The president of St. Johns Radiology Associates talks about its middle revenue cycle tech implementation process.
Implementing new technology to reduce administrative burdens and increase bottom lines is commonplace in the revenue cycle, but getting there isn’t always an easy road.
Between administrative buy-in and complicated go-lives, there always tends to be hiccups from conception to implementation. But this is where St Johns said its experience differed.
Just like other healthcare organizations, St. Johns needed to streamline revenue cycle processes. The group decided to do this by implementing an advanced speech reporting solution with built-in computer-assisted physician documentation functionality for its middle revenue cycle.
HealthLeadersrecently chatted with Dr. Arif Kidwai, president of St. Johns Radiology Associates, about the steps the organization took when implementing an AI-powered clinical documentation and workflow management solution and how it was able to avoid any major hurdles in execution.
HealthLeaders:Healthcare organizations have had a rough few years financially as they try to navigate inflation and labor shortages, among many other challenges, so this has led to a lot of leaders in your position to look toward technology to fill gaps and help their bottom lines. Can you tell us about the gaps that you were seeing at your organization and what technology you implemented to help fill those gaps?
Dr. Arif Kidwai: Yes, the last two to three years have been really rough for everybody in the healthcare industry across the board, radiologists included.
I've been fortunate to be a part of a hospital system where the executives are very proactive and ahead of the curve. They've always been aggressive with looking at new technology and trying to find ways to deliver healthcare more efficiently and provide better care for the patients.
About ten years ago, we started moving towards creating a better workflow within our own department and part of that process was to look for a new voice recognition system. At that time, we looked at a lot of the major players. But then we came across the 3M Fluency for Imaging product. For us, that was a game changer.
Once we started using a better workflow with a better voice recognition system, we were able to improve our turnaround times in radiology so that we had faster reports coming out to the clinic patients. We now have better accuracy in our reports because the voice recognition technology is the best that we've ever seen.
Having that voice recognition technology with a better workflow package made us better radiologist's both in quality and in our efficiency. Its something that we've seen now play out positively in the last three years, especially as things have even been more tight in the industry as the number of radiologists relative to the number of cases that we see annually has continued to grow and grow and grow.
There’s a great data graph out there that shows this gap between the increasing imaging volume year over year versus the relative flat number of radiologists that we've had nationally. And it's a challenge for everybody you know, as patient volume continues to grow and the shortage of clinicians persists. I think just finding that efficiency and the technology has been the only way to cope with that.
HealthLeaders: I know you said you're a part of a larger health system, so did you have to get an ample amount of buy-in from others in the system when it came to which solution you wanted to adopt?
Kidwai: We were really fortunate. When we were going through this process our chief medical information officer came to us and said the hospital organization wanted to buy one vendor product that would provide voice recognition software both in the radiology arena as well as hospitalwide for the new EMR that they were purchasing.
He came to me and said, ‘you know, at the end of this, it's the radiologists’ decision. You tell us what you like, and the hospital will follow.’ So, we worked hand-in-hand with his team, and we brought in all the major players at the time and we went through the standard inner product review of product demos.
For us, it was an easy decision. We had an ‘open mic night’ of sorts because our executives basically sat down in a room and had all the radiologist come in one by one. We came in, sat in the chair, and dictated into the microphone—signed in under a generic account with no voice training—and we just watched it work. It was really refreshing because technology before that had really been lagging as far as the radiologist expectations.
Everybody knew the pain of trying to correct reports, and to be able to sit down just see it work was really the thing that changed everybody's attitude about moving forward with new technology. That night we basically had a unanimous vote from the radiologists that this was the tech we wanted.
We went to the CMIO the next day and said, ‘this is our choice,’ and he smiled. He said, ‘that was my choice to, I just didn't want to tell you.’ That's how we as an organization came to this decision, and then we moved forward with it.
HealthLeaders: I frequently hear from other leaders that new technology is great, but implementation isn't always the easiest. So now that you’re over that hurdle, can you tell us a little bit about how implementation went at your practice and how you overcame any obstacles?
Kidwai: Yes, adoption of new tech is always a challenge for everybody. But prior to go-live our vendor did a lot of prep with our team. They did lot of training for our IT department. They came and they coached the radiologists of what to expect. Then on the go-live date they had trainers on site. We had both of our major sites covered with staff.
We also already had IT people that had been trained, so we were all ready for it. We also purposely decreased our outpatient volume for two days just to kind of handle the change and knowing that there would be a little bit of a kind of a learning curve to this.
But, for us, the shock was that after about three days, we were back to 100% productivity. And so, everybody went from being afraid of what's going to happen to three days later just simply doing our jobs again and forgetting that we had to go through this learning curve.
The CFO of Brightside Health talks financial strategy amid a telehealth boom.
CFOs know that COVID-19 changed the game completely—not only from a financial lens but from a strategy perspective as well.
Traditionally, there has been hesitance to adopt telehealth due to reimbursement issues. Reimbursement is still a hinderance, especially with the pandemic waivers expiring and some payers reluctant to expand coverage, but the curtain has been lifting and the barrier to access is shrinking.
Now, it’s not uncommon for organizations to implement a virtual care road map across the care continuum as a lower-cost, more productive option for care delivery. As strategy shifts, we are seeing the creation of more orginizations that specialize in 100% virtual care.
From a cost perspective it can seem like a no-brainer, but without a mature telehealth strategy, the implementation of a 100% telehealth service may encounter resistance from all corners—IT, billing, clinical teams, and even patients. On top of this, the numerous downstream consequences for failing to financially plan are vast.
Chris Murray, the new CFO at Brightside Health—a completely virtual, mental health provider organization, is well aware of the risks, but a solid telehealth understanding and financial strategy is the key to success, Murray says.
Murray recently chatted with HealthLeaders about the organization’s financial strategy along with the three main differences he sees between the financial strategy of a completely virtual provider organization versus that of a brick-and-mortar provider.
HealthLeaders: You have over 15 years’ experience in roles across finance, operations, and go-to-market functions at healthcare and technology companies, so what drew you to the CFO role for Brightside Health?
Murray: The current spotlight on mental healthcare is critical, especially as one in five Americans live with some form of mental illness. Like many of us, mental health issues have touched my family personally. My passion for changing the way the healthcare industry evolves to meaningfully support people living with severe depression and anxiety aligns with the mission of Brightside Health to deliver life-changing mental health care to everyone who needs it.
I’ve been in the CFO role at Brightside Health for a few months now, and I truly believe our solutions are changing people’s lives for the better. I am excited to see what the future holds for Brightside Health and how I can help grow the business.
HealthLeaders: What direction do you plan to take Brightside’s financial strategy?
Murray: The financial strategy for Brightside Health is exciting and complex. Because we work with many different markets, there’s opportunity to grow the revenue stream in a variety of ways. We’re driving momentum in the commercial market among payers, providers, and even employee assistance programs and are exploring other avenues such as Medicare and Medicaid, while still serving consumers directly. We know each stakeholder presents a unique opportunity and plan to examine how their differentiators fit into our broader mission and vision, while also addressing their financial objectives.
HealthLeaders: 100% virtual care is a relatively new concept, so how do you plan to drive growth and strategic initiatives?
Murray: An important role of a CFO is to build an infrastructure that supports the efforts of our product and technology teams. To do this we need robust performance tracking in place to ensure we’re monitoring progress against our objectives and putting numbers and structure to our challenges and successes. My team and I will also continue to analyze where there’s whitespace in the competitive landscape, working to identify areas that are primed for innovation that Brightside Health can play a key role in.
HealthLeaders: How does building a financial strategy for a digital-first mental healthcare provider differ from building a plan for a hospital or health system?
Murray: There are three differences that come to mind when thinking about our financial strategy versus that of a brick-and-mortar provider.
The first is the difference in compliance and legal requirements. As a mental healthcare provider, we must think about state-by-state licensing for our therapists (in all 50 states plus D.C.) whereas health systems typically work in one or a handful of states and don’t need to be mindful of local laws and regulations.
The second is infrastructure. We don’t have brick-and-mortar costs, which means much less overhead and ultimately allows us to treat more patients.
Third are the marketing costs–essentially how we reach people and how people can find us virtually. Traditionally, this isn’t something that a hospital or health system has to think about as there’s already awareness of the physical location (and often less options within the community to select from). Building brand awareness and ensuring our key differentiators are well known in the industry and among potential patients is a critical function of our business and something we are implementing in a meaningful way.
HealthLeaders: From a financial perspective, what do you see for the future of telehealth over the next few years?
Murray: The industry has no doubt been accelerated by the pandemic, and telehealth has proven to be a viable solution that will continue to be the future of healthcare. Traditionally, there has been hesitance to adopt telehealth due to reimbursement issues, but since the pandemic, the curtain has been lifted and the barrier to access has been removed. We’ve seen patients express the desire and interest to stick with telehealth, especially for behavioral healthcare. I think we’ll see increased demand across the industry to adapt and implement more telehealth solutions into platforms because that friction no longer exists.
Prepare your revenue cycle teams for several hundred new fiscal year 2024 ICD-10-CM codes now finalized to take effect October 1.
CMS recently announced the addition of 395 new diagnosis codes, 25 deletions to the diagnosis code set, and 13 revisions. An ample amount of these changes pertains to reporting certain diseases, accidents and injuries, and social determinants of health (SDOH). As mentioned, these code updates will take effect on October 1.
The new diagnosis codes are spread throughout the code set, with several dozen pertaining to osteoporosis with fractures, retinopathy and muscle entrapment in the eye, and disease of the nervous system—including Parkinson’s disease and epilepsy.
For example, the final update confirms the introduction of five new codes for Parkinson’s disease:
G20.A1, Parkinson’s disease without dyskinesia, without mention of fluctuations
G20.A2, Parkinson’s disease without dyskinesia, with fluctuations
G20.B1, Parkinson’s disease with dyskinesia, without mention of fluctuations
G20.B2, Parkinson’s disease with dyskinesia, with fluctuations
G20.C, Parkinsonism, unspecified
Of the 395 new codes, 123 of them reside in the external causes of morbidity chapter of the ICD-10-CM manual, specifically new codes to capture accidents and injuries.
When it comes to SDOH, there are 30 new diagnosis codes for factors influencing health status and contact with health services. There are also a host of new guidelines for reporting these codes.
For example, there is a new code for reporting an encounter for HIV pre-exposure prophylaxis. A “code also” note instructs coders to report risk factors for HIV, when applicable.
An extensive “code also” update for “other specified problems related to upbringing” says codes for the following diagnoses should also be reported when applicable:
Absence of a family member
Disappearance and death of family member
Disruption of family by separation and divorce
Other specified problems related to primary support group
Other stressful life events affecting family and household
This 2024 diagnosis code update comes at a time when hospitals and health systems are working more diligently than ever to address their patients’ social needs and the broader SDOH in the communities they serve.
Robust data related to patients’ social needs is critical to hospitals’ efforts to improve the health of their patients and communities. One way to capture data on the social needs of patient populations is through proper documentation and keeping revenue cycle staff up to date on code changes, which will help to better identify non-medical factors that may influence a patient’s health status.
CMS recently launched a new consumer webpage for the No Surprises Act.
CMS launched a webpage for consumers detailing patient protections from unexpected out-of-network medical bills under the No Surprises Act.
The website also addresses the dispute resolution process for uninsured and self-pay patients interested in disputing their bill based on a provider’s good faith estimate.
Surprises bills continue to be sprung on patients, even with a federal ban in place, with one in five adults receiving an unexpected medical charge this year, according to a survey by Morning Consult.
As revenue cycle leaders know, the No Surprises Act is meant to protect patients from receiving unforeseen bills for out-of-network and emergency services after receiving treatment, yet 20% of respondents in the survey say they or their family have been charged unexpectedly, with another one in five billed after being treated by an out-of-network provider at an in-network facility.
The bills have been especially costly in some cases, as 22% of respondents say their charges were over $1,000.
Creating more resources for patients, such as CMS’ webpage, could help patients better understand the law and what to expect when receiving care.
A bipartisan group of over 30 senators penned a letter to CMS asking the agency to reevaluate the 2024 inpatient payment rate.
The recent letter sent to CMS, led by Sens. Robert Menendez (D-N.J.) and Kevin Cramer (R-N.D.), informs the agency of concerns that the payment rate increase put forward in the fiscal year (FY) 2024 inpatient prospective payment system (IPPS) proposed rule will actually result in an overall payment reduction for hospitals.
According to the letter, in the FY 2024 IPPS proposed rule CMS relies heavily on data that does not account for the impact of the current elevated costs and expenses in providing healthcare. The senators also pointed out that the productivity update in this proposed rule assumes that healthcare facilities can replicate the general economy’s productivity gains.
“However, the critical financial pressures that hospitals and health systems continue to face have resulted in productivity declines, not gains,” according to the letter.
Each year, CMS is required to update payment rates for IPPS hospitals using the hospital market basket index to account for price changes in goods and services. To ensure Medicare payments more accurately reflect the cost of providing healthcare today, the senators asked CMS to use its special exceptions and adjustments authority to make a retrospective adjustment to the FY 2022 market basket update.
Unsurprisingly, the American Health Association (AHA) is backing the Senators’ letter.
“The AHA thanks Senators Menendez and Cramer for leading this important bipartisan effort urging CMS to ensure hospitals and health systems have the resources they need to continue delivering high-quality care to their patients and communities,” Lisa Kidder Hrobsky, AHA’s senior vice president for advocacy and political affairs said in a statement.
“This support is more needed than ever as the hospital field continues to confront rising inflation, workforce shortages and surging costs for supplies and drugs,” Kidder Hrobsky said.
Earlier this year, the AHA penned its own statement to CMS saying the association was “deeply concerned with CMS’ woefully inadequate proposed inpatient hospital payment update.”
According to CMS, under the FY 2024 IPPS proposed rule, acute care hospitals that report quality data and are meaningful users of EHRs will see a net 2.8% increase in payments in FY 2024 (compared to 2023). However, disproportionate share hospitals could be facing a payment cut of $115 million.
The national healthcare expenditure topped $4.4 trillion in 2022.
Now may be the time to assess your organization’s financial future as healthcare spending is growing, so much so that the United States spent $4.4 trillion on healthcare in 2022, a growth rate of about 4.3%, according to a federal estimate released today.
That rate of growth is projected to average 5.4% annually through 2031, according to Centers for Medicare and Medicaid Services’ (CMS) estimates put forward in a new study published in Health Affairs.
Despite that robust rate of growth, healthcare spending in 2022 is not expected to keep pace with overall economic growth in the United States, and healthcare’s share of the gross domestic product in 2022 is expected to fall from 18.3% to 17.4%, CMS says.
However, that trend is not expected to last. GDP growth through 2031 is projected to average 4.6% annually—0.8% lower than the average growth in national health expenditures—which means that health spending will hit 19.6% of GDP by 2031, CMS says.
“Altogether, and consistent with its past trend, health spending for the next ten years is expected to grow more rapidly, on average, than the overall economy,” says Sean Keehan, an economist in the Office of the Actuary at CMS, and the Health Affairs study’s first author.
The projections could spell trouble for providers.
As we know, when national health spending growth increases, reimbursement rates may not keep up, which means hospital leaders may have increased expenses while receiving less revenue. Now is the time to consider strategic decisions regarding the allocation of resources, managing expenses, and revenue growth.
CMS also says Medicare spending growth is projected to accelerate from 4.8% in 2022 to 8% in 2023, with expenditures expected to exceed $1 trillion, despite the end of the public health emergency in 2023 and the associated expirations of the skilled nursing facility 3-day rule waiver and the 20% payment increase for inpatient COVID-19 admissions.
Payers will be feeling the squeeze as well. Among the major payers, Medicare spending is expected to grow the fastest over the course of 2022-201 as the last of the baby boomers enroll in the program through 2029, the report says.
Private health insurance spending is expected to grow 5.4% annually, whereas Medicaid’s average rate of spending growth is projected to be 5.0% during the same period.
Hospital spending is expected to grow more quickly on average (5.8%) than average spending growth for physician and clinical services (5.3%), and prescription drugs (4.6%) during this timeframe.
Similarly, the report says the average price growth for hospitals (3.2%) is projected to be greater than that of prescription drugs (2.2%) and physician and clinical services (2.0%).
According to the report, businesses, households, and other private revenues are expected to pay the same proportion of total health spending in 2031 as they did in 2021 (51%). Government spending is projected to account for the remaining 49% (also the same as 2021). Before the pandemic, in 2019, those shares were 54% and 46%, respectively.
Quality reporting is an essential revenue cycle task tied closely to reimbursement, but it can cost providers big time, a new study says.
CMS says it collects quality data from hospitals paid under the IPPS with the goal of driving quality improvement through measurement and transparency to help consumers make more informed decisions, however gathering this information for CMS is proving time consuming and expensive for hospitals.
The new study published in JAMA set out to evaluate externally reported inpatient quality metrics for adult patients and estimate the cost of data collection and reporting, independent of quality-improvement efforts, and the conclusion was staggering.
The retrospective study at Johns Hopkins Hospital found that in 2018, quality reporting for 162 metrics cost the system over $5 million and took 108,478 personnel hours to complete.
In fact, according to JAMA, the hospital spent an estimated $5,038,218.28 in personnel costs plus an additional $602,730.66 in vendor fees that year.
Of the quality metrics studied, a total of 162 unique metrics were identified, of which 96 (59.3%) were claims-based, 107 (66.0%) were outcome metrics, and 101 (62.3%) were related to patient safety, according to the study.
The study also found that claims-based (96 metrics; $37,553.58 per metric per year) and chart-abstracted (26 metrics; $33, 871.30 per metric per year) metrics used the most resources per metric, while electronic metrics consumed far less (4 metrics; $1,901.58 per metric per year).
Johns Hopkins is a large system and the $5 million spent on quality reporting was a small portion of the hospital’s $2 billion in annual expenses that year, but that is not to say these metrics are not costly and time consuming overall.
The authors go on to explain that significant resources are expended exclusively for quality reporting, and some methods of quality assessment are obviously far more expensive than others.
“Claims-based metrics were unexpectedly found to be the most resource intensive of all metric types. Policy makers should consider reducing the number of metrics and shifting to electronic metrics, when possible, to optimize resources spent in the overall pursuit of higher quality,” the study said.
One expert shares five ways CFOs at prominent organizations across the country are maintaining financial stability in 2023.
CEOs say that 2023 is all about embracing the current reality and deciding maybe it’s not as bad as it could be. But now is not the time to ease up on strategy.
While this could be seen as good news, CFOs know they need to stay ahead of the curve and keep preparing for the next big financial hurdle.
“There is no single strategy [to maintaining financial stability]. It is highly multifaceted, and all levers must be pulled,” Swanson said. But there are five trends that Swanson says CFOs are deploying to ensure they remain financially stable:
Workforce optimization
When we talk about labor expenses and managing the workforce, a lot of organizations are looking at how they can think about workforce optimization by employing data and analytics in a more useful way to understand the appropriate complement of staff and workforce that they’d need to deliver care in the appropriate ways and in the most economical fashion.
Reducing the reliance on contract labor is another lever to pull. Some organizations are re-examining their float pool size or perhaps even creating their own internal staffing agency for some of those large systems. Some are considering recruitment retainment and those pipelines for ensuring that talent is coming in.
Some organizations are partnering closely with local nursing schools, in some cases offering tuition assistance or even full tuition assistance to build a pool of candidates to address some of the labor shortages. That strategy will take a few years, but it’s useful. It's also critical to create an environment where everyone works to the top of their license and top of their ability across the organization.
Supply chain management
What we’re seeing on the non-labor side is around more effective supply chain management by building scale and leveraging that to get preferred rates with vendors and in many cases, reducing the amount of variation in suppliers.
Payer negotiations
On the revenue side, negotiating with payers as those opportunities arise and negotiating in a way such that those dollars are focused on where the patient populations will be, versus where they have historically been, is important.
Value-based care models
Some organizations are exploring where to move on as they move more towards a value-based care model. Organizations that had greater value-based care models tended to outperform those that did not during the pandemic.
Reexamining the future of care delivery
Leaders also need to think strategically about what care looks like. What does care delivery in the future look like? And making sure that they are positioning themselves for the future, while managing their day-to-day, but not losing sight of what that future may hold.
The VP of finance and revenue cycle at PMHA outlines eight keys to success when implementing technology.
When budgets are tight, leaders need to be strategic when investing in technology. Because cost efficiency is so important, revenue cycle leaders need to make sure there is a substantial ROI when considering technology.
Nicole Clawson, VP of finance and revenue cycle at Pennsylvania Mountains Healthcare Alliance (PMHA), feels these same pressures at her health system. And, as a collaborative network of independent community hospitals located primarily in Western and Central Pennsylvania, the system needs to be cognizant of costs while improving operations.
To help ensure financial stability, Clawson says PMHA is in the process of implementing a combination of technology and operational expertise to monitor revenue cycle data flow from beginning to end with four of its member hospitals.
As Clawson and her teams are currently in the throes of technology implementation, she has eight keys to success for other finance and revenue cycle leaders looking to make the most of new technology while keeping costs low.
Nonprofit hospitals are seeing substantial growth in operating profits and cash reserves but at the cost of charity care, a new study says.
It seems not all finance leaders are fighting against poor operating profits.
In fact, according to a new study published by Health Affairs, the mean operating profits for nonprofit hospitals grew from $43 million in 2012 to $58.6 million by 2019, while mean cash reserve balances increased from $133.3 million to $224.3 million.
As developing and executing a strategic path to a financially sustainable future is essential for these leaders, it looks like it’s at the expense of charity care, the study says.
While profits grew from 2012 to 2019, the increase was not associated with the provision of more charity care by nonprofit hospitals. In fact, spending on charity care actually dropped during that time period: from $6.7 million in 2012 to $6.4 million.
The IRS has not stated specific quantitative requirements for the community benefits that nonprofit hospitals must provide, the study said. But, “Our results suggest that linking minimum contributions to charity care with profit increases may be helpful,” the study authors wrote.
With operating profits for nonprofit hospitals growing, the share of community health benefits they provide should also be growing to justify their favorable tax treatment, the study said.
The new study published in Health Affairs is not the first to take aim at nonprofit charity care spending as they are required to provide charity care and other community benefits in exchange for their tax-exempt status.
A Lown Institute hospitals index report said nonprofit hospitals collectively failed to invest nearly $17 billion in their communities in 2021, which included charity care spending.
At the time, the hospital index highlighted Vanderbilt University Medical Center and several other nonprofit, blue-chip providers for enjoying large tax breaks while falling short in making appropriate community health investments.
Vanderbilt University Medical Center responded with the following statement defending its charity care spending:
[For fiscal year 2021], Vanderbilt University Medical Center [VUMC] provided more than $829 million in charity care and other community benefits in service to the citizens of Tennessee. These funds support direct patient care and a range of initiatives that positively impact Tennesseans in other ways through improvements in community health.
The analysis by this organization allows only certain financial measures to be counted while intentionally excluding other beneficial activities traditionally supported by academic medical centers like VUMC that require considerable financial commitment.
In addition to the Lown Institute, a report from the state treasurer's office published last year took aim at North Carolina’s nonprofit hospitals. It found that although the nonprofit hospitals in the state received tax exemptions to provide charity care that were valued at more than $1.8 billion in 2020, most didn't provide enough charity care to equal the amount of those tax breaks.
Instead, "North Carolina's nonprofit hospitals billed the poor at an average rate up to almost three times the national average," the report said.
"Nonprofit hospitals are often more profitable than for-profits in North Carolina," the report said. "All the top 10 most profitable hospitals were nonprofits in fiscal year 2019."
