Payment And Finance

Trying to predict a hospital's inpatient nurse staffing needs is a tough day-to-day challenge that involves matching often unpredictable patient demand to the nurse resources needed to care for those patients. Case in point: the Chesterfield, Mo.-based Mercy health system, a 31-hospital network serving Missouri, Kansas, Oklahoma and Arkansas, a hospital system that ranges from critical care hospitals with an average census of perhaps five to 10 patients a day to large tertiary care facilities. In March, 2011, Mercy implemented enterprise-wide web-based scheduling software that has significantly reduced the guesswork involved in its inpatient nurse staffing allocation.

Changes in the industry landscape are forcing health plan leaders to reevaluate their value proposition while continuing to execute effectively on these core competencies. There is additional pressure on health plans to now be the engine that seamlessly powers the all-important patient-provider relationship. This is the perfect time for a health plan to embark on a transformation of its core service model, thereby putting itself in a position to capitalize on the service expectations associated with the changing industry landscape.

In recently submitted comments, the Charlotte-based Premier alliance urged the Centers for Medicare & Medicaid Services (CMS) to make changes to outpatient payment policies and quality measure reporting proposals issued in July. Responding to the outpatient prospective payment proposed rule, healthcare network systems alliance voiced strong support for CMS' proposal to reimburse hospitals for separately payable drugs and biologicals using the statutory default rate.

After a win with the Atlantic City Special Care Center, the Cambridge Mass.-based Iora Health is replicating its care model of intensive primary care management services, aligned incentives, and actionable analytics, across the country. Iora Health's guiding principle is to target the small group of patients who generate the most healthcare costs, and treat them using a global budget, rather than fee-for-service infrastructure.

Aetna's Charles Kennedy, M.D., heads up a division of that health insurer focused on collaborative development of accountable care organizations with hospitals and physician groups. He offers his perspectives on where accountable care is going, and what provider IT leaders need to do to move their sector forward.