Adapting Your Growth Strategy to Meet the Needs of Aging and Racially and Ethnically Diverse Patient Populations
By Michael Shipley
Senior Product Manager
By Michael Shipley
Senior Product Manager
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Tags: Blog, Stratasan, strategic planning, strategy, data, data analysis, data analytics, data-driven decisions, data strategy, growth, health, health care, health strategist, health strategy, healthcare, healthcare data, healthcare planning, healthcare strategic growth, healthcare strategic planning, healthcare systems, hospital, Market Share, healthcare growth, data analyst, all-payer claims data, decision-driven decisions, data aggregation, payers, Gist
Stratasan recently began offering a new capability: ZIP5 analysis of our All-Payer Claims Database. This capability helps health systems and hospitals better assess critical business performance in areas such as patient outmigration and physician referral tracking.
Stratasan assigns a ZIP5 to patient IDs in order to provide an enhanced level of granularity. The ZIP5 assignment is for All-Payer Claims 837 submit data since that is the data being rolled up to the ZIP. This modeling is based on the patient’s observed healthcare utilization from All-Payer Claims Data (APCD). In this blog, we’ll explore our methodology for ZIP5 modeling, but first, let’s explain why this level of insight is useful.
On July 1, 2021, the Departments of Health and Human Services, Labor, and Treasury, and the Office of Personnel Management issued an interim final rule to implement fundamental parts of the No Surprises Act (NSA). Despite the disarming title, the No Surprises Act will lead to many surprises, around lack of parity in reimbursements within a market. In upcoming years, payers and providers will be forced to evaluate their value proposition, market positioning, customer/patient transparency, and data analytics.
The NSA contains key protections to hold consumers harmless from the cost of unanticipated out-of-network medical bills. According to the Kaiser Family Foundation, “surprise bills lead the list of affordability concerns for many families; 2 in 3 adults say they worry about unexpected medical bills, more than the number worried about affording other health care or household expenses. Surprise bills can number in the millions each year.”
While the major implications of the NSA will benefit consumers, the severity of impact that this legislation will have on payers and providers will depend on how they react. In this post, we’ve worked to summarize this new law and discuss some of the ways that both providers and payers can be prepared to act.
Beginning in Q1 2021, significant adjustments went into effect for how payments are calculated for physician services. These changes are the result of modifications to the Calendar Year 2021 Medicare Physician Fee Schedule (MPFS).
These updates will particularly help both primary care providers (PPC) and specialists that bill high volumes of Evaluation and Management (E&M) codes. It will hurt specialists who bill mostly for procedures rather than E&M visits. Consider these specialist examples:
As summarized by Gist Healthcare, the implication of these changes will result in “higher pay for some primary care physicians and medical specialists, but reduced payment for many proceduralists.”
Our partners at Ancore Health provided a helpful summary of how reimbursement is calculated, and the impact of this update, in this blog post.
These changes, which make E&M coded visits more financially valuable, were a significant move by CMS to prioritize primary care and increase the focus on value-based interactions. The clear goal is to encourage more facetime with patients, which can give physicians the opportunity to catch health issues in earlier stages. Quality primary care patient interactions can happen when quantity isn’t the priority.