Assignment: An Integrated Healthcare System (IHS) brings together multiple physician offices and sometimes hospitals. In this lab, you will explore some of the challenges that come about when LiveWell

Week 10 Lab-Assignment, Rubric, & Lesson Content

Assignment:

An Integrated Healthcare System (IHS) brings together multiple physician offices and sometimes hospitals. In this lab, you will explore some of the challenges that come about when LiveWell IHS acquires a group of small regional healthcare facilities.

For this assignment, you will need to download and complete the worksheet below:

• Worksheet: Module 10 Lab - Worksheet

• If you cannot open the information above, copy & paste the link below to a web browser.

https://content.learntoday.info/Learn/HIM3202_Summer_17/Media/HIM3202-Mod_10-Lab_Worksheet%20v2.docx

Save your assignment as a Microsoft Word document.

Rubric:

None for this week

Lesson Content:

Integrated Healthcare Systems (IHS) and History

Traditional Fee-for-Service Physician and Hospital Care

For much of the history of healthcare in the United States, providers (physicians, hospitals, long-term care) offering care to patients have operated mostly independent of one another. Physicians practiced from their own offices mainly in independent practices and small group practices. This is still the case in many areas. Hospitals cared for patients who were too ill to remain at home and needed continuous nursing care. They granted "privileges" to physicians so that the physicians could admit patients, render orders for hospital staff to follow, perform surgery at the hospital's facilities and so forth.

The hospital served to augment the capabilities of the physician when patients needed inpatient care. However, the hospital remained independent as an organization, especially as it pertained to billing and reimbursement. It was a physician's workshop, but only in rare cases did physicians own the hospital.

As you know, the patient who is hospitalized typically will receive more than one bill for care. The patient will receive the hospital bill including the room rate, supplies used, medications and various other items. Separate from the hospital bill, is the bill for physician's fees. The physician's bill originates with the physician practice or group practice. The physician who admitted and monitored the patient decided what they charged as their own fee, and a hospital does not bill for the physician's services. The physician "does rounds" and writes orders for their own hospitalized patients, then goes off to their physician office to care for outpatients. Hospitals and physicians did not consult with each other on what they charged. Of course, not every provider gets paid what they charge, thanks to insurance and fee schedule restrictions, but they have still been paid independent of each other. Now, some hospitals employ "hospitalists," specialty physicians who just care for the inpatients in hospitals, and the hospitalist has no independent office. Other arrangements are also possible, such as rotating hospital-duty among group practice associate physicians. Still, the customary way that physicians and hospitals are paid is separate from each other.

Prepaid Practice: Kaiser Permanente

There were early exceptions to the traditional scenario of the physician versus hospital split in roles and billing. The Kaiser Permanente group was an early example of prepaid group practice and hospital cooperation, including fee-sharing with physicians. The Permanente group of physicians, plus the Kaiser hospitals serving patients using the group, were paid out of the same pool of funds. According to the "Our History" page of the Kaiser Permanente website, the Workers who built the massive Grand Coulee Dam and, later on, other industrial workers on the West Coast of the U.S. were enrolled into a service that provided both hospital care and physician care under the same "umbrella" organization. The workers paid just a single monthly fee to have both hospital and physician care through the Kaiser Foundation Health Plan. Paying a per-month fee is a bit similar to paying for regular medical care insurance, but there was one resounding exception for those in the Kaiser Plan: a worker paying into the Plan could only receive care from the Kaiser Permanente providers. Obtaining care outside of the plan would receive no reimbursement so the worker would have to pay all costs for any out-of-Plan care that was received. Yet, not many individuals would seek care outside of such a Plan because they had a "good deal" already compared with many other workers. Since the hospital care and physician care were offered under the same "umbrella" organization, the consumer did not have to worry about getting bills from hospital and physicians separately.

HMOs

The arrangement like the Kaiser Plan came to be known later as a Health Maintenance Organization (HMO). The name HMO was coined in the 1970s, long after Kaiser Permanente was formed. The idea was similar, however. If the doctors and hospital were aligned in focus and in finances, then they would not be prone to ordering or providing duplicative or unnecessary services. Ultimately, care would be well coordinated. Instead, focus is on the patient and providing just-enough care. Inefficiencies were supposed to be reduced. The doctors who knew they would be caring for the same batch of patients for a long time could supposedly focus on preventive care: keeping their patients well, reducing patient's lifestyle risks (discouraging smoking, obesity, etc.), and encouraging preventive screening, immunizations, and the like. It sounded like a great plan.

Managed Care

For a variety of reasons, the HMOs and PPOs (preferred provider organizations) of the 1970s and 1980s became known collectively as "managed care." HMOs were promoted via federal policies. Consumers were enrolled, often through their employer-based health insurance options. They would encounter fewer or no copays for numerous services and care. Hospitalizations and intensive-style of care were potentially reduced or modified. Instead of using a single group practice and hospital working together as Kaiser did, though, many of those managed care plans would engage in agreements with physicians community-wide. Some imposed a "gatekeeper" model of care where the patient had to see a primary care practitioner first before seeing a specialist. If the specialist referral was not forthcoming from the primary care doctor, then the patient could not go to see the specialist -- or at least their health plan would not pay for it. Partly as a consequence, HMOs and managed care would try to enroll mainly healthier, younger populations. This would keep the insurance premiums down and help the younger, healthy enrollees who would perhaps not mind having their choices restricted.

Underlying all this, managed care physicians still had to get paid for their work. They were doing procedures, and the procedures and visits were getting coded. Coding and billing went on as usual. The physicians would bill the managed care entity/insurer but, in many scenarios, a percentage of their fees was "held back" and not paid out until the whole utilization picture was clear at year's end. If patient care utilization was high system-wide, the physician might not get 100% of their fees in the year-end settlements. This resulted because the physicians were considered to be partly at risk for what happened in the whole system which included the utilization of patient services and treatments. This is managed care.

It could be hard, though, to determine just why utilization was high or low in a given year. The managed care insurance plan might end up paying out more in claims than planned and have to keep the "held back" money which was intended for the providers, or they might raise the rates to consumer patients the next year, or both. Variables made it difficult to predict just how much care and spending would happen in a particular year. This risk-sharing seems like a good idea to start, but is only equitable to the extent that providers really have any control over the matter of utilization.

At the same time, some patients who became ill would decide they did not like being restricted in choices. They would ask, why can my Uncle Joe across town go to see Dr. Verygood Cardiologist, and I can't? This would result in appeals for a denial of care or for a failure to refer. If the appeal was granted for a very costly procedure, that increased the costs of care, on average, for the group of patients. In many cases, patient care has still remained less coordinated than possible, too. The goals of managed care have been good ones. The actual results are sometimes less than expected.

Integrated Healthcare Systems: A Search for Better Alignment

The task of bringing together various parts of the healthcare-delivery system to best serve the consumer is ongoing. Hospitals seek to get their patients well enough for discharge and out quickly enough so that the hospital does not lose money or encounter Medicare or other insurance denials. Physicians and medical groups seek to have a stable group of patients so that they can preserve the staffing and mission of the group practice from year to year. They want to provide enough care so the patients keep returning and are reasonably satisfied. The typical patient does not want to be "under-served," in their eyes. Insurance plans do not want too much utilization and too many claims. Overall, the coordination of care and exchange of information from provider to provider still needs improvement, even after the advent of managed care. Managed care delivered on only some of its promises, but the quest for quality and coordinated care continues.
Now enters the idea of the integrated healthcare system. Integrated healthcare systems bring together medical group practices, or physicians and medical groups plus a hospital, under the same "umbrella" of ownership and governance to align incentives. Bringing in other healthcare entities such as home healthcare and mental healthcare practices can close the loop of providing services that might lead to higher functionality of the patient population, too. Some integrated healthcare systems (IHS) seek mergers with many group practices in an area, and then even expand into other towns and areas. The "urge to merge" has taken hold in healthcare. The merged entities can pool their resources to improve the care and systems. Integrated healthcare systems are not the same as "managed care," though. It is more a way of organizing the providers, not an insurance arrangement. The idea is that the Integrated Healthcare Systems might be able to make the improvements in care, beyond what managed care can do. Having the providers become better coordinated and integrated seems beneficial, as well. Payment methods alone were not doing the job, so the need to have more organizational alignment continues. As organizations merge and cooperate with other entities, they may also experience economies-of-scale and shared resources which helps to lower those costs.

How does a system become "integrated?" Common ownership such as being held under the same corporation, having the same board of directors for the entire group, or very clear contracts about coordination need to be formed in order for the system to be integrated. Common ownership means that all entities (physician offices, hospitals) are under the same umbrella organization. A new corporation may be formed for the system, or organizations may be merged into an existing non-profit or for-profit corporation.
The Kaiser Permanente Foundation is a fully integrated healthcare system. It includes hospitals and medical group practices and does have a healthcare payment plan. The Mayo Clinic system (with main offices and clinics in Minnesota, but also clinics in Florida and Arizona) is also a very well-integrated healthcare system. The Mayo organization accepts payment from Medicare and a variety of private insurers. It is considered an integrated healthcare system, as well. The Cleveland Clinic in Ohio is yet another example of a large, multi-specialty integrated healthcare system.

Challenges and Repercussions of Integration

Integrated healthcare systems such as the Cleveland Clinic and the Mayo Clinic have grown larger over the years. These two examples brought together multiple specialties under the same roof many years ago. For these long-standing organizations, their computer systems, financial systems for billing, and governance structures have historically been well-integrated. The same is not often true of IHS that result from mergers and acquisitions of disparate medical practices and hospitals. Challenges result from trying to merge the financial, clinical systems, and other patient registration and communications systems. These "legacy" systems have to be considered and re-configured so that the organization can communicate effectively. There are large growing pains from having to integrate systems and finances.

The HIM Professional's Role in Integration

Systems Merging

As the various clinical entities and information systems are combined within integrated delivery systems, the HIM professional can play a role in helping to understand these various systems. There will need to be consistency of patient medical record IDs, and other systems must communicate with each other such as the lab and radiology results. There will be many inconsistencies and incompatibilities to be reviewed, analyzed and resolved. Sometimes the decision is made to "go with" the system that one of the merging entities, like the hospital, uses already. For example, the hospital might be using Epic already, but physician group practices merging in are using other, different EHR brands. The clinics might need to switch over to using the Epic system. These kinds of costly "big decisions" will be usually made at the upper management level.

Once the decision has been made as to whether one practice switches over to another practice's (or hospital's) system, or if everyone will switch at once to a completely different system, there are still be more decisions to make about the individual systems. The HIM staff and the IT professionals will need to work together to get through these transitions.

As we have learned in our database practice and studies, most computerized systems are rather particular about how items are named and labeled. Remember developing several Entity names and Attribute names from the first part of this class. Different systems will contain inconsistent data names, types and lengths. Examples:

TrueCare Associates Patient Demographics Table

Metropolis Care Patient Demographics Table

Both these tables could represent viable, working systems that met the needs of each practice. A working system could be designed according to either demographic table above. A patient ID could be stored as text -- although an auto-numbered field is better since it makes sure there can be no duplicate numbers. You can name the patient's first-listed phone number either their "home phone" or their "primary phone." The computer does not care if it is called one or the other name -- until it comes time to retrieve the data or to merge tables together.

Can you identify some of the inconsistencies that could make merging the data tables above extremely difficult? Look at the item names, data types, lengths, and so on. As far as the patient's medical ID number alone, one system contains a text data element not easily converted to numbers, while the other is auto-numbers alone. Neither system will "play well" with the other system in this example. There will need to be re-coding and re-naming. We would first decide upon a single format for the Patient's medical identifier code.

Therefore, many decisions must be made as organizations merge if we want to communicate effectively and to run queries and studies across systems. TrueCare and Metropolis Care have a lot of work to do. They could decide to adopt one system's conventions, such as Metropolis Care's, and go to the time and expense to convert TrueCare's systems data to the new formats. They might also decide to go forward on an item-by-item basis, with both practices having to make some system changes. Either way, the long-term goal of achieving interoperability will take time and effort.

Release of Information Policies

Release of Information policies need to be clear and have some consistency system-wide as well. Will we require Release of Information signatures from consumers if their record is going to be sent to a specialist who has come under the same organizational umbrella, or not? We could notify patients as follows:

When the Release of Information policies -- from one internal system entity to another, and releases to outside the merged system -- get worked through and standardized into policy, the HIM professional will have duties regarding their implementation. Training of staff system-wide and testing of the new policies and systems will occur as well.

Care Documentation Standards

The HIM professional will also play a role in aligning the organization-wide standards for documentation of clinical care. Policies and regulations about records completion will need to be examined and aligned. Improvement in clinical documentation so that each entity is achieving objectives for support of the patient's care and billing practices are also matters for the HIM department and its professionals. Clinical Documentation Improvement (CDI) efforts may be established system-wide so that quality of documentation, completeness and consistency are enhanced which will result in meeting financial and reimbursement goals while operating in a DRG based payment system.

References

Kaiser Permanente. (2017). Our History. Retrieved May 1, 2017, from https://share.kaiserpermanente.org/article/history-of-kaiser-permanente/

Accountable Care Organizations (ACO)

ACO Defined

Accountable Care Organizations (ACOs) are entities that are being defined and encouraged by Medicare. According to the U.S. Centers for Medicare & Medicaid Services (2015), these ACOs are "groups of doctors, hospitals, and other healthcare providers, who come together voluntarily to give coordinated high quality care to their Medicare patients."

This sounds quite a lot like an Integrated Healthcare System (IHS). The main difference is that, with respect to Medicare payments, when an ACO provides high-quality care and spends healthcare money "more wisely" as decided by Medicare, it can share in the savings generated.

The three ACO types currently offered by Medicare are:

• Medicare Shared Savings program: For regular fee-for-service providers

• Advance Payment ACO model: For selected participants who are enrolled in a supplementary incentive program

• Pioneer ACO model: For "early adopters" of the ACO coordinated care idea. Participants are no longer being accepted to this model.

No provider has to participate in an ACO; it is a voluntary program. As is usually the case with Medicare payment initiatives, there are rules and policies to be followed. According to Health Affairs Blog (2016), by January, 2016, more than 800 different ACOs had been identified.

Incentive programs and payments have become a fact of life for providers when dealing with Medicare reimbursements. Some ACOs have tried but not achieved the planned savings. The American Association of Family Practitioners (AAFP) considers strong primary care physician leadership to be at the heart of improving care coordination and preventive care delivery. Providers need to hit "benchmark" levels in order to earn the incentives based on shared savings and quality measures. How is it determined that these benchmark levels are attained? By using data collected from the ACO providers which is then reviewed for the kinds of services provided and quality of care given, of course.

Some Integrated Delivery Systems have chosen to take part in the federal ACO program. To the extent that the IDS can support the kind of care coordination and quality initiatives that the ACO program involves, they may experience rewards via the incentives. It is not essential to be a formal Integrated Delivery system to take part in the ACO initiative, though.

Please review the reading authored by Hacker, Santos and Thompson on one organization's experience with becoming part of the ACO initiative, and the changes it observed with quality and finances.

References

U.S. Centers for Medicare & Medicaid Services. (2015). Accountable Care Organizations (ACO). Retrieved May 1, 2017, from https://www.cms.gov/medicare/medicare-fee-for-service-payment/aco/

Health Affairs Blog. (2016). Accountable Care Organizations in 2016: Private and Public-Sector Growth and Dispersion. Retrieved May 1, 2017, from http://healthaffairs.org/blog/2016/04/21/accountable-care-organizations-in-2016-private-and-public-sector-growth-and-dispersion/