Health Technology, Medical Devices
Article | May 22, 2023
The fall is a time of renewals and choices. It is also a time of so called “open enrolment” for health plans. It is the one time of year we can study and learn about the options offered through employers or government sponsored plans. Individuals and small business owners alike are also are faced with a myriad of choices with confusing and often contradictory language promising lower premiums with higher out of pocket costs for covered services subject to deductibles. What does it even mean anymore when your monthly premiums exceed your pay check and you still have to pay for your colonoscopy or your insulin? Where is it all going?
Let’s imagine you twist your ankle playing basketball. You might go to an urgent care, receive an X-ray, probably be examined by a non-physician, and then referred to your primary care, who can’t see you for a few weeks but eventually sends you to an orthopaedic who takes another X-ray and treats your injury. Weeks have passed, multiple visits, time out of work, and co-pays, not to mention the out-of-pocket fees associated with imaging and perhaps a $100 ace bandage. What stops you from going straight to the ankle specialist in the first place? First, we have become conditioned to follow the directions dictated by the insurance companies, even when restrictions are not in place, patients have been convinced that stepping out of line will make all insurance promises null and void resulting in catastrophic bills and financial ruin. Second, the doctors and their office staffs have been conditioned to deny entry to any patient who does not have the proper referral, authorization, or identification. There are dire consequences for both if the insurance rules are not followed and fear keeps both sides aligned.
The past two decades have seen an explosion of healthcare costs. Health insurance has become the single biggest line item second only to payroll for most businesses. It is no coincidence that as the government increased its role as payor with state subsidies, the prices have gone up. Much like college tuitions, when loans are easy to obtain and guaranteed by federal support, there is little to deter those in charge from increasing the price. After all, everyone is doing it, it must be OK, and even if students end up in debt, it will be repaid because they have received the value of a great education. Right? But unlike higher education, healthcare is a necessity. We cannot avoid it, and there needs to be a reliable mechanism in place to guarantee access.
Ironically, as charges and prices have continued to escalate, payments to doctors have diminished. Why medicine is the only service industry where there is no transparency is truly astounding, especially since the there has been no increase in so called “reimbursements” for decades. As physicians, we have been complicit, being fully aware of the discrepancies between what is charged and what a patient’s insurance will pay. Even as patients began to have higher deductibles, and therefore higher out of pocket expenses, we continued to follow the rules, asking insurance permission to collect payment from the patient. It is not surprising that bad debt accounts for over 50% of most account receivables and why over 70% of doctors are now employed by hospital networks or private equity, who not only go after patients, but benefit from the repricing that occurs when insurers pay a negotiated amount as opposed to the charge. In other words, we pay more not just for less, but for nothing.
But what if we twisted our ankle and went directly to that specialist and paid out of pocket a transparent price? What would it take for that to happen? Not much, the cost of care is predictable, and because payments have always been decreasing, most physicians have learned to be economical. Plus, out of pocket costs are capped by federal law, so no patient is really responsible for catastrophic bills. Charges inflate to cover overhead, but if payments were guaranteed and immediate, then the cost of doing business goes down. Add technologies like telemedicine to a practice and you have increased patient access to a doctor without adding more personnel. Direct pay doctors are emerging all over the country and have consistently offered better access and more affordable care. The bar is also being set by independent surgery centers and imaging centers who offer better outcomes at lower costs. Perhaps motivated by prohibitive pricing, better options have emerged that have moved patients away from expensive operating rooms to safe, office-based procedures. Even cutting-edge cancer therapies can be delivered at home, preserving more of the healthcare dollar for medical care rather than the complex system built to manage it.
Competition and choice inevitably drive prices, but in a monolithic system the price is not negotiated, but instead it is set by only a few, in this case the big insurers. Small businesses cannot compete when bigger companies come to town. Eventually, the local hardware store gives way to a national brand, and the consumer is left with fewer choices and eventually higher prices. Amazon disrupted this equation by creating a marketplace for individual buyers and sellers. The convenience of finding a trusted brand, no longer available locally, is irresistible and the reason why we became loyal consumers. Healthcare is no different. Trust exists implicitly between a physician and patient, because it is an authentic, empathetic, and logical relationship. Trust does not exist between a patient and their insurer, on the contrary it is an unsympathetic business relationship without transparency or consistency. Few doubt the insurance company’s top priority is the premium, not the patient. Creating a direct relationship between the doctor and patient is a common-sense approach that serves both stakeholders well, and requires merely a fair and affordable price. But do doctors have the capability or the will to do it and if so, can the rest of the system follow?
Never in the history of modern medicine have physicians been more dissatisfied. US healthcare used to lead the world in innovation and outcomes, now we struggle to break the top thirty. We may have the most brilliant doctors and scientists with access to the best resources, but the need to maximize profits while catering to special interests, be they commercial or political, has led us to favour certain therapies over others despite marginal proven benefits. Doctors have little autonomy and less authority; prescribed treatments are routinely denied by insurance companies without a second thought or appropriate peer review. In fact, insurers even renamed us “providers”, a term used to by Nazis when referring to Jewish doctors to devalue them professionally. Over 56% of physicians are burned out, nearly all report moral injury and as hospitals have systematically replaced doctors with non-physicians with limited training, we have watched the standard of care deteriorate. It is no wonder we have witnessed the single biggest loss in life expectancy since WWII. The prognosis is grim, but there are solutions.
We need to reinvent healthcare by removing the middleman. We don’t have to set the price, but we can make it transparent so patients can decide for themselves if it is worth the inconvenience, the delay, and the co-pay to use insurance or just pay directly. Health savings accounts are tax deferred and can cover an out-of-pocket maximum in just a couple of years. Paying for care means there are no surprise bills or out of network costs, because there are essentially no networks and therefore no need to follow restrictions. You’d be hard pressed to find a doctor or hospital unwilling to accept an immediate cash payment, especially when it costs nothing more than the service provided. There are no billing cycles, or claims to prepare, no up coding, or authorizations. Doctors free to care for patients, patients treated individually and not subject to protocols designed to maximize charges. There are literally thousands of direct pay primary care and specialists now available all over the country and they are building alliances with likeminded people providing imaging, ancillary services, surgery centers, and prescriptions all at fair market prices. More and more employers are moving toward medical cost sharing plans that not only lower the cost of care but the cost of administration. Even the biggest payor, namely the government, sees the benefit of price transparency and is piloting models of direct contracting.
We will always need coverage for those unexpected events, emergencies, or hospital-based services, but all the rest - doctor visits, screening tests, and outpatient procedures - are easily affordable. After all, do we use our car insurance to pay for an oil change? If we did, the cost would be prohibitive and few of us would drive. But health insurers have lost our trust, they no longer cover necessary services and no longer honour contracts with physicians or patients. It is time to offer another option and let the patients and doctors get back to the real business of medicine.
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Health Technology, Medical Devices
Article | April 17, 2023
As competition for patients intensifies, more hospitals and health systems are embracing a consolidated, single-bill approach for services rendered. Creating a single bill for the patient’s portion of inpatient or outpatient services can help eliminate confusion and reduce the ill will that frequently results when patients receive multiple invoices for a single care event. Yet incorporating anesthesia charges into a consolidated invoice is often problematic due to the unique nature of the anesthesia billing compliance.
Anesthesia Billing Service Hurdles
A few weeks ago, I met with the CEO of a 300-bed hospital. We discussed anesthesia billing, and he explained that his hospital traditionally outsourced this portion of its billing due to the more complex nature of anesthesia coding and the need to collect anesthesia minutes for billing. Unlike most inpatient services, anesthesia charges are not directly derived from CPT codes but instead utilize minutes and modifiers unique to the specialty.
That means coders must use a CPT crosswalk to account for ASA codes, base and time units, emergency- and physical-status monitors, split anesthesia units reflecting CRNA involvement, and other specialty-specific nuances. Most coders and hospital billing staff are not trained in these complexities, and hiring and retaining capable staff in today’s competitive market can be difficult. Moreover, many billing platforms are simply not equipped to incorporate all the variables necessary to produce an accurate anesthesia bill.
As a result, producing a consolidated patient bill that includes anesthesia is tricky. Yet leaving anesthesia off a single bill can undercut its value since, after facility and surgical charges, anesthesia often is one of the largest cost items patients incur. Fortunately, we at Change Healthcare know how to roll anesthesia charges into existing hospital billing systems to produce an accurate and timely single patient bill.
Helping to Reduce Costs
The benefits of consolidated billing extend beyond an improved patient experience. Producing just one bill reduces costs and repetition at both the front and back end of the revenue cycle management process. It can also ease staff burden when collecting on self-pay accounts, since there’s only one bill per patient. Finally, consolidated bills can help increase revenue by simplifying collections when patients present for follow-up care.
Here’s an example: When the patient comes back for post-surgery physical therapy, a hospital employee at the registration desk can remind them that they still owe $150 for anesthesia and ask if they’d like to take care of that now. In my experience, patients usually hand over their credit card and settle their bill on the spot when asked at the time of care about a balance due.
System-Agnostic Billing Across Hospital Platforms
Change Healthcare has a long history of providing full-service, outsourced anesthesia-billing services to hospital and health-system clients. Unlike most other billing vendors, we’ve developed what we call a system-agnostic approach. That means we’ll provide billing services on our proprietary system or on the hospital’s existing billing platform, regardless of type, to generate accurate anesthesia-billing results.
In practical terms, we’ll function as part of your billing team and use the same system your coders and billing staff rely on to generate anesthesia charges that can be included in a single patient bill.
System-agnostic billing also allows us to provide clients with custom anesthesia reporting that wouldn’t otherwise be available with an outsourced billing solution. This helps clients gain far greater visibility and insight into anesthesia-billing charges. And by incorporating our anesthesia coding and billing capabilities into your existing billing system, you’ll be spreading the platform’s fixed costs across a greater number of departments.
The bottom line? It’s not a heavy lift for us to virtually embed our trained anesthesia coders and billing professionals into your system. Our specialists will review your existing platform and provide, at no obligation, a return-on-investment analysis that can help you determine whether outsourcing anesthesia billing to capture claims on a single hospital bill makes sense for you.
We expect the answer will be yes. Not only will you enjoy greater system efficiencies, but you’ll be in a position to produce a single bill that truly reflects the entire episode of care.
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Digital Healthcare, Medical Devices
Article | May 17, 2023
COVID-19 has been a catalyst for change, with the diagnostics industry taking centre stage and rising to the challenge of a global pandemic. One of the silver linings of this mammoth task has been the unprecedented time and focus dedicated to finding new technologies and solutions within the sector.
The lessons learned from the pandemic now need to be taken forward to improve breast and cervical cancer detection, prevention and treatment across the UK over the coming years.
In the more immediate term, the diagnostics industry, alongside public health leaders, faces a daunting backlog as screening programmes for breast and cervical cancer were put on pause for months. These two life-saving tests have been some of the most overlooked during the pandemic and getting back on track with screening is critical as we start to turn the corner. We believe innovation in diagnostics, particularly artificial intelligence guided imaging, is a key tool to tackle delays in breast and cervical cancer diagnosis.
The scale of the backlog in missed appointments is vast. In the UK, an estimated 600,000 cervical screening appointments were missed in April and May 2020. And an estimated 986,000 women missed their mammograms, of which an estimated 10,700 could be living with undiagnosed breast cancer. It is clear that hundreds of thousands of women have been affected as COVID-19 resulted in the reprioritisation of healthcare systems and resource allocation.
Both cervical and breast cancer screening are well suited for digital technologies and the application of AI, given both require highly trained medical professionals to identify rare, subtle changes visually –a process that can be tedious, time-consuming and error prone. Artificial intelligence and computer vision are technologies which could help to significantly improve this.
What does AI mean in this context?
Before examining the three specific areas where digitisation and AI can help, it is important to define what we mean by AI. It is the application of AI to medical imaging to help accelerate detection and diagnosis. Digitisation is the vital first step in implementing an AI-driven solution – high quality images demand advanced cloud storage solutions and high resolution. The better the quality of the input, the more effectively trained an AI system will be.
The first area where AI-guided imaging can play a role is workflow prioritisation. AI, along with increased screening units and mammographers, has the potential to increase breast cancer screening capacity, by removing the need for review by two radiologists. When used as part of a screening programme, AI could effectively and efficiently highlight the areas that are of particular interest for the reader, in the case of breast screening, or cytotechnologist when considering cervical screening.
Based on a comparison with the average time taken to read a breast screening image, with AI 13% less time is needed to read mammogram images, improving the efficiency with which images are reviewed. This time saving could mean that radiologists could read more cases a day and potentially clear the backlog more quickly.
For digital cytology for cervical cancer screening, the system is able to evaluate tens of thousands of cells from a single patient in a matter of seconds and present the most relevant diagnostic material to a trained medical professional for the final diagnosis. The job of a cytotechnologist is to build a case based on the cells they see. Utilising these tools, we are finding that cytotechnologists and pathologists are significantly increasing their efficiency without sacrificing accuracy to help alleviate the backlog of cervical screening we are seeing in many countries.
Prioritising the most vulnerable patients
Another key opportunity is applying AI to risk stratification, as it could help to identify women who are particularly at risk and push them further up the queue for regular screening. Conversely, it would also allow the screening interval for those women at lower risk to be extended, creating a more efficient and targeted breast screening programme.
For example, women with dense breast tissue have a greater risk factor than having two immediate family members who have suffered from breast cancer. What’s more, dense breasts make it more difficult to identify cancerous cells in standard mammograms. This means that in some cases cancers will be missed, and in others, women will be unnecessarily recalled for further investigation.
A simple way to ensure that those most at risk of developing breast cancer are prioritised for screening and seen more regularly would be to analyse all women on the waiting list with AI-guided breast density software. This would allow clinicians to retrospectively identify those women most at risk and move them to the top of the waiting list for mammograms.
In the short term, to help tackle the screening backlog, prior mammograms of women on the waiting list could be analysed using the breast density software, so that women at highest risk could be seen first.
Finding new workforce models
Being able to pool resources will allow resource to be matched to demand beyond borders. Globally, more than half a million women are diagnosed with cervical cancer each year and the majority of these occur where there is a lack of guidance to conduct the screening programme. The digital transformation of cervical screening can connect populations that desperately need screening to resources where that expertise exists. For example, developing countries in Africa could collect samples from patients and image these locally, but rely on resources in the UK to support the interpretation of the images and diagnoses. Digital diagnostics brings the promise of a ‘taxi-hailing’ type model to cervical cancer screening – connecting groups with resources (drivers with cars) to those who are in need (passengers): this is an efficient way of connecting laboratory professionals to doctors and patients around the world.
It’s going to take many months to get cancer screening programmes up and running at normal levels again, with continued social distancing measures and additional infection control impacting turnaround times. But diagnostic innovation is on a trajectory that we cannot ignore. It will be key to getting cancer screening programmes get back on track. AI is a fundamental piece of the innovation puzzle and we are proud to be at the forefront of AI solutions for our customers and partners.
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Health Technology
Article | June 9, 2022
Healthcare leaders are embracing the benefits of the cloud and software as a service (SaaS) after the pandemic challenged them to adapt and innovate like never before. 66% of them expect to move their technology infrastructures to the cloud this year – a number that is set to rise to 96% by 2024 [1]. Yet moving to the cloud is more than just a technology transformation. It’s an organizational transformation. Through cloud-based platforms and solutions, healthcare systems can begin to unlock clinical and operational insights at scale while speeding up innovation cycles for continuous value delivery.
Integrating data across the care continuum
In many ways, COVID-19 catapulted healthcare into the future. The pandemic created a new urgency for healthcare leaders to expand their virtual care offerings as a way of connecting with patients beyond the walls of the hospital. At the same time, they wanted the flexibility to scale up or down without large upfront capital expenditures. Effective crisis management also required the rapid exchange of patient information across systems and care settings. Thanks to the flexibility of pay-as-you-go cloud-based services and solutions, healthcare providers were able to quickly scale up digital health technologies to meet new demands. As a result, the acceptance of cloud has increased remarkably [2].
Keeping patient data secure and compliant
As healthcare leaders embark on this journey to the cloud, data protection is a critical consideration. Data processing in healthcare must comply with rigorous standards, whether it is HIPAA in the US or GDPR in the EU. Unfortunately, healthcare organizations also remain a top target for data breaches, calling for additional data security protection measures [3].
While the need for data security and regulatory compliance has historically motivated healthcare organizations to keep data on premises, today there is a growing awareness that moving to the cloud can in fact be the better road to travel. In fact, 60% of healthcare leaders now cite security as one of the top benefits of the cloud [4]. When healthcare organizations rely on their own data centers, they are responsible for security from end to end, which can become prohibitively complex and time-consuming as IT infrastructures expand over time. Cloud-based services and solutions can reduce dependency on local hardware to store sensitive data while automated software updates keep systems current.
Turning data into insights at scale at the point of care
Working from these foundations, the next big opportunity in healthcare is to capture the insights in the data that we are beginning to connect and integrate. This is where the cloud is also turning into a vital enabler, with its powerful computing resources and advanced machine learning capabilities, offered as microservices. These microservices provide the building blocks to develop new digital solutions that, once validated and approved, can be deployed at scale to help improve clinical outcomes and operational efficiency.
Enabling rapid experimentation and continuous value delivery
Embracing the cloud also changes the very nature of innovation in healthcare.
Healthcare-compliant cloud platforms offer a flexible foundation for rapid development and testing of digital applications. Cross-functional teams working in short and agile cycles can put new digital applications into the hands of physicians or patients more quickly, and then add new or improved features and functionalities as they gather additional user feedback. That means healthcare organizations get to innovate faster. And in smaller, more digestible increments.
Moving to the cloud is not all or nothing
Of course, none of this is to suggest that moving to the cloud is like switching a button. It’s a complex and multi-year journey for most of our customers. And it’s quite a journey for Philips, too. Any organization that has accumulated a large number of legacy systems and infrastructures over the years will have to manage a hybrid architecture during their journey to the cloud [5].
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