"The technology and the tools are there to do this," says Rizk of better clinical and claims data sharing. "There's just an immense mistrust for each other. It's a much greater divide than I thought."
Ned Moore, CEO and cofounder of Portico Systems, a healthcare technology company headquartered in Blue Bell, PA, says insurers see the importance of shifting from a transactional claims organization to a full managed care organization. Insurers have begun to invest in better technology that would allow for more information sharing. Rizk says this transformation can improve three areas: financial, clinical, and transactional.
Insurers are still in the infancy of better information sharing with providers, but they have made some inroads in the area of transactions through such technology as real-time claims adjudication.
One example is a pilot program in Ohio that involves America's Health Insurance Plans, BlueCross BlueShield Association, eight insurers, and five Ohio physician organizations. The project created a one-stop Web portal for electronic transactions intended to reduce health insurance paperwork. Ninety-one percent of all Ohio residents insured through private carriers are part of the project.
Justine Handelman, executive director of legislative and regulatory policy for BCBSA, which consists of 39 independent BlueCross BlueShield companies that provide healthcare coverage for 100 million members, says having providers go through one portal saves staff time and reduces administrative costs. Greater collaboration between payers and providers will lead to improved quality of care and system efficiencies, she says.
Health insurers are increasingly linking finances with clinical information through pay-for-performance projects, such as quality contracts.
Opening up a dialog between payers and providers could also allow for quicker distribution of patient information, which could have the biggest impact for patients with chronic diseases.
Rather than wait for claims information, health plans can create immediate communication with physicians' offices and hospitals so they know when a chronic disease patient has received services—and also find out their test results. This promptness and level of detail are not available in claims data, so new real-time technological solutions are needed.
But better relationships between the two can take place even without better technology. Todd M. Fowler, past president of the Ohio Medical Group Management Association and chief administrative officer of the 130-physician, nine-clinic, Gallipolis, OH-based Holzer Clinic, says creating a dialog can help build better relationships. MGMA does that through sessions with group practices and payers.
"We wanted to make a cordial, professional team approach where they are sharing information with us, we're sharing information with them, and that helps in and of itself," says Fowler.
This kind of work changes the stereotype of the faceless health insurer. It's easy for providers to blame insurers for their problems, but it's better to talk with insurers so they understand where the provider community is coming from and providers can understand what insurers want, he says.
"We are partners in healthcare. We provide services, they pay for them . . . I would strongly encourage constructive dialogs so that we understand each other. And that we realize we're partners in this whole healthcare industry—not competitors," says Fowler.
4. Quality and safety based on design and layout
Inside intensive care unit rooms at Sharp Memorial Hospital in Southern California, even the window blinds are considered in the infection control effort. Unlike most dusty blinds, these panels are encased between two panes of glass and don't incubate germs. Housekeepers don't even have to clean them.
That one creative design in the new $200 million facility helps the hospital protect patients from the increasing threat of infections from airborne bacteria and viruses. It improves the chance a patient stay will not be prolonged, says Sharp's executive vice president for hospital operations, Dan Gross. A bonus: It protects the employees from infection as well.
As facilities nationwide resume their capital building projects and continue to increase the amount of remodeling projects they undertake, hospital executives should be exploring hundreds of evidence-based physical design techniques and tweaks that can reduce patient harm, shorten patient stays, and improve quality of life in recovery.
Unfortunately, most hospital executives aren't thinking along these lines, says Blair Sadler, an expert in building the business case for evidence-based design.
"If you were to survey 5,000 hospital CEOs, probably not more than 10% would say, 'Oh yes, we really understand the compelling connection—that having the ideal physical environment helps reduce harm to patients and staff,'" says Sadler, a senior fellow with the Institute for Healthcare Improvement in Cambridge, MA, and a former hospital CEO.
"What we need is a national wake-up call. And if I were a healthcare czar for a day, I would have a national campaign similar to the Institute of Medicine's '100,000 Lives' initiative. We have to figure out how to get this information in front of the busy CEO."
For example, Sadler points to dozens of fixes now shown to have positive effects on quality outcomes. Among the most cost-effective:
Infection control: Viruses, bacteria and fungi are transmitted by touch, through air, or through water, so it's important to implement environmental improvements that affect all three.
That might include installing HEPA filters in rooms that treat patients, especially those with immune system suppression, and installing sinks or, at least, alcohol-based hand gel dispensers at patient room entrances so staff will be more likely to clean their hands upon entering and exiting. Though less cost-effective, converting rooms from double- to single-bed can reduce the chance infection can spread between patients.
Patient safety: To prevent falls, beds can be moved closer to bathrooms, reducing the distance at which about 40% of all in-hospital falls occur. "An average hospital fall costs the hospital $10,000 in additional care, and that's a conservative number," Sadler says.