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In a move with implications for not-for-profit (NFP) healthcare business models, Kaiser Permanente (KP) has announced plans to acquire Geisinger and form a new organization. Upon acquisition, Geisinger will join [...]

The business of health care faces unprecedented challenges. The combined, related costs of materials management, staffing, tracking, and maintenance make optimizing medical assets a major budget concern for hospitals. And [...]

Across the country, innovations in care delivery models at organizations of varying size and type are enhancing continuity of care, changing utilization patterns, and reducing costs. Almost every healthcare organization [...]

Health system leaders should view any steps they take to prepare for their state's Medicaid reform initiatives as integral to their organization's evolution toward value-based care and population health. More [...]

Improving data capture is a strategic priority for many hospitals and health systems. By accurately and comprehensively documenting and coding to reflect each patient's condition, these organizations have the potential [...]

Learn strategies for improving the patient financial experience, negotiating payer contracts, going beyond point-of-service (POS) collections, and more from winners of the 3014 MAP Award for High Performance in Revenue [...]

Taking the right approach to ICD-10 testing can help organizations turn a potential drag on cash flow into a strategic advantage once the new coding system takes effect in October [...]

Revenue cycle management literature is replete with methods for measuring team performance, whether in patient access, health information management (HIM), patient accounting, or physician practice areas. Various articles within hfm [...]

Although the number of acute care hospital mergers declined from 94 transactions in 2012 to 79 in 2014, the development of new regional partnerships, collaborations, and joint ventures that can [...]

Achieving good collections can mean getting needed equipment, annual wage increases, or cash to finance start-up costs for a new service or building for a healthcare organization. Good collections will [...]

Few healthcare organizations have sufficient capital resources to meet their comprehensive, strategic capital requirements. Their leaders must make choices. How much capital to spend and the projects on which dollars [...]

Current levels of outstanding debt for hospitals are astoundingly high. According to the American Hospital Association, the nation's hospitals provided approximately $28.8 billion of uncompensated care in 2005, a greater [...]

Usually efficiency, belt tightening, and doing more with less. Such talk inevitably makes staff anxious. Managers everywhere know the drill on cost management from this perspective. In a departure from [...]

"Out of life's school of war: What does not destroy me, makes me stronger." --Friedrich Nietzsche The key to strong executive leadership is knowing when and how to act in [...]

Much ink has already been spilled extolling t he perceived virtues--and vices--of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) in general and of private delivery in [...]

Gateway Health System, formerly known as Clarksville Memorial Hospital, is the sole acute care medical facility in Clarksville, Tenn. The town is located in Montgomery County, which has a population [...]

Despite reports to the contrary, managed care is pervasive and growing. By understanding employers' needs and how those needs are forcing managed care to change, hospital and physician provider organizations [...]

H. Michael Flasch, FHFMA, is vice president of claims/administrative services and support for Detroit, Michigan-based Health Alliance Plan (HAP), a subsidiary of Henry Ford Health System (HFHS), which also comprises [...]

After experiencing operating losses of more than $15 million and a growing number of days in accounts receivable and payment denials, Capital Health System implemented a multidisciplinary recovery program to [...]

An increasing number of health plans are initiating disease management programs, particularly for asthma, congestive heart failure and diabetes, in their effort to reduce costs without compromising the quality medical care they provide to patients. However, some of the programs are not producing cost savings. The reasons for the minimal cost savings include insufficient program design, ineffective management and unrealistic goals., The increased development and implementation of disease management programs reflect attempts by a growing number of health plans to reduce costs while providing patients with high-quality care. Unfortunately, few of [...]

Healthcare organizations require corporate compliance programs for their integrated delivery systems to ensure their commitment in legal and ethical operations. These organizations must avoid the common obstacles in the development of the compliance programs such as cost, time allocation, lack of necessity and effects on the morale on employees. The compliance program development has four phases: identification of compliance risk, implementation of the program, auditing of claims processes and continued monitoring and training., A compliance program in an integrated delivery system (IDS) must facilitate coordinated compliance efforts across all of the health system's components (eg, flagship hospital and attendant home health agency, nursing [...]

Health maintenance organizations (HMOs) can improve member retention for their managed care plans by explaining the value of customer loyalty to employees and senior management. This can be done by educating executives and staff about the full cost of lost members compared with the benefits of member retention and loyalty. It is also advisable to form a cross-functional team whose sole responsibility is member retention. Another helpful strategy is to determine why members and payers leave health plans and develop the necessary plan of action., Although most plans measure member satisfaction, this measure is not an accurate indicator of member retention. Plans reporting 90 percent satisfaction rates also report disenrollment rates of 20 to 40 [...]

Impending changes in the health care market will affect the survival of integrated delivery systems. These changes include increased managed care penetration, reduced monthly health insurance premiums and the increased demand for nonacute care. A case study on how a 10-year-old independent delivery system developed a strategic marketing position based on expected market changes is discussed., In the next five to 10 years, managed care penetration in large metropolitan areas and small cities could reach 90 percent, while per-member-per-month premium payments could fall to an average [...]

Risk sharing arrangements allow healthcare providers and health maintenance organizations (HMOs) to align their financial incentives and avoid conflicting care management patterns. Thus, the right choice of a risk-sharing arrangement will help HMOs and providers achieve their cost, quality and profit objectives. Three of these risk-sharing arrangements are performance-based payment arrangements, percent-of-premium or capitation arrangements and inpatient case rate arrangements., Choosy integrated delivery systems are putting pressure on HMOs to come up with creative risk-sharing arrangements. The three primary participants in the healthcare delivery system are patients, payers, and providers. [...]

Comprehensive clinical pathways can win more managed care contracts for health maintenance organizations. Clinical pathways are detailed plans for the management of medical conditions or surgical interventions which take into account standards of care and the human and material resources necessary to provide medical services. They result in shorter lengths of stay, reduced costs and increased patient satisfaction that convince payers and consumers of an organization's cost-effectiveness and high-quality care., Providers that have "must have" status with managed care organizations have achieved quality and cost outcomes that demonstrate the providers' ability to manage risk and communicated these outcomes in a [...]

The refusal of insurers to reimburse healthcare providers for certain days of care or entire admissions can lead to losses amounting to millions. However, providers can avoid insurer-denied days of care by assigning a quality assurance coordinator and peer review physician to dispute cases of denials, evaluating processes that contribute to denied days and studying utilization and quality provisions in managed care contracts., To help reduce inpatient expenses, insurers establish utilization management protocols and perform utilization reviews of the care provided in inpatient settings. As a result of these reviews, insurers may deny [...]

Health maintenance organizations (HMOs) normally use one of two strategies to manage patient-care expenses provided under workers' compensation insurance benefits. They either create a network of HMOs to provide medical care or utilize managed care services such as utilization management, case management and medical care protocols to minimize expenses related to workers' compensation insurance benefits., MANAGED CARE Health maintenance organizations (HMOs) have become very active in managing workers' compensation medical expense benefits. A survey of 316 HMOs shows that this activity takes the form of [...]

Health care providers are forming networks for managed care contracting in response to trends in the healthcare industry. Such networks should be managed based on market-based strategies following the example of the retail industry and other industries that operate in a competitive market. Healthcare provider networks should set goals and formulate strategies to reach those goals. Strategies should be based on a vision of the future of the healthcare industry and avoid relying mainly on past financial data.

Health insurance providers and other entities that pay for rising medical claims are subjecting such claims to intense scrutiny. These reviews take the form of payer system edits, payer case management and medical reviews. Healthcare providers can use internal case management to better handle these reviews. Such a program would also increase the efficiency of claims processing while increasing patient access to a range of services, lowering medical costs and promoting continued care.

The development of successful partnerships in healthcare delivery follows integration patterns either as affiliations, acquisitions, consolidations or mergers. The complexity of the healthcare industry has made it inevitable for some organizations to integrate their operations to become more qualitatively and financially competitive in providing the best possible services to their patients.

The success of integrated health care delivery systems depends substantially on the primary care physicians that they are able to recruit. These physicians represent their vital link to patients since they are mainly responsible for the provision of primary services. Thus, healthcare systems compete actively in the market to recruit quality physicians. Their affiliations must forge a balance between the organization's and the physicians' needs.

Managed care and risk sharing, regulation of capitation and varying schemes for risk sharing in different states are analyzed to understand how risk-sharing arrangements are evolving. At issue is the growing importance in healthcare delivery of how healthcare providers and health maintenance organizations (HMO) should share the risk of providing healthcare services to HMO enrollees.

A do-it-yourself strategic plan is a cheaper alternative to the ones developed by consultants, offering easier implementation by providing organizational staff members with more control over its content. To be effective, a do-it-yourself plan should be a departmental rather than an individual effort, involving the health organization's president, CEO, department heads and top managers. Several components of a strategic plan are enumerated and discussed.

Projects fail for many reasons, but often failure can be the result of the actions and inactions of senior leadership. October's column discussed several factors that can cripple projects, such [...]

With so much on the line, what can you do to increase your likelihood for success? Hospital executives are best served by following the five steps for effective IT investment [...]

Most healthcare providers do not maximize their profit potentials because of systems and administrative processes that do not effectively monitor and enforce contract terms. This inefficiency may be caused by the lack of understanding of managed care contracts, terms and requirements and the use limited information systems. To optimize revenues, healthcare organizations should employ sufficient information systems and well-informed contract management staff and implement process improvements., Many provider organizations are losing millions of revenue dollars each year due to errors and inefficiencies of their systems and administrative processes to monitor and enforce managed care contract terms. [...]

Integrated delivery systems must realize that the main obstacle to creating an integrated organization is the different cultures of the system's components. However, 10 steps can be taken to address this problem. These include facing the reality that cultural conflicts exist, obtaining the entire system's support for a single culture and emphasizing to managers the need for cultural change., Many integrated delivery systems (IDSs) perform poorly because of cultural differences of their constituents. To reconcile such differences and start to develop one unifying culture, IDSs need to promote a [...]

Managed care companies must follow certain guidelines in developing a provider-sponsored organization (PSO) that would take advantage of opportunities presented by the Medicare+Choice program. First, they must provide the PSO with information related to the Balanced Budget Act of 1997, Medicare+Choice and the PSO regulatory framework. It is important for managed care organizations to establish PSO objectives that complement the corporate mission, strategies and goals. They must also create a formal business plan for the PSO once its feasibility has been established., With the introduction of the Medicare + Choice managed care program, the opportunity for healthcare providers to contract directly with Medicare through provider-sponsored organizations (PSOs) has finally arrived. But the [...]

Integrated delivery systems (IDS) usually partner with health maintenance organizations (HMO) to make managed care patients more available. Other advantages of affiliation includes reduction in the cost of administering health management, enhancement in healthcare outcomes and leverage in the seamless care process. Meanwhile, some states, such as California and Minnesota, are promoting IDSs with HMO components by drafting laws that enable IDSs to act as insurers., Healthcare purchasers are increasingly turning to managed care plans for help in reducing the cost of providing healthcare benefits. Recent market research by SMG Marketing Group found that HMO penetration [...]

Health maintenance organizations (HMO) are continually depending on risk-bearing Independent Programming Associates (IPA) as they develop their networks due to IPA's capacity to handle risk and to contribute to the expansion of HMO-provider networks. IPA organizers must learn to balance the financial and clinical autonomy they offer physicians with effective management procedures so as to create a sustainable, risk-bearing IPA. Some factors which are vital to the attainment of this balance are selection of participating physicians, management information systems, and compensation., To succeed, risk-bearing IPAs need to balance the clinical and financial autonomy they afford physicians with centralized management and governance. HMOs are increasingly sharing risk with IPAs because IPAs have [...]

Many hospital executives who form health maintenance organizations to attract managed care contracts fail due to a lack of strategic focus. They fail to evaluate their market position in terms of their organization's reputation, managed care services offered and competitive strength. Among the other mistakes in planning managed care strategies are the failure to set strategy priorities and failure to hire individuals with managed care expertise and background., Hospital executives, steeped in hospital business traditions, sometimes fall victim to those traditions when planning their managed care strategies. They may fail to sufficiently evaluate their hospitals' market position or [...]

Healthcare providers have three options for sponsoring their own health maintenance organizations (HMOs): by forming their own HMO, by buying an existing HMO or by forging a joint venture with an existing HMO. The different market conditions for providers to consider when choosing the best option are managed care area penetration, potential competition, market demand, provider reputation and provider marketing ability., Providers can sponsor their own HMOs in one of three ways: by creating their own HMO, by joint venturing with an existing HMO, or by purchasing an existing HMO. When [...]

Top HMO executives are receiving huge compensation packages, according to a report by Families USA, Washington, D.C. The report examines compensation in 2000 for the highest-paid executives of the 10 [...]

By implementing a process-centered revenue cycle, healthcare organizations and group practices can achieve a seamless payment process with clear lines of accountability to achieve target outcomes. The integrated, end-to-end, revenue-cycle [...]

Harvard Pilgrim Health Care, Boston, Massachusetts, will remain not-for-profit, coverage and care for its subscribers will remain uninterrupted, and the HMO's provider network will continue to be paid in full [...]

Whether a healthcare organization's investments are managed by in-house staff or an outside investment management firm, a proper operational framework that includes reporting, performance monitoring, and audit and risk management [...]

Harvard Pilgrim Health Care, Boston, Massachusetts, could drop 900 physicians from its 5,000-member network if the physicians do not form or join new, local negotiating groups. The HMO wants to [...]

UnitedHealth Group Inc., Minneapolis, Minnesota, plans to let physicians have the final say on medical treatments for their patients, even if the insurer's staff thinks the treatments are medically unnecessary. [...]

Some providers offering to take on risk have been turned down by Centene Corp., one of the fastest-growing U.S. health insurance companies, because they were found by the company to [...]

The Problem Community Health and University Health are two healthcare organizations in a state that has recently seen the continued growth and rising market power of a large health system, [...]