Wednesday Sep 17, 2014

The Need to Shift to Oracle Health Insurance Alternative Reimbursement

Kathy McCarthy, Director of Sales Consulting for Oracle Health Insurance, discusses the topic in today’s post:

The healthcare system is dramatically changing within the United States – both out of necessity and want.  In the current economy, the US spending on healthcare is more than any other nation, more even than this country can sustain.  With the fastest rate of growth compared to any other nation on gross domestic product, the US does not have the best action plan to solving this dilemma. Consumers are left with higher costs and decreased attention to their care, when the focus should be primarily on their well-being. 

The Affordable Care Act (ACA) is putting consumers back in charge of their health by requiring the government to ensure that payers improve outcomes, lower cost and increase access to care.  This application of value-based reimbursement will have four plans that will be implemented by 2015.

  • Physicians in group practices of 100 or more who participate in Fee-for-Service Medicare will be subject to the value modifier in 2015, based on their performance in calendar year 2013.
  • Physicians in group practices of 10 or more provider who participate in Fee-for-Service Medicare will be subject to the value modifier in 2016, based on their performance in calendar year 2014
  • For 2015 and 2016, the value modifier does not apply to groups of physicians in which any of the group practice’s physicians participate in the Medicare Shared Savings Program, Pioneer ACOs, or the Comprehensive Primary Care Initiative.
  • The value modifier starting in 2017 will affect all physicians who participate in Fee-for-Service Medicare.

The value-based payment models are aligned with better outcomes for the consumers and the healthcare providers are forced to work more closely with their patients.

  • Capitation payment is managed by care organizations to control the cost of healthcare.  The fixed amount of money per time period is determined on age, how many individuals and services provided in the geographical area. 
  • Shared Savings Program is services established for Medicare and Medicaid (CMS). This program simplifies communication among providers to improve and ensure optimal healthcare for those using CMS. 
  • Pay for Performance is an incentive payment used to improve the quality of healthcare through a collaboration of measuring the overall care of the patient, resources used and other factors.
  • Bundle Payment is a single payment made to providers or healthcare facilities based on treatments and conditions given.  This method was designed to focus on improved care that providers have clear metric to follow in order to maximize their payments.
  • Fee-for-Service is a specific reimbursement for an individual service done to a patient. Payment is based on formula and funding levels by what the consumer wants to pay, the cost of service and type of service provided.

As a result, healthcare payers need to have better access to data, tools, efforts and a significant increase in time to carry out the implemented models. Therefore, there will be an emerging need for payers to have agile and open systems to meet the new market demand.  Data will need to be merged by payers, in order to provide crucial information that will accurately determine payment.

As the models change so will the need for flexibility and delivery methods.  Cloud-based solutions that have insight, agility and operational efficiency will be the game changers. The Oracle Health Insurance Alternative Reimbursement solution supports a wide range of models that formalizes and automates data. Oracle Health Insurance holds accountable details for contracts, products, providers and members to create financial messages.

To learn more, download and read the white paper, Emerging Healthcare Value-based Payment Models for Improving Patient Outcomes and Cost Efficiency.

Don’t forget to keep up with us year-round:

 

Tuesday Jul 29, 2014

What Providers Should Consider Before Jumping into the Payer Market

The evolution of ACOs in the market has led to an increase in provider based payer organizations, the addition of some 400 this year require a new level of data sharing and analytics. The ability to analyze impacts of changing payment models and care guidelines on healthcare delivery and payment will define the stability and growth of the integrated organization.

Kathy McCarthy, Director of Sales Consulting for Oracle Health Insurance, discusses the topic in today’s post:

With the ACO model, healthcare organizations will continue to acquire groups and services within a specific demography.  Using integrated analytics to predict the impacts when entering new markets where different services and payment models overlap will be a key for accelerated expansion.

Providers need to consider several criteria before entering the payer market. The provider organizations needs to:

  • Understand the complexity of the market
  • Have clear goals
  • Conduct the necessary research
  • Evaluate delivery systems

Research has shown that there is no correlation between success and market share, location or deep pockets.

Providers need to:

  • Have positive relationships with other health systems in your area.
  • Have existing risk-based contracts with your providers.
  • Look at your market.
  • Have a relationship with a  payer organization

Providers will require systems that can:

  • Respond to rapid changes in policy
  • Merge clinical and financial data
  • Provide quality cost-efficient care
  • Support HIPAA PHI requirements
  • Create new sustainable payment and delivery models

Operational efficiency will be a key to success. Payers will need to have IT and analytics that will play an important role .Being able to merge clinical and financial data will be crucial to success. They need to improve the overall IT efficiency and gain more predictable costs and outcomes.

IT needs providers should consider:

  • Be prepared to implement changes required to improve performance.
  • Need for analytic capabilities.
  • Need for alternate payment arrangements.
  • Need to quickly introduce new plans, support efforts to reduce operating costs and take advantage of the emerging opportunities.
  • Many legacy systems are decades old and require costly and time-consuming hard coding to make even simple changes.
  • Seek and require rules-based systems.
  • Seek new payment models.
  • Provide quality care for a reasonable cost.

Oracle Health Insurance components help address these issues by providing:

  • Rules-based componentized products allow plans the agility and flexibility needed for success.
  • SOA-based components allow plans to purchase solutions that do not require an entire new system.
  • Scalability and reliability are built into all Oracle products.
  • Solutions can be delivered in multiple ways.

Learn more by watching the recent webcast, How to Navigate the Emerging Trend of Providers Shifting Focus to Healthcare Financing.

Don’t forget to keep up with us year-round:

Wednesday Jun 26, 2013

Challenges and Opportunities to Drive Change in the Healthcare System Explored at America’s Health Insurance Plans Exchange Conference and Institute 2013

The program theme at the June America’s Health Insurance Plans (AHIP) Exchange Conference and AHIP’s Institute 2013 was Transforming Our Health Care System: Navigating and Succeeding in the New Marketplace.  Topics included care delivery transformation, innovation for a new healthcare eco system, Health Insurance Exchanges, the nexus of consumerism, retail and healthcare, driving value through improved operations and leveraging technology, data and innovation to transform care. Oracle participated as a sponsor of both conferences, signaling the significant investment and activity Oracle continues to make in helping health plans, providers and government agencies become more efficient and more relevant in the healthcare market place.

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Oracle's flexible solutions can help insurers navigate the change necessary to meet today’s challenges and have the business agility to be prepared for the future.

For mor information, visit oracle.com/insurance.

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