Upload
layton-harding
View
1.782
Download
5
Embed Size (px)
DESCRIPTION
Final Presentation for my Healthcare Reimbursement class
Citation preview
Information Systems in Managed Health Care Plans
By: Jolly PandyaccAnthony Harding
Jitka GruntovaTony Mbirwe
Content
• I. Part: Introduction• II. Part: IT Function Overview• III. Part: Delivery Attributes of The IT System• IV. Part: Market Trends and IT• V. Part: Conclusion
Introduction
• http://youtu.be/9jAH9hdF0xk• http://youtu.be/Lo_3qOejQzI
• Execution of Business and the customer experience are nearly entirely information technology driven
• Technology enables everything from core processes, such as claims adjudication, to consumer touch points, such as, websites, and customer service systems, to internal enablers, such as, employee email and medical management enabled technology systems
What Technology Can Do• Information technology can help reduce errors in medications• Use of computerized physician order entry (CPOE) can reduce
medication errors by 80% • (foundation for e-health)Picture archiving & communication
system (PACS) eliminates need for films, allows interaction on a global scale: savings, improved quality & cost reductions
• Improvements in diagnosis & treatments with technology help the quality & availability of care
• Telemedicine/telehealth: monitoring chronic diseases over distances allows for access to care, quality of care, & reduces costs
To The ConsumerTo the consumer
• Insurance is not a simple transfer of risk, but rather a series of interactions that are all technology enabled
Example-Young woman experiencing lower back pain
1. She visits her health plan website to research her symptoms and boor for a Doctor
2. At the Doctor office she hands I.D card to the staff member at front desk who confirms eligibility by using a interactive voice response system.
3. After visit the provider submits a claim via claims clearing house to the insurance company
4. Claims processing system adjudicates the claim according to the patients current benefit
5. Young woman receives explanation of benefits in mail but is concerned with error
6. She visits website to look for information related to claim and places to call customer Service
7. Customer Service call is routed to a customer service representative who then uses interface to health plan’s internal membership, claims, and benefits systems responding to the inquiry documenting the interactions with the member
8. Scenario represents the pervasive nature of Technology
Critical Internal Information Technology Function Overview
• I.T department designs, implements, operates, and maintains systems that perform critical core business processes essential to day to day operation of the health plan organization
• Must be completed efficiently and accurately on an ongoing basis, and new efficiencies must be created to achieve cost reduction opportunities
• Storage system must be packed with a set of interfaces that allow other systems, such as claims and customer service applications to access this data for processing inquires
Products• Products are the entities that are sold by health plans
and bought by consumers• 2 main consumers groups in the health insurance
market-employers who offer it to employees and individuals who don’t receive it through employers
• I.T must support the systems that manage the individual variables for each product
• I.T solutions must facilitate the input and ultimately store benefit levels, procedures, code information, deductible amounts, co insurance or co pay amounts, and other data points that determine how members get paid
Eligibility• Moved to IVR phone system to Web
based provider portals• The systems are queried by providers
to determine how a patient should be billed at the time of service
• Eligibility systems are also involved in determining how to bill the employer or member
• Information is loaded when individual or group signs up then is put in eligibility system (older system is called legacy system.)
• Electronic loading-entering info on secure website and password protected IVR system
• Imaging is used strict security and privacy are used under HIPAA
• Tape-Tape data base transfers from employer
• Or Via a secure electronic connection• Advance health Plans offer Automated
tools to sales agents and brokers like demographic information which is transmitted
• Maintenance phase is when information is updated
• I.T must support both the enrollment, and maintenance process
• Custom feeds must be designed from employer’s personnel system, and Interfaces must be built by customer via secure web
• Some large firms outsource but I.T still runs it
Claims processing
• Provider network system or databases are queried to determine whether the provider or hospital billing for the services is part of any of the health’s plan’s network (HMO or PPO)
• In network out of network claims• Authorization & precertification• HIPAA mandated standards for submission, query, and
response• Lags behind even though physicians are starting to grow to
more modern software• Paper fax & phone common use
Claims Submission to Health Plan
• Electronic EDI=electronic data interchange reduces labor
• Large Hospitals=claims clearing house which establishes electronic connections between Physicians hospitals, billing services, and health Plans
• Moves claims and inquires electronically among the parties
• Large Insurance companies have outsourced manual data checking, and entry to off shore locations
Medical Management and Predictive Modeling
• All medical management activities are supported and enabled by I.T
• Including Decision support systems, tracking and case management systems
• Enabled patient centric devices and interfaces like a scale that sends congestive heart failure patients daily weight to the health plans disease management program
• More Access better health management and better out comes keeping the cost low
I.T Responsibility to Plan
• Creation of (PHR) Personal Health Record & more availability through system
• Adopt EMR electronic medical record• Must maintain data warehouse, and use sophisticated
data mining and informatics tools to transform the raw data into information for use by the medical management systems
• Systems must be designed so that data gathered can be quickly and easily transformed into actionable information
I.T Support leading practices
• Automated Creation Care Plans• Automated routing of new participants care plan to
correct disease manager• Ability to view claim history, and EMR (Electronic
Medical Record)• Customer Relations Management System• Quality Plus Program• NCQA Accreditation Review Process• PBX telephone system• (transactions & code sets• Electronic transactions
Documentation
Risk stratification Predictive Modeling
software ranking levels of severity
Establish outbound call frequencies
Periodic care call for prevention care
Provider Credentialing and Network Maintenance
• Data feed provider directories printed and online used by consumers to make contacts
• Provider Credentialing and Network Maintenance• Data feed provider directories printed and online used by consumers to
make contacts• Credentialing program collects detailed information about the provider’s
medical training, certifications, and any specialties disciplinary actions• National Practioner Data Bank is a requirement under credentialing• Maintenance of provider Database or file is function of Network
management• I.T organization must design solutions and interfaces that can assist in the
collection use, and maintenance of provider Data• Electronic communication
Challenges of I.T
Use of imbedded intelligence to help drive reimbursement systems
Hard coding of identifiers Provider ID field type cannot accommodate the
format of NPI
Member Service
Key Market Differentiator for Health Plan
Positive & negative experiences Challenge since call centers, and
Web Portals is customer expectations
Members demand accurate information across multiple channels for convenience
Email & Web chat more Prominent Self Service Channels such as online
member Portals
IVR Systems must integrate well with traditional services channels like customer service, and tracking
Tracking and reporting solutions must be deployed to identify issues and key metrics for management
Sophisticated load balancing software to help calls move from location to location
Outbound calls to influence members behavior
I.T must support member services by integrating multiple technologies
I.T must educate so service associates can educate members effectively
Consumerism and the Proactive Approach
• Easy to use decision support system enables the front line to assist members in their treatment choices
• Robust customer insights and analytics tools• Enabling the identification and segmentation of
member populations for targeted interventions• Enabling view of PHR
Information Systems in Managed Health Care Plans
Employer I.T Portals can enable
enrollment and maintenance capabilities
Employers can edit employee eligibility
View and Pay bills online Enable features for
employees to complete initial enrollment online
Provider I.T Provides method to verify
patient eligibility Web Portals to submit
claims or reconcile receivables against payments
Information Systems in Managed Health Care Plans
Bookers and I.T agents Provide tools and
information to assist in the sales cycle
Member Provides a way to deliver self-service
capabilities to existing customers, and a way to deliver product information
and decision support tools to potential customers
I.T must support E-Business initiatives by ensuring web based
solutions are complementary to other channels
Must be in place to monitor and correct system issues outside of
business hours
Internal Enablers
I.T organization is to manage, maintain, and service enabling capabilities such as email, telephone, and other communication channels for health plan employees
Borrowing Technology
Technology from the financial service industry plays role in payment of healthcare
Swipes Cards-is easy access to spending account funds & relief in Account Receivables
Use of Card to verify eligibility & Co pay Smart cards do the same thing but it holds limited personal
health record information Providers receive timely & accurate information that
minimize bad debt No paper work for consumer filing
Healthcare Integrity
• HIPDB- fraud Program and fraud tracking system• HIPAA- mandate standards for electronic transactions
became effective in May 2002 (May 2003 for small health plans)
• Privacy regulations became effective in April 2003 (2004 for small health Plans)
• National Provider Identifier-May 23 2007 • Additional measures for electronic PHI (protected health
information that is maintained in electronic media which includes hard drives, computer disk, internet, and email
Security Standards Applicable to electronic protected Health
Security management processAssigned security responsibilityWorkforce Security Information access managementSecurity AwarenessSecurity Incident proceduresContingency PlanEvaluationBusiness associate contracts
Facility Access controlsWorkstation useWorkstation securityDevice and media controlsAccess control Audit Controls IntegrityPerson or identity
AuthenticationTransmission security
Delivery Attributes of the IT Systems
The Nationwide Health Information Network governance expects entities that participate in the Nationwide Health Information Network to include elements of:
• privacy and security
• usability
• flexibility (interoperability)
1) Security and Privacy
• In order for providers and patients to have trust in health IT and information exchange, they must be confident that privacy and security laws are in place and will be enforced.
• Federal laws and regulations such as HIPAA and the Sarbanes-Oxley Act, as well as state laws and regulations in some cases, mandate additional constraints on technology and processes to ensure the security and privacy of consumers
Statutes and RegulationsStatutesAmerican Recovery and Reinvestment Act of 2009 (ARRA) This statute includes the Health Information Technology for Economic and Clinical Health Act (the HITECH Act) which establishes the Medicare and Medicaid EHR Incentive Programs that encourage meaningful use of certified EHRs and other health information technology (IT) to improve quality of care.
Health Information Technology for Economic and Clinical Health Act of2009 (The HITECH Act) The Health Information Technology for Economic and Clinical Health (HITECH) Act, passed as part of the American Recovery and Reinvestment Act of 2009, allocated billions of dollars for the health care system to adopt and meaningfully use health IT to improve health. A number of provisions in the HITECH Act strengthen the privacy and security protections for health information established under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Health Insurance Portability and Accountability Act of 1996 (HIPAA) HIPAA called for the establishment of standards and requirements for transmitting certain health information to improve the efficiency and effectiveness of the health care system while protecting patient privacy.
Statutes and RegulationsRegulations
Medicare and Medicaid Programs: Electronic Health Record Incentive Programs Final Rule This rule specifies the initial criteria that eligible providers must meet to qualify for the Medicare and Medicaid EHR incentive payments, and it includes other incentive programs participation requirements.
Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology Interim Final and Final Rules Under these rules, the Secretary has adopted the initial set of standards, implementation specifications and certification criteria that are required for the certification of EHR technology.
Establishment of the Temporary Certification Program for Health Information Technology Final Rule This final rule establishes a temporary certification program for the purposes of testing and certifying health IT, thereby ensuring the availability of Certified EHR Technology for eligible health care providers seeking incentive payments available under the Medicare and Medicaid EHR Incentive Programs.
Statutes and Regulations
Regulations
Establishment of the Permanent Certification Program for Health Information Technology Final Rule This final rule establishes a permanent certification program for the purpose of certifying health IT.
Breach Notification for Unsecured Protected Health Information Interim Final Rule This rule implemented section 13402 of the HITECH Act by requiring HIPAA covered entities to provide notification following a breach of unsecured protected health information to individuals, HHS, and in some cases the media. This rule also requires business associates to notify covered entities following a breach of unsecured protected health information.
HIT Standards and HIT Policy Committees Information Flow
3) Usability
• In delivering technology solutions, the IT organization must be aware of the ultimate use of the system; in other words:
How will the system be accessed? What are the characteristics of the users? • Increasing the engagement and understanding of
patients and providers may increase their willingness to participate in information sharing that they trust and that is private and secure, including secondary uses of EHR data in research.
4) Flexibility
• The first priority of health IT is to enable primary care physicians and specialist to electronically exchange lab results, patient care summaries, and medication histories
• Health IT is also a critical tool in empowering patients. Existing and emerging technologies allow data to flow directly to and from the individual, wherever the individual may be. As a result, patient interactions with the health care system are no longer confined by the walls of the clinical setting and may occur frequently in between visits.
• Personal Health Records (PHRs) allow patients to capture their own health observations. For example, mobile phones with glucometers allow individuals to track their blood sugar levels through their mobile devices. Mobile phones and related applications are being used in mental health to track moods and provide therapeutic interventions with personalized messages, exercises, and coaching.
Using these tools, individuals can become more attuned to healthy behaviors, monitor their health, make informed personal health decisions, and receive preventative care.
MARKET TRENDS AND INFORMATION TECHNOLOGY (IT)
The market research report analyses the key trends in global healthcare information technology market, and segments it into various submarkets as per their sizes in various geographies
The global healthcare information technology market is estimated to be $53.8 billion in 2014
The market is expected to grow at a high CAGR of 16.1% (from 2009 to 2014) because of government initiatives to reduce healthcare costs and the tremendous demand for healthcare IT applications such as electronic medical records
Information technology offers solutions for almost all the areas in the healthcare system, including clinical trial management and clinical decision support
Hospitals are also increasingly implementing e-prescribing systems
Consumerism
• Today’s healthcare consumers demand more information about their healthcare providers in order to get quality services
• This has led to more need for IT to collect and disseminate data
• Data collected must be in compliance with, links to state records, consumer feedback
• The system built must be flexible enough to accommodate structured and unstructured data.
• IT must also support the consumerism movement by identifying ways to educate members on their own health – primarily through online tools and information – and supporting innovative product designs that incorporate new financial instruments and benefit designs
• Health plans must justify the theory of consumerism to employer groups by reporting on the success of consumerism products. Data are required to illustrate that when more responsibility is transferred to consumers, they use health care services more intelligently
Pay-for-Performance
• Due to increased focus on healthcare costs, health plans are developing new ways to pay providers for services rendered such as:
-The pay-for-performance model- compensation is tied to compliance with best practices and results achieved, not just on the number or duration of services
• IT must support this model by crating solutions that can collect these data from different sources, transform and load data into a storage area, and provide access methods for reporting systems and consumers
Plan as Financial Institution
• The health insurance industry has often looked to the financial service industry as a role model in the evolution of the technology organization.
• This helps evaluate risk and security involved while providing care
• Consumers often bring expectations from other industries, such as financial services. Financial services are a decade ahead of the health plan industry in terms of delivering high-quality self-service capability to consumers.
• For example financial institutions introduced self-service Web sites and automatic teller machines (ATMs) in the late 1980s and have quickly evolved those offerings based on consumer demands and feedback.
Conclusion
• Evolving Information Systems of upcoming times is not so much about delivering bits and bytes, but “supposedly” rather about delivering information, solutions (not creating problems!), and services to support managed care organizations.
• Physicians and those doctors who are not very familiar with the electronic based information systems is going to face a major challenge since they will be at the bottom of the learning curve
• Either it can increase the efficiency and functionality of the healthcare system or it can affect the quality of patient care where doctors/physicians are spending more time on computer than patients and their problems.
Conclusion - Where We Are Today• Only 15% of hospitals have some form of computerized medication
order entry implemented. In those hospitals, physicians enter less than 25% of the orders
• Only 10% of hospitals utilize bar-coded medication administration at bedside. Fewer than 5% of providers use computerized patient records
• About 80% of the estimated 35 billion health transactions each year are conducted by phone, fax, or mail—not via the Internet. The financial services industry spends about 8-10% on information technology; HE healthcare industry = 2-3%
• In 2010 only 25% of physician offices and 15% of acute care hospitals take advantage of EHRs. Even fewer use remote monitoring and telehealth technologies.
• While many consumers access their banking information online daily less than 10% use the web to access their personal health information.
• http://youtu.be/NleWPN6CADE
Questions??
• Do you anticipate betterment in efficiency and functionality of current managed healthcare organizations?
• Will it overcome setbacks and provide more efficiency than current information systems?
• Where do you see Information Systems in upcoming 3-5 years?
Resources
• Geisler, E. (2008). The Role of Technology in Healthcare Delivery. Retrieved form www.chicagofed.org/../presentation_role_of_technology.pdf
• Kongstvedt, P., R. (2007). Essentials of Managed Health Care. Sundbury, Massachusetts: Jones & Bartlett Learning.
• www.wikipedia.com