Monday, April 28, 2014

Charitable Care for non profit healthcare

I have read an interesting article from the HealthCareBlog.

The idea I took away is how tax codes have changed the reporting status of not for profit hospitals. I have seen a few financial statements posted on the web one in particular Sherman Hospital.  The Affordable Care Act

There are some measurements in the amounts of charitable care these organizations provide however, some dispute that these organizations provide enough care to warrant the tax breaks they receive. I believe that this is the case as well. I have seen where these organization charge individuals without insurance higher prices and this goes towards their charity care or uncompensated care. There has been tax language that has effectively put a cap on this amount.

A few weeks ago I was looking at the financial statement of Sherman Hospital. 
  • Sherman Hospital reported about 10% of their revenue going towards bad debt. Then due to the medicaid assessment program this institution received about 35% of that bad debt back. This shifts their uncompensated care to a range of about 7% I’m not sure if the allowance for bad debts would be kind of the same thing but the ratio for Google a for profit company is at 6.63%
Further the company in 2013 had used $30 million cash for investing. I wonder how much value is being done by offering tax exemption in this instance. There is also the question of the true cost of services is the cost figured at the CMS reimbursement rates which means that the profit range is higher or is the true cost reflected in the billing? I’m not sure where to find this out yet but I imagine it is on the lower side of the equation.

Medicaid assessment program

Sherman Hospital Financial information

Wednesday, April 23, 2014

My view on Healthcare Waste

According to PriceWaterhouseCoopers (PwC) Spending can be classified into three waste “baskets”: behavioral, clinical and operational. These baskets cross all of the health sectors and include consumers, government and industry.  The top three areas of wasted spending are defensive medicine ($210 billion annually), inefficient claims processing (up to $210 billion annually), and care spent on preventable conditions related to obesity and overweight ($200 billion annually). (PwC 2008)

Clinical Waste
What is Clinical Waste? According to PricewaterhouseCoopers (PWC)  article The Price of Excess Identifying waste in healthcare spending Clinical waste is” where medical care itself is considered inappropriate, entailing overuse, misuse, or under-use of particular interventions, missed opportunities for earlier interventions, and overt errors leading to quality problems for the patient, plus cost and rework.”  (PWC 2008)

Defensive medicine is defined as the ordering of treatments, tests and procedures primarily to help protect the physician from liability rather than to substantially further the patients diagnosis or treatment While perhaps not “unnecessary care, defensive medicine is meant more to offer economic  and psychological benefit to the physician than to the patient (Hermer 2010) According to a recent national physicians’ survey by Jackson Healthcare, the nation’s third largest healthcare staffing agency, 75% of doctors say that they order more tests, procedures and medicines than are medically necessary in an attempt to avoid lawsuits. (Scherz 2013)

According to Forbes magazine:
A middle aged man enters the emergency room with chest pains. The attending physician diagnoses the patient with indigestion. The physician wants the patient to change his diet, take medication and go home. Due a worried look on the faces of the patient and wife, the doctor has second thoughts.  Despite the

doctors conviction that the diagnosis is correct, the physician orders a battery of tests to rule out a heart attack, and everything is normal. This is defensive medicine. (Scherz 2013)

According to Healthcare Finance News there was an interview of 462 physicians, and the doctors believed that 26% of overall healthcare expenses could be attributed to defensive medicine. Nearly 3 out of 4 respondents said they practiced some form of defensive medicine in the past 12 months. In 2010 dollars, such lawsuit-inspired medicine may have cost the nation $650 billion. The article goes on to highlight that the threat of lawsuits drives defensive medicine, an analysis published in the August issue of Health Affairs suggests that physicians’ fear of a lawsuit may overshadow their actual risk of being sued.  Researchers tried to find a correlation between physicians’ propensity to order tests with the actual risk of a malpractice lawsuit as measured by award caps and a risk index based on how many malpractice claims were filed and award amounts they did not find one. This means that the doctors ordering additional test was not based upon the relative threat of being sued but rather the fear of being sued. (Cerrato 2013)

According to another article in Healthcare Finance News a report from advocacy group Public Citizen shows the results of an analysis of data from the federal government’s

National Practitioner Data Bank, which has tracked malpractice payments since 1990 found the following: (Irving 2013)

·         The number of malpractice payments on behalf of doctors (9,379) was the lowest on record in 2012, falling for the ninth consecutive year.
·         The value of payments made on behalf of doctors ($3.1 billion) was the lowest on record if adjusted for inflation. In unadjusted dollars, payments were at their lowest level since 1998.
·         More than four-fifths of medical malpractice awards compensated for death, catastrophic harm or serious permanent injuries.
·         Medical malpractice payments’ share of the nation’s healthcare bill was the lowest on record, falling to about one-tenth of 1 percent (0.11 percent) of national healthcare costs.
·         Medical liability insurance premiums, which takes into account defense litigation costs and other factors as well as actual payments, fell to 0.36 of 1 percent of healthcare costs, the lowest level in the past decade. (Lincoln 2013)
 According to the New England Journal of Medicine article Claims, Errors, Compensation Payments in Medical Malpractice Litigation reviewed a random sample of 1452 closed malpractice claims from five liability insurers to determine whether it was due to medical error. The result was that claims involving errors accounted for 78 percent of total administrative costs. (Studdert 2009)

Preventable Readmissions Is another category of clinical waste.
Hospital readmission rates have been proposed as an important indicator of quality of care according to an article in Health Care Financing Review a readmission may result from actions taken or omitted during the initial hospital stay. A readmission may result from incomplete treatment or poor care of the underlying problem or poor coordination of services at the time of discharge and afterwards, such as incomplete discharge planning and or inadequate access to care. (Goldfield 2008)
According to Health Affairs magazine article titled Reducing Hospital Readmissions: It’s About Improving Patient Care the CMS paid $17.8 billion a year on patients whose return trips to the hospital could have been avoided.  (Ness 2013) Statistics also show that about one in five patients discharged from a hospital are readmitted within 30 days. Medicare Payment Payment Advisory Commission concluded that about three-quarters of readmissions within 30 days were potentially preventable. (James 2013)  According to the Article one program has had some success in reducing readmission rates is Project BOOST (Better Outcomes by Optimizing Safe Transitions)  Some of the procedures are:
·         Medication Reconciliation Forms
·         A Checklist for discharge patient Education
·         A Checklist for post discharge continuity checks.
In addition to the process of follow up there have been provisions made by the ACA where facilities were charged a hospital for excess Medicare readmissions. Interestingly, hospitals, serving a large number of low-income patients were about twice as likely to receive penalties (77 percent) as hospitals with fewest poor patients (36 percent) (James 2013)

According to the Robert J Woods foundation:
One patient, Eric, said he left the hospital dog tired with a diagnosis of chronic obstructive pulmonary disease but no understanding of when to use his inhaler. He also continued to smoke. To no one’s surprise, he was back in the hospital. Thankfully, the second time around, he was flagged by his health plan and received better follow-up care. He now answers five questions daily so his care team can monitor his breathing, and he takes smoking cessation classes.
(Goodman 2013)
Another issue to why patients are readmitted to hospital is when a patient leaves the hospital with a treatment plan for one illness when other problems of equal importance are ignored. Many patients are discharged without understanding their illnesses or treatment plans, or inadvertently discontinue important medicines needed to stay well.

Operational Waste
What is operational Waste? According to PriceWaterhouseCoopers Operational waste is, ”where administrative or other business processes appear to add costs without creating value.” (PwC 2008)
Inefficient payment for services is an idea that money can be saved based upon how the transaction occurs. Instead of sending healthcare information via mail or other land based carrier significant money can be saved. According to PNC Bank on Average hospitals send information four times before it is paid in full. Health plans said they have to go back to providers on average six times to get additional pay a claim. In 2006 9 in 10 executives still use regular mail and receive paper claims. In 2010 United Health estimated paying for over 145 million claims at $.21 per claim. Electronic claims are estimated to have brought down the transaction cost to $.018 per transaction or a total of $2.7 million. (Mitchell 2011) According to the American Health Information Management Association the process goes like this, when a patient makes an appointment the process begins there must be a collection of the patient’s information to include name, address, insurance or payer, and medical history. Once the patient sees the physician the physician must document the procedures sometimes through dictation, annotation, or through the electronic medical records system.  The information may then go to through a process to record the information in the patient’s medical records. Then the coders need to make sure that the coding is correct or add coding for the services performed.  Next there must be a charge entry to the record and the information must then be transmitted to the insurance payer for further review to make sure evidence of care. Once the insurance firm has the correct information and evidence of care then the payment posting is made to the healthcare facility. As accounts receivable receives payment the bill is finally closed out. (Crocker 2006)

According to articles here are 3 benefits for using an integrated EMR
·         Records management one of the advantages is that multiple users can access the records with an ability to monitor usage and effective security controls.
·         Chart analyses and completion with the EHR if there are missing signatures then a flag can be raised on the system versus waiting for the medical record to be audited and pass through a series of steps to complete the information the amount of time saved from this is significant. Chart analysis can be done for rural areas to optimize workforce strategies.
·         Coding and reimbursement is another area where EHRs can effectively enhance operations. Due to data being available real time the coding process can be done in prior to discharge. Also coding can be done outside of the local labor market. (Deschenes 2012)

Behavioral Waste

What is Behavioral Waste? Behavioral Waste PriceWaterhouseCoopers defines behavioral waste as, “where individual behaviors are shown to lead to health problems, and have potential opportunities for earlier, non-medical interventions.  (PwC 2008)

Preventable conditions in healthcare are unhealthy behaviors such as smoking, poor eating habits, and lack of exercise. According to A Partnership for Prevention paper titled The Economic Argument for disease Prevention: Distinguishing between Value and Savings “unhealthy behaviors account for 38% of all deaths in the United States.” There are three kinds of prevention Primary prevention, Secondary prevention and Tertiary prevention.  Primary prevention is enhancing the lifestyle. Secondary prevention is screening for the diseases caused by lifestyle. Finally, Tertiary prevention is treating the disease. It is important to distinguish between healthcare and medical care. Preventative medicine can be categorized as healthcare. Secondary care can be categorized as medical care. (Woolf 2009) This distinction is noted because a person can receive medical care but it the unhealthy habits persist; all the money spent will only treat the problem versus eliminating the problem. In order to get the biggest value out of this category prevention is the biggest value.

Possible Solutions
Clinical waste
In the category of clinical waste one of the main areas is defensive medicine or the idea that medical professionals are running extra tests in order to prevent lawsuits.  Studies have shown how the amount paid for malpractice lawsuits has been on the decline. (Lincoln 2013) The article goes on to conclude that there is no evidence that the decline in medical malpractice payments is due to safer medical care. If medical malpractice litigation were truly the, “the biggest cost driver” in medicine, then declining payments should have pulled overall health costs down.  The article goes on to conclude that instead of focusing on malpractice claims and lawsuits facilities should focus on avoidable medical errors.  This overlaps with the hospital readmission rates. Just by virtue of hospital readmission being a component of quality of care. (Lincoln 2013)

Operational Waste
Under operational waste is the component of inefficient payment of services. To remedy inefficient payment there is information technology. Under this category PricewaterhouseCoopers also listed inefficient use of technology as an area of waste.
Behavioral Waste
Under the category of behavioral waste are the preventable portions where education and lifestyle changes can work as a primary solution to problem. According to Harvard School of Public Health lists 6 key behaviors:
·         Choosing healthier foods (whole grains, fruits and vegetables, healthy fats and protein sources) and beverages
·         Limiting unhealthy foods (refined grains and sweets, potatoes, red meat, processed meat) and beverages (sugary drinks)
·         Increasing physical activity
·         Limiting television time, screen time, and other “sit time”
·         Improving sleep
·         Reducing stress (Harvard 2014)
The underlying things that could help on the clinical and operational side are the ability to coordinate and to be able to decide. To be able to enhance coordination and decision

there are information technology systems that can streamline the way the business is done. 
For example in the clinical waste basket there are issues with defensive medicine or medical errors as well as hospital readmissions which can also be described as a medical error.  If we examine what happens from the time a person enters a healthcare facility to the time they go home we can note that all of the detailed patient information and services has to go into the medical record as well as the billing record.
Technology is now to the point where the patient can be managed real time by multiple people versus in the old way information was recorded by one singular person at a time.  Sometimes there are errors in patient data as in the example of the patient that comes in with the worried look and indigestion the physician can look at the patient medical record to see which tests have been run already and not duplicate services. The patient can then receive their prescription a cross reference against what the patient is taking so that the physician and pharmacist can cross reference against allergies or check for interactions. All of this can happen while simultaneously coding the information for billing purposes and as soon as the patient is leaving the facility the billing and paying entity can receive their information. The patient can receive the information of services as well as any instructions for follow on care. All of this can happen from the ability to effectively utilize the electronic medical record as well as networking capabilities.
When it comes to behavioral waste this component can be moderately helped through education and information. After the patient receives their services through the electronic medical record the patient can receive educational materials. In the future the hospitals or healthcare provider can track whether or not the patient is following the instructions that have been sent to the patient to be able to continue their care.
The applications of information technology and sharing can have huge impacts on the way current processes are done. I think that a large amount of processes can be managed through information technology beginning with the electronic health record and integrating of information sharing between care facilities as well as payers. Even if there are more reporting requirements are needed with IT systems it would be a matter of deciding which information is tracked and which information needs to be communicated to whom.
According to the Pathways to “Evidnce-Informed” Policy and Practices a frame work for action “The framework encourages research and planning in the area of how to “adopt, adapt, and act” on the evidence and in capacity for implementation as part of the evidence-informed policy development process.” (Zwi 2005) This review of what the issues in healthcare waste are will help get a basic understanding of what ideas to adopt; and how to put actions into place to solve some of the issues with cost.


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BPR vs BPO and IT

Estimates according to Rand Corporation Paper titled The 21st Century at Work Forces Shaping the Future Workforce and Workplace in the United States mentions that in the coming 10-15 years, work in the United States would have been shaped by demographic trends, technological advances, and economic globalization (Karoly 2004) The article further explains that through synergies across technologies and disciplines will generate advances in research and development, production, processes, and the nature of products and services. This will further support higher productivity growth, and change the organization of business and the nature of employment relationships. (Karoly 2004)

BPR BPO and Technology
Business Process Reengineering (BPR) was first introduced by Hammer, Davenport and Short, as an approach to management process involved in raising performance.  Since its initiation, it has become popular management tool for dealing with rapid technological and business change in today’s competitive environment. BPR evolved from the experiences of a few US-based companies in the late 1980’s (Pellicelli 2012)
Business Process Outsourcing (BPO) is the model of delegation of one or more information technology enabled business processes to an external source provider.  Outsourcing of business processes that involve the manipulation of either physical or informational objects constitutes contract manufacturing.  Information Technology is integral to process execution and management in BPO. This is true of transactional processes such as administration or processing services, where IT performs simple automation or process updates, as well as more strategic processes such as customer analytics or financial planning, where IT facilitates linkages with other processes and delivers business information to process workers in a timely fashion.  (Mani 2010)
Business Process Reengineering generally is more dramatic and higher risk than Business Process Outsourcing.  According to Bain and Company there are five steps to the business process reengineering:
           Refocus company values on customer needs
           Redesign core processes, often using information technology to enable improvements
           Reorganize a business into cross-functional teams with end-to-end responsibility for a process
           Rethink basic organizational and people issues
           Improve business processes across the organization (Rigby 2013)
According to the Rand Corporation they have predicted a vertical disintegration, whereby firms change the production process and specialize in broad products and services that define core competencies, while outsourcing non core activities. (Karoly 2004)
Some of the technologies that have helped enabled business re-engineering are:
           Shared databases, making information available at many places
           Expert systems, allowing generalist to perform specialist tasks
           Telecommunication networks, allowing organizations to be centralized and decentralized at the same time
           Decision support tools, allowing decision-making to be part of everybody’s job
           Wireless data communication and portable computers, allowing field personnel to work office independent
           Interactive videodisk, to get immediate contact with potential buyers
           Automatic identification and tracking, allowing things to tell where they are, instead of requiring to be found
           High performance computing, allowing on the fly planning and envisioning.
(Johnson 2011)
According to Gunasekaran, in Modeling and analysis of business process reengineering in the 1980s, Total Quality Management (TQM) helped incremental process improvements in manufacturing/service organizations, but in the 1990s it was replaced by BPR using advanced IT (Gunasekaran 2002) according to the article the most efficient method was process mapped through the restructuring of an information system that should support functional integration to improve productivity and quality. There are several modeling methods for IT to help the BPR process.  Since the strategy begins with a top down approach here are some of the steps and software.
The decision support systems help businesses decide on a strategic level.  These enterprise systems help select suitable strategies and methods for reengineering based on a set of performance measures and metrics. Decision Support Systems (DSS) have evolved from two main areas of research the theoretical studies of organization decision making conducted during the 1950s and 1960’s at Carnegie Institute of Technology and Massachusetts Institute of Technology respectively. (Shim, J.P. 2002)
Some of the DSS systems in use today are in the healthcare field particularly a component of the Electronic Health Records. This allows the ability to improve care at the point of delivery with a variety of tools called Clinical Decision Support System where the software provides general clinical knowledge and guidance, intelligently processed patient data, or a mixture of both; and information delivery formats can be drawn from data and order entry facilitators, filtered data displays, reference information, alerts, and others. (Teich, J 2012)
The business process system design helps with system design considering the non value added activities the tools used for this activity are usually the analytical models such as queuing and simulation models. (Gunasekaran 2002)
Under the umbrella of project management are the Program Evaluation Review Technique/ Critical Path Method (PERT/CPM) and flow charts are used for the implementation of various reengineering processes. (Gunasekaran 2002)
Under the area of reengineering business process there are activity based analysis (ABA) and workflow model including flow charts used to analyze the business process and identify the value and non value added activities. (Gunasekaran 2002)
To understand the business process system there are Integration Definition models (IDEF),  European Forum for Quality Management (EFQMO) Models and Petri-Net Models these produce visual forms. (Gunasekaran 2002)
How the Technology works
How does the business achieve its goals? How does this tie in to the achieving customer needs? According to an article in Educause Quarterly the University of Wisconsin had an issue with their computer systems. Some of the systems implemented in the 1980’s could not keep up with the web environment in the 90’s so the school system purchased a system wide license for Peoplesoft. This tied some of the older systems together an Admissions module, a Student Records module, Student Financials module. With these new modules the school administration was able to produce more accurate and meaningful reports for various levels of the university.
Some of the main things highlighted by this Process reengineering were the sharing of multiple databases also known as modules between different parts of the business. In this case they were student Finance, Admissions, and Student Records.
Some of the telecommunications networks allowed for multiple access of information in a timely manner. E-Hive web application allowed successive enrollment by student classification Seniors, Juniors, Sophomores, and Freshman. If a student doesn’t meet the time and classification requirements they may not be allowed to enroll during that window. Students with financial hold will not be allowed to register this is another example of the database integration that the school did not have before the integration. This is also an example of shared decision making between users. One can easily see the parallel between this situation and some of the technology drivers. (Yakovlev 2002)
Some of the interesting finds were Mutual Benefit Life had an issue where it would take several months to process an insurance policy with 225 people in 5 departments using 19 specialist undertaking 30 specific tasks and 7 different computer systems. It is now processed the same day with 1 case manager, 55% less staff doing 20% more business and a 40% cut in overhead using a single computer system. (Norman 1993)
Process Integration
According to the Chartered Institute of Purchasing and Supply in an article titled Business Process Re-engineering & Business Processing Outsourcing – what the procurement professional needs to know BPR is just one element of making a step change.
When an organization has chosen the appropriate process and considered the use of IT to deliver that process, it will need to think about other aspects such as structure, systems, people, culture, and of course whether it is obtaining optimum value for money from its external suppliers.  Are they going to do the process re-engineering in house or will they outsource the process.  (Bates 2013)
So from a more generic view a firm may analyze Total Quality, then decide if a more dramatic change is needed or re-engineering. Finally the question becomes if the firm wants to use in house staff to complete the engineering or outsource the process.  (Bates 2013)
Domestic vs Offshore Outsourcing
According to an article in Industrial Labor Relations Review estimates staffing services reduced the amount of employment by manufacturers by 6 million or 3%.  The rapid growth of blue collar workers in the staffing sector began in the 1980’s. In 2010 the staffing services sector comprised of three industries temporary help services, professional employer services, and employment agencies comprised 77%, 15%, and 9% respectively.  (Dey 2012)
American manufacturing companies chose to outsource production overseas, for various reasons. Some reasons were to establish presence in China, Brazil, and India others were the low cost of labor. This low cost labor allowed the products to flood the global marketplace.  There are, hidden costs of outsourcing estimated to be between 14 and 60 percent of purchase price according to CCMP Supply Chain Quarterly article titled The 10 hidden costs of outsourcing.  According to the article there can be some faulty assumptions:
·         Oil Prices have tripled since 2000, making shipping more expensive
·         Wages in China have increased five fold
·         Some American Labor Unions are becoming globally competitive
·         The natural gas boom in the United States has lowered operating and facility costs. Natural Gas in Asia can be four times as high as those in the US.
·         Higher material-value content in products combined with productivity gains through continuous improvement has made chasing labor savings outdated.
·         Much of the labor savings has been trumped by waste and overhead costs required to make the supply chain function well. (Burton 2013)
Because of these assumptions and points of friction some authors are expecting manufacturing to return to the US.  According to Mayer in his article Strategies: U.S. companies are bringing back manufacturing jobs he argues that some 70% of large manufacturers had some production in non U.S. locations. (Mayer 2013)

Information Technology has had a powerful effect on the process of business operations. We have seen the manufacturing sector undergo several changes as a result.  From Total Quality Management, to Business Process Re-engineering to Business Process Outsourcing business have transition from a centralized hierarchy to a, “disintegrated” firm with production and manufacturing overseas.  This has all been enabled with Information Technology systems that integrate data systems for de-centralized information with real time implications due to newer World Wide Web applications and networking.  I think the next step is to move the business based upon where the services or products are consumed AJ Sweatt has used the term of Manufacturing in Markets of Consumption. (Sweatt 2011)   Manufacturing and servicing both have abilities to be decentralized at some point.  There has to be some gained benefit at approximation of consumption in the future it might be some other method of evaluating where these processes take place and this in itself will could lead to a further change in the way that business is conducted.


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