Tracking Care Coordination: What Healthcare Insurance Reimbursement Reform Means for Healthcare Technology

By Bill Bunker, Executive Vice President, SCI Solutions

While 2014 brought monumental changes to healthcare insurance, 2015 is set to bring even bigger changes to insurance reimbursement. The White House reports that in this past year alone approximately 10 million Americans gained insurance coverage through the Affordable Care Act (ACA). With healthcare coverage adoption rates rising, new insurance payment models continue to evolve towards rewarding “value-based” medicine. But is healthcare technology meeting the needs of providers to provide high-quality coordinated care and tracking to be properly reimbursed?

The Emergence of the New Insurance Payment Model

In the past year, the ACA set out to identify and promote payment models that encourage efficient care delivery, reduce care fragmentation, and reward physicians, hospitals, and others that invest in providing high-quality care rather than just a high-quantity to care. The three biggest changes from the ACA were:

  1. Incentives to Reduce Hospital Readmissions. Hospitals are now penalized for high readmission rates for patients with a specified set of diagnosis. As a result, hospitals are proactively seeking follow-up care for patients to ensure they will not return to the emergency room, resulting in better care coordination and lower healthcare spending.
  2. Accountable Care Organization (ACO) Payment Models. ACOs are a group of healthcare providers who voluntarily join together to give coordinated care to a defined population of Medicare patients. This payment model marks the transition from “fee-for-service” to “value-based” medicine to better reward high quality care.
  3. Cross-Payer “Spillovers”. As a result in changes to Medicare, private insurance payers have responded with cross-payer “spillovers”. Researchers have found that when Medicare reduces the price it pays for certain services, private insurers are often reducing the amount they pay for care by similar accounts.

Better Healthcare Technology for Effective Care Coordination

With the shift towards value-based medicine, it is crucial providers have effective tools to track their patients across multiple settings to provide follow-up care and records for reimbursement. Three areas where technology can accelerate and improve tracking for “value-based” medicine are:

  1. Electronic Sharing of Patient Information. Although many practices are utilizing EHR technology, many still rely on their antiquated fax machine to send and receive patient referrals as most EHR vendors are not interoperable. (The problem is so bad that the ONC is threatening to de-certify EHRs that block the sharing of information.) While legacy EHRs do not show promising signs of interoperability in the near future, third-party vendors have stepped up to create EMR-agnostic solutions that enable electronic, bi-directional sharing of patient information.
  2. Emergency Discharge Notifications. Providers are often unaware when their patient has a visit to the ER, which means patients are often not receiving proper follow-up care to prevent another costly ER visit. By creating an electronic alert and real-time information so providers can quickly follow-up with patients after they leave the hospital, care coordination is vastly improved. Read how one practice utilized cutting-edge technology to receive alerts when their patient left the ER in their community.
  3. Real-Time Patient Status Updates. In addition to the ability to electronically share patient information and receive ED alerts, the ideal care coordination infrastructure would give providers real-time patient status updates across EHR systems. While EHR interoperability does not exist today, other EHR-agnostic solutions, such as Clarity Health do deliver real-time patient status updates across care settings so providers can track and provide coordinated care.

While keeping up with the changes with healthcare and insurance reimbursement policies can feel daunting at times, it’s crucial to stay-on-top or otherwise you’ll risk being left behind.

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