their providers. The report “A Two-Way Street: Building Trust Between People with Medicaid and Primary Care Doctors” published by Public Agenda found that four in 10 say doctors need to earn their trust. Communicating with these patients in culturally sensitive and health literate language should be central to the strategy for engaging them to play a more proactive role in their healthcare.

By leveraging patient data and insights, technology can help personalize the content and optimize the outreach by channel, ultimately improving effectiveness and ensuring that patients do not get lost, while building a greater bond of trust between them and their providers.

As states continue to unwind the Medicaid continuous enrollment provision, there are opportunities to promote continuity of coverage among enrollees who remain eligible by implementing a patient engagement strategy that leverages digital communications along with human efforts to reach, educate, and activate patients.

Readers Write: The Illusion of EHR Interoperability

The Illusion of EHR Interoperability
By Pawan Jindal, MBBS

Pawan Jindal, MBBS, MHI is CEO of Darena Solutions of Chesterfield, MO.

Isn’t EHR interoperability great?

It would be, but there is a huge gap between the published standards and the reality. Sharing data among healthcare providers, health plans, and patients was supposed to be much easier now that EHR interoperability through FHIR-enabled apps is the universal standard. Developers should have been able to integrate their SMART on FHIR apps with virtually any EHR and have the resulting integrations work seamlessly across multiple platforms. Sadly, it is not working as intended.

In Q1 2023, the Office of the National Coordinator for Health Information Technology (ONC) reported that 95% of certified health IT developers met the December 31, 2022 compliance deadline to enable access to information through application programming interfaces (APIs) “without special effort.” However, our experience with FHIR app developers, providers, and EHRs shows that true EHR integration remains elusive, despite ONC’s claims.

Out of the nearly 300 EHRs certified by ONC to be interoperable with FHIR-enabled apps, only a few allow developers to integrate apps with their EHRs. By enforcing the Cures Update requirement only on EHR vendors, ONC is not penalizing providers, the ones who seem to be refraining from information sharing. Out of the total 763 claims of information blocking filed so far with the ONC, 85% of the claims (646) are against providers. This problem is further exacerbated by the fact that provider education on the benefits of information sharing from ONC is severely lacking.

The Information Blocking provisions of the Cures Act currently only mandate making data available to patients upon request. The EHRs have geared up to allow providers to honor these requests. However, if you ask providers, they say, “No one is asking for it, or I send them to the patient portal, or I ask them to fill out a request form to obtain a hard copy of their records.”

Most providers aren’t aware of the requirement to provide data to patients in an app of their choice. If healthcare is ever to achieve a reality that includes easily integrated apps facilitating the seamless sharing of patient data between organizations, it must actively engage providers in information sharing.

Healthcare has been working toward interoperability for a while through the creation of rules and standards. It’s been three years since the Centers for Medicare and Medicaid Services (CMS) adopted the interoperability rule, removing many barriers that prevented patients from accessing their health data. The rule also issued version 1 of the US Core Data for Interoperability (USCDI v1) standard that EHR vendors must meet for ONC certification.

An information blocking provision went into effect in 2021 requiring EHR vendors, providers and others to share the data specified in USCDI v1. That rule was expanded in 2022 to include even more types of data. Last year, ONC also published the Trusted Exchange Framework and Common Agreement (TEFCA), which sets a nationwide standard for interoperability and establishes the process for health information networks to become Qualified Health Information Networks (QHINs), a sort of “super network” for sharing data.

FHIR (Fast Healthcare Interoperability Resource) is the standard developed to enable this data exchange. It can be used on its own and with existing standards, like the USCDI and billing-related data elements used in EHRs. FHIR-based apps are designed to be used with any FHIR-capable EHR. It is important to note that the TEFCA agreement is meant to establish a minimum standard for performance across the healthcare continuum. Based on that, FHIR is on the map for future phases and is not required out of the box.

So why does widespread EHR interoperability remain an illusion despite ONC claims?

Glitches are to be expected any time there is development and adoption of a new technology standard, particularly one that must integrate with older EHR platforms. Companies, sometimes unwittingly, fail to disclose all the ins and outs of their products and capabilities. Take for example, NextGen Healthcare’s agreement this summer to pay a $31 million fine to settle claims that the company misrepresented its software’s capabilities and paid users kickbacks for their endorsements. Similar cases have resulted in settlements with other EHR vendors, including EClinicalWorks, Practice Fusion, Greenway Health, and Modernizing Medicine.

Even when considering glitches and a few bad actors, it’s become obvious that ONC certification alone doesn’t necessarily guarantee successful app integration in the field because developers, EHR vendors, and healthcare systems continue to struggle to achieve interoperability.

For its Health IT Certification Program, the ONC includes a Real World Testing annual requirement. According to the website, “The purpose of this Condition and Maintenance of Certification requirement is for Certified Health IT Developers to demonstrate interoperability and functionality of their certified health IT in real world settings and scenarios, rather than in a controlled test environment with an ONC-Authorized Testing Lab.”

Anyone with experience in IT development (or any complicated technology, for that matter) knows that what works well in the lab can fail in the field. That’s because real-world conditions and demands can be more challenging than what designers anticipated. This highlights the need for more realistic real-world testing from the ONC in addition to tests conducted by independent entities. Currently, each EHR tests its own application in the field. Unsurprisingly, they all seem to replicate the certification testing. We need a Consumers Reports-style impartial review for health IT.

In the meantime, app developers and other stakeholders can work with third-party experts who can guarantee EHR integration.

Readers Write: From EHRs to EOM: Enhancing Oncology Model Highlights Limitations of Current Clinician-Facing Tech

From EHRs to EOM: Enhancing Oncology Model Highlights Limitations of Current Clinician-Facing Tech
By Kathy Dalton Ford

Kathy Dalton Ford is chief product and strategy officer at Ronin of San Mateo, CA.

For years, healthcare leaders have prioritized improving patient access and care delivery through value-based care (VBC) initiatives. However, according to a 2022 report, value-based contracts only accounted for 7% of medical revenue among primary care specialties, 6% among surgical specialties, and 15% among non-surgical specialties. These percentages indicate that despite the efforts of healthcare leaders, there is still a long way to go to implement VBC programs fully.

To address this issue, the Centers for Medicare & Medicaid Services (CMS) introduced a range of value-based care models, including the Enhancing Oncology Model (EOM). EOM, a voluntary five-year model that commenced on July 1, 2023, aims to improve the quality of care while reducing costs through payment incentives and required participant redesign activities.

Provider organizations must use certified Electronic Health Record (EHR) technology as part of the required redesign activities. EHRs are ubiquitous, with nearly four in five office-based physicians (78%) and almost all non-federal acute care hospitals (96%) adopting a certified EHR as of 2021. However, EHRs facilitate billing rather than inform care decisions, lacking the all-important ePROs and daily insights into patient conditions to inform effective cancer care. 

While EHRs support billing and reimbursement, they present several challenges for physicians in delivering timely, quality patient care, resulting from time-consuming data entry, interoperability issues, un-optimized user interface design, and lack of standardization. These problems make it challenging to access vital patient information at the point of care, increasing the time required to document patient encounters and potentially leading to errors or missed details.

Many organizations don’t have the tools to implement VBC-based programs and payment models, making EOM’s implementation governance and reimbursement support critical in realizing these life-saving initiatives. Meeting EOM requirements cannot solely be fulfilled by care teams and EHRs alone. Health systems must adopt clinical decision-support technologies that consider the patient experience outside the hospital, connect patients to their care team, and integrate safe and ethical artificial intelligence (AI) to fill the gaps in existing capabilities and realize the benefits of value-based care.

Today’s AI technology can pull data from unstructured clinician notes, accelerate time-consuming chart reviews, and improve care by analyzing data to produce actionable predictive insights. By pairing AI with a robust decision support platform and ePROs, cancer centers can provide patients with 24/7 access to care teams, streamline patient-to-care team communications, engage patients, screen for social needs, deliver health education, and identify patients at risk for adverse events.

Health systems must adopt solutions incorporating safe and ethical AI tools that accelerate precise clinical care decisions and rise above the competition to leverage EOM and capture new revenue without the burden of adding more steps to their workflows. By doing so, healthcare leaders can improve patient access and care delivery while reducing clinical and administrative burdens and realizing the full benefits of VBC programs.

Ultimately, the goal of EOM is for patients to feel better supported in their care; have a clearer understanding of their diagnosis, prognosis, and outcomes; and adhere to their treatment plan. However, the tools and data to help clinicians meaningfully facilitate their job have yet to be available.

Hospitals now have an opportunity to leverage technology to help them realize the vision of comprehensive, coordinated cancer care.

Readers Write: Navigating the Future of Clinical Information Post-Public Health Emergency

Navigating the Future of Clinical Information Post-Public Health Emergency
By Greg Samios

Greg Samios, MBA is president and CEO of the clinical effectiveness business of Wolters Kluwer Health.

The global health community has acknowledged the official end of the COVID-19 public health emergency (PHE). The impact of the PHE had both positives (telehealth) and negatives. Of the latter, there are many, but the rampant flow of inaccurate and misleading information, also known as the infodemic, is a key one because of its direct impact on patients.

This infodemic highlighted the important role clinical decision support (CDS) tools play in distributing a high volume of reliable, trustworthy, and ever-evolving information to clinicians around the world. As the global health community looks to the future, there are a few lessons from COVID-19 to consider about the power of CDS.

The PHE may have ended, but what about the Infodemic?

The end of the PHE offers a moment of reflection about where the industry goes next to ensure that CDS continues to support clinicians through distributing reliable, transparent, and consistent information across care teams. It also opens the possibility for a period of uncertainty and unpredictable increases in the variability of care.

Looking ahead – as healthcare leaders consider both ongoing threats of COVID-19 as well as the inevitable next pandemic – CDS resources could be leveraged to improve speed and transparency and more effectively reach public health goals during an infodemic. The industry needs to focus on how it can be agile in distributing continually emerging and changing information in the next PHE.

But there is another challenge looming to further deepen the entrenchment of the infodemic: the arrival of generative AI, including ChatGPT. While generative AI offers potential for healthcare, it may also present risks if not developed and applied responsibly. This could be particularly critical around its use in clinical care.

CDS everywhere, including virtual

The PHE helped deliver new avenues for patients to interact with healthcare providers, such as virtual visits. It also proved and elevated the important role that local retail pharmacists play as an extension of a patient’s care team – providing COVID tests, vaccines, treatment, and counsel to patients, among other key responsibilities. The challenge for the future will be to ensure that no matter where patients interact with their care team, they receive the most optimal and consistent care as possible.

In tandem with these shifts, it’s crucial that healthcare systems work together and provide smart, consistent, and accurate information. CDS resources offer a standard approach to align the thousands of micro-decisions clinicians make every day, from physicians in the emergency room to primary care doctors at urgent care to virtual care at home and pharmacists at the neighborhood pharmacy.

Closing the care variability gap

There is still a great deal of care variability, depending on which clinician a patient visits, where the patient lives, how much insurance and social support a patient has, and numerous other factors. Regardless of circumstances, clinicians should still have access to the most recent data and treatment recommendations. COVID-19 demonstrated that when information is widely shared, CDS resources can swiftly close the gap whether clinicians are eight or 8,000 miles apart.

More data, more insight

CDS is standard for clinicians to search data to diagnose patients. But the power of those searches can also create new data that can provide a broader set of insights. By analyzing clinician search queries, CDS enables providers to see around corners and proactively observe trends and understand usage patterns, such as which clinical questions are most important.

CDS resources can also share new medical updates with millions of providers and push notifications within the workflow of electronic medical record (EMR) systems to quickly educate clinicians with treatment recommendations that are trustworthy, verified, and improve patient outcomes, which can be incredibly valuable during a public health emergency.

Ultimately, it’s to everyone’s benefit to create an ecosystem where clinical knowledge systems and EMR vendors can work harmoniously to capture and inform point-of-care decisions.

During the PHE, global healthcare leaders learned how to adapt and make changes to everyday healthcare operations to improve patient outcomes. To make progress as an industry towards closing the care variability gap, and to ensure we are prepared for the next PHE, health organizations should seek a CDS partner that can provide both access to trustworthy and timely information, continuity to support patients no matter where they seek care, and provide insights to benefit the entire healthcare system.

Readers Write: Leveraging a Digital Ecosystem to Simplify Specialty Medication Onboarding

Leveraging a Digital Ecosystem to Simplify Specialty Medication Onboarding
By Julia Regan

Julia Regan, MBA is founder and CEO of RxLightning of New Albany, IN.

Specialty medication onboarding has historically been a manual and frustrating process, riddled with complexities, administrative hurdles, and delays. However, the convergence of technology, interoperability, and a robust ecosystem of partners can revolutionize this experience, offering a glimmer of hope and path to a smoother, more efficient onboarding journey for patients.

The Complexities of Specialty Medication Onboarding

Getting a patient started on a specialty medication goes well beyond the enrollment forms. In most cases, onboarding a patient requires enrollment paperwork, benefit verification, prior authorization, financial assistance, and ongoing communication between multiple parties. The trouble is that each of these steps has typically occurred in a standalone manner, without any connection to the other steps in the process. This creates an opaque and disjointed journey for patients and providers, slowing time-to-therapy and causing avoidable administrative burden.

In addition to the process being fragmented and unclear, some parts of the journey are still completed using paper, phone, and fax – hindering transparency from the start! Whether completing the initial enrollment, approving a PA, or submitting Patient Financial Assistance forms, we are living in a world in which the system we’ve created impedes patient outcomes – instead of improving them. We must do better.

The Power of Technology and Collaborative Ecosystems

Thankfully, the advent of interoperable technology and collaborative ecosystems are beginning to bring about significant improvements to the specialty medication onboarding experience.

The first step in creating a better onboarding journey is eliminating the need for paper-based forms and communication. By leveraging fully digital portals for documentation submission and collection, we can provide immediate feedback to users about missing information, statuses, and next steps. And once digital becomes the norm, providing transparency to key stakeholders is no longer an impossibility.

The next – and arguably most important – step is developing an open ecosystem, where each participant plays a vital role in the medication onboarding journey. Each interconnected partner must be aligned in achieving a shared vision, and each plays a critical role in the final delivery and adherence of the medication. Providers and pharmacies can review and confirm coverage information, care teams can find and submit financial assistance applications, and patients can be more effectively supported by manufacturer and hub support teams.

Stakeholders should not need to log into multiple systems to manage one patient journey; instead, they should have access to one platform with all the data and integrations they need. With a truly connected ecosystem, each stakeholder can make informed decisions based on accurate and up-to-date information, ensuring the timely initiation of therapy without unnecessary hurdles.

What’s Next for Specialty Medication?

While today’s specialty medication landscape is already complex, tomorrow’s is set to become even more convoluted. At the 2023 Academy of Managed Care Pharmacy meeting, IPD Analytics shared that nearly 80% of the drugs the FDA is expected to approve in 2023 are specialty drugs, up from 68% in 2020.

How the industry navigates this wave of specialty drug approvals could significantly influence patient care. From my perspective, a transparent, interoperable system could address many of the previously mentioned challenges by streamlining communication and providing real-time access to critical information that can be used to support patient engagement, affordability, and adherence.

As specialty pharmacy continues to expand and evolve, the need for a unified, comprehensive medication onboarding ecosystem becomes increasingly important. By harnessing the power of technology, interoperability, and a collaborative ecosystem, we have the opportunity to revolutionize this space. Together, we can build a world in which every stakeholder, from the provider to the patient, is empowered to navigate the intricacies of the specialty onboarding experience.

Readers Write: The Shift Toward an Employer-Driven Market in Healthcare Technology

The Shift Toward an Employer-Driven Market in Healthcare Technology
By Mike Silverstein

Mike Silverstein is managing partner of the healthcare IT and life sciences practice of Direct Recruiters, Inc. of Solon, OH.

Throughout the last few years, the healthcare technology market has been largely candidate driven. During the “grow at all costs” period that started in late 2020 and continued through fall of 2022, capital was cheap, and companies were doubling down on product that was to be delivered by expensive and newly hired engineering and data talent.

That has slowed tremendously in recent months and has been coupled with significant layoffs across most of big and medium tech. What felt like an inelastic demand for technical talent over the last number of years, which corresponded to growing compensation demands, has flipped.

Below are three market trends we are seeing that signify a shift toward an employer-driven market.

Technological Advancements

It’s no secret that technology continues to change the landscape of the global workforce. The continuous stream of new AI and automation tools being introduced has the potential to change processes, procedures, and potentially even replace human labor in some situations. According to a March 2023 report from Goldman Sachs, the automation of certain tasks could disrupt a staggering 300 million jobs worldwide.

As these changes evolve, employers’ expectations of current and prospective talent are to be able to adapt and leverage new technology to their advantage versus letting it replace them.

An Emphasis on Talent That Has a Near-Term ROI

Sales, business development, demand generation marketing, customer success, and FP & A roles are crucial right now. Investors are demanding greater discipline from their portfolio companies as the cost of capital has increased and the bottom has fallen out of company valuations, particularly in tech. Right now, each company is tasked with showing a path to break even and/or profitability. No investor wants their portfolio company to have to go out for a fundraise right now for fear of a down round.

While healthcare technology employers hire and retain talent, the pressure is high for candidates to showcase that they are results driven to land great roles. If you can help make a dollar, protect a dollar, or count a dollar – sales and marketing, customer success, and accounting and finance, respectively — there are still strong opportunities in the market. As companies strive toward profitability in a tumultuous time, there may be more uncertainty for roles further away from revenue.

The Abundance of Tech Talent

With recent layoffs, there is now an abundance of healthcare technology talent on the street with far less demand for its services. As a result, passive candidates have become more risk averse. Clients are realizing there is a bit of an opportunity to buy low(er) on some needle-moving talent.

A lot of mediocre candidates did really well for themselves over the last couple of years. Healthcare technology companies are seeing an opportunity to top grade on positions where they settled in the last 24 months, and there is added scrutiny on every candidate in the hiring pipeline.

As we face this potential shift in the market, talent that has a track record of being able to perform and execute in a capital-constrained environment will continue to thrive. Candidates who are more entrepreneurial in the traditional sense — in that they are comfortable doing more with less, versus relying on the ability to obtain unlimited growth capital whenever needed — are still in high demand, along with those with a strong accounting and operations acumen.