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Hospital Revenue Unstable Despite Outpatient Volume Growth
Payer mix shifts, increases in self-pay, and lower Medicaid revenue per case are troubling hospital revenue despite a 2.4 percent boost in outpatient volume.
Hospitals recently saw increases in national inpatient and outpatient volumes. However, net hospital revenue continues to be unstable for non-profit organizations, according to a new analysis from the public accounting, consulting, and technology firm Crowe.
“As many health systems expand their portfolio of services (more outpatient facilities, entrees into insurance products, and other ancillary investments), stability of hospital-based net revenue becomes more important to financial decisions,” the analysis stated. “Unfortunately, instability appears to be the current trend, forcing many CFOs of not-for-profit healthcare systems to study operations and budget them on a monthly or quarterly financial performance basis, in the same manner that their peers in for-profit organizations do.”
The consulting firm analyzed data from its revenue cycle analytics solution for 622 hospitals in Medicaid expansion states and 389 hospitals in non-expansion states. The analysis of data from January through September of 2017 and 2018 revealed some positive results for 2018.
Inpatient volume is up 0.6 percent in 2018, and gross revenue per case also increased 5.3 percent during the period.
At the same time, outpatient volume rose 2.4 percent and gross revenue per case increased 7.1 percent on the outpatient side.
Hospitals may be reaping the benefits of higher volumes. However, net revenue per case demonstrated greater volatility on the inpatient and outpatient sides, the firm pointed out. Net revenue per inpatient case only increased 1.6 percent between 2017 and 2018 and net revenue per outpatient case rose 5.5 percent during the same period.
“It is important to consider that these trends do not hold true across all payers. As a result, some hospitals may be more exposed to diminishing growth in net revenue per case,” the analysis stated. “Although an increase in net revenue appears to be good news for hospitals, the manner in which revenue is increasing follows some troublesome trends.”
The “troublesome trends” identified by Crower researchers included a significant shift in payer mix. Medicare managed care, self-pay, and other payers (i.e., third-party liability and worker’s compensation) increased by 1.6 percent for inpatient and 1.1 percent for outpatient overall, the firm reported.
“In addition to these payer classes having a lower net realization overall, they also challenge finance leadership’s ability to forecast net revenue, as seasonality and patient engagement vary by facility,” the analysis explained.
Increases in self-pay accounts particularly contributed to hospital revenue instability, Crowe added. Self-pay increased 16.1 percent by 2018, representing six percent of the average hospital’s payer mix. Self-pay accounts continue to be the most difficult to collect, suggesting a growing obstacle for hospital revenue.
Medicaid net revenue also fell from 2017 to 2018, the analysis showed. Net revenue per case for both traditional and managed care Medicaid decreased 6.9 percent for inpatient and 1.1 percent for outpatient.
Hospitals that treated a greater number of Medicaid beneficiaries will continue to see their Medicaid revenue drop under new regulatory changes, researchers predicted.
For example, CMS finalized a new policy that will change the methodology for determining Medicaid Disproportionate Share Hospital (DSH) payments. Medicaid offers DSH payments to hospitals that treat a greater proportion of low-income and vulnerable patients and bases the payment amount on the hospital’s uncompensated care costs.
The new policy will clarify that uncompensated care costs include only the costs for Medicaid-eligible patients with payments remaining after accounting for the reimbursement to the hospital by or on behalf of Medicaid-eligible individuals, including Medicare and third-party payments.
A federal judge vacated the new policy’s implementation on a national level in March 2018, arguing that changing the policy exceeded CMS’ authority because the Medicaid Act specifically identifies what constitutes uncompensated care costs. Several states have also challenged the policy in court.
CMS is currently challenging the rulings.
New rules for the 340B Drug Pricing Program could also further decrease Medicaid revenue for hospitals, the analysis stated. CMS recently finalized $1.6 billion in hospital payment reductions for 340B covered drugs.
The American Hospital Association (AHA) and several other groups sued CMS over the payment cuts. But a federal judge ruled that CMS can enforce the billions of dollars in payment reductions.
Additionally, the Crowe analysis uncovered a decrease in final denial write-offs, or patient bills that were not paid by payers. Final denial write-offs for outpatient services fell by almost 15 percent from 2017 to 2018, the data showed.
While a drop in final denial write-offs indicates business office improvements, researchers noted that recent changes in managed care contracting may challenge denial rates going forward. Contracts for outpatient diagnostic imaging are likely to see the greatest challenge to denial rates, they reported.
PwC names 6 healthcare issues to watch in 2019
PwC’s Health Research Institute believes 2019 is the year the “New Health Economy” will finally become a reality.
The past year marked record interest in the healthcare industry, especially from outside forces like venture capitalists and business giants like Amazon, Berkshire Hathaway and JP Morgan Chase. PwC believes forces like these mean healthcare will no longer be an “outlier” industry that operates in its own world outside the greater U.S. economy.
In its 13th annual report, PwC’s HRI identified the following six healthcare trends to watch in 2019:
1. With an injection of $12.5 billion from investors over the past two years, PwC expects connected health devices and digital therapies to become integrated into care delivery and the regulatory process for drug and device approvals. PwC expects several new products to come to market in this category in 2019. What does this mean for providers? They will need to find a way to integrate this data into the EHR so it can be used to maximize the patient visit.
2. Artificial intelligence and automation will require healthcare organizations to invest in and train their workforce to succeed in a digital economy. Almost half (45 percent) of executives surveyed by PwC’s HRI said skill deficiencies among their workforce are holding their organization back, yet few employers are offering training in AI, robotics and automation or data analytics.
3. The 2017 Tax Cuts and Jobs Act will continue to create tax savings for healthcare organizations while creating new challenges. Providers are likely to feel the biggest challenges via changes to unrelated business taxable income, which could create new expenses. Academic medical centers may also feel minor negative pressure from the net investment excise tax on educational foundations.
4. The healthcare industry is ready for its own budget airline provider. It needs a disruptor that is low-cost, transparent, informed by technology and “laser-focused on the consumer” like Southwest Airlines, according to PwC. Organizations that answer this call are starting to emerge — like a profitable, Medicaid-focused, walk-in-only family medicine practice in Denver — but progress is slow and there isn’t one simple formula to follow. PwC advises healthcare organizations to look for patient segments that need a “budget airline” and determine how to meet those needs.
5. The pace of private equity investment is expected to accelerate as healthcare companies continue to divest noncore business units to investors next year. It also expects PE-healthcare partnerships to evolve, with some healthcare companies co-investing in their own spinoffs. PwC suggested healthcare organizations pursue PE partnerships not only for financing, but also for PE firms’ ability to provide strategic views of trends across their portfolio of investments.
6. Republican changes to the ACA will shift the law’s winners and losers. Providers are on the losing end of most of these changes, including softened insurance mandates, short-term health insurance plans, less federal support for ACA exchanges and reduced federal Medicaid spending, according to the report.
Download the report here.
26% of Hospitals Without Effective Revenue Cycle Management System
Without a workable revenue cycle management system, 82 percent of the hospitals plan to go blind with value-based reimbursement and 85 percent may seek consulting services.
Approximately one-quarter of US hospitals (26 percent) do not have an effective healthcare revenue cycle management solution in place, according to a new Black Book survey.
Black Book surveyed over 4,640 individuals from 522 hospitals and healthcare delivery networks on their use of 165 revenue cycle management technology services and solutions. The survey showed that revenue cycle management improvement is happening, but a significant portion of hospitals still do not have workable solutions.
While 26 percent of hospitals do not have a plan to optimize or replace legacy revenue cycle management systems, the proportion of hospitals without a transition plan is down compared to six years ago. In 2012, 35 percent of all hospitals did not have a revenue cycle management strategy in place to improve or replace their solutions.
The most recent survey results show that about 400 hospitals implemented a viable, effective revenue cycle management optimization or replacement plans over the past six years.
However, the opportunity to improve healthcare revenue cycle management remains. Of the 1,600 hospitals without a revenue cycle management optimization plan, about 82 percent expect to make value-based reimbursement decisions in 2019 without the use of an advanced software or outsourced partner, the survey showed.
Value-based reimbursement is overtaking the traditional fee-for-service system. The proportion of healthcare payments tied to an alternative payment model is rising, reaching 29 percent of healthcare payments by 2016, the Health Care Payment Learning and Action Network (LAN) recently reported.
The number of payments linked to value-based reimbursement is only going to increase as private and public payers implement alternative payment models to lower costs and improve care quality. And hospitals will be expected to take on the clinical and financial risks associated with the models.
Effective revenue cycle management solutions can help hospitals make the transition to value-based reimbursement.
“What providers absolutely must have are really powerful analytics that are able to take clinical and outcomes data, a lot of which resides in clinical systems, and combine it with financial data to accurately measure where we improve quality based on outcomes results,” Deanna Kasim, Research Director of Payer Health IT at IDC Health Insights, told RevCycleIntelligence.com.
“There is an absolute need that if this is going to be successful in terms of changing reimbursements and care delivery models, payers need to get providers and the consumers to the table and there has to be the next generation of analytics applications to support these efforts.”
Without a viable, effective revenue cycle management solution, hospitals could lose revenue during the transition to value-based reimbursement.
In light of the challenge, 85 percent of Black Book respondents said they would partner with a revenue cycle management consultant or advisory company for short-term direction.
For the long-term, however, hospitals will need to partner with a third-party vendor to implement an optimized revenue cycle management solution that can deliver value-based reimbursement results.
Black Book explained that hospitals can invest in core, platform, and/or point solutions, which cover enterprise-wide functions. Or hospitals can implement bolt-on solutions that automate specific components of the healthcare revenue cycle.
At this stage in the market, hospitals are currently turning to bolt-on solutions to complement their legacy financial and clinical systems. About 45 percent of large and community hospitals in a recent Black Book survey plan to use multiple bolt-on solutions for revenue cycle management in 2019.
Few hospitals expect to use one core legacy vendor for a software solution. Only 23 percent of small hospital staff, 15 percent of community hospital staff, and 17 percent of large hospital staff stated that relying on a core solution was their organization’s revenue cycle management strategy for 2019.
Hospitals are investing in more bolt-on solutions versus core software because of staffing concerns, Black Book reported in the most recent survey. The five-month polling process revealed that staffing concerns were the top challenge hospitals faced with implementing new revenue cycle management solutions or improving legacy software.
Finding skilled revenue cycle management human resources for new solutions was a major obstacle to optimizing or replacing legacy systems. Therefore, outsourcing core functions or implementing bolt-on services was a short-term alternative, hospitals leaders said.
“If hospitals are to maximize revenue and reduce claims take-backs, it is imperative that those still behind the curve find a way to dedicate appropriate resources toward implementing an effective RCM system,” the market research firm concluded.
20% of Americans are deferring healthcare because of cost, poll finds
Americans are delaying medical care as they struggle with its affordability, according to the latest NPR-IBM Watson Health poll.
The survey of more than 3,000 U.S. households in July found about 20 percent of respondents or someone in their household had postponed or canceled a healthcare service due to cost in the prior three months.
Younger respondents were more likely to put off their healthcare needs. Thirty-four percent of respondents under 35 said they deterred care because of cost, compared with 8 percent of respondents 65 and older.
The poll also found 26 percent of respondents or someone in their household had difficulty paying for some type of healthcare service in the prior three months.
Again, younger respondents were more likely to experience trouble. Forty-one percent of respondents under 35 said they or a member of their household struggled to pay for a healthcare service, compared to 11 percent of respondents 65 and older and 26 percent of respondents ages 35 to 64.
The poll found 66 percent of respondents said they received a prescription in the prior three months, and 97 percent of those respondents had it filled. Of the respondents who said they had a prescription filled, 19 percent reported they had trouble paying for it.
Access the full poll results here.
12 health systems with strong finances
Here are 12 health systems with strong operational metrics and solid financial positions, according to recent reports from Moody’s Investors Service, Fitch Ratings and S&P Global Ratings.
Note: This is not an exhaustive list. Health system names were compiled from recent credit rating reports and are listed in alphabetical order.
1. St. Louis-based Ascension has an “Aa2” senior debt rating and stable outlook with Moody’s. The health system has a large diversified portfolio of sizable hospitals and strong liquidity. Moody’s expects Ascension’s margins to improve in fiscal year 2019.
2. Wausau, Wis.-based Aspirus has an “AA-” rating and stable outlook with S&P. The health system has solid debt and liquidity metrics, according to S&P.
3. Morristown, N.J.-based Atlantic Health System has an “Aa3” rating and stable outlook with Moody’s. The system has a strong market position, favorable balance sheet ratios and strong operating performance, according to Moody’s.
4. Charlotte, N.C.-based Atrium Health has an “AA-” rating and stable outlook with S&P. The health system has a strong operating profile, favorable payer mix, healthy financial performance and sustained volume growth, according to S&P.
5. Durham, N.C.-based Duke University Health System has an “Aa2” rating and stable outlook with Moody’s. The health system is a leading provider of tertiary and quaternary services and has solid margins and cash levels, according to Moody’s.
6. Inova Health System has an “Aa2” rating and stable outlook with Moody’s. The Falls Church, Va.-based health system has consistently strong cash-flow margins, a leading market position and a good investment position, according to Moody’s.
7. Baltimore-based Johns Hopkins Health System has an “Aa2” rating and stable outlook with Moody’s. The health system has favorable liquidity metrics, strong fundraising capabilities, a healthy market position and regional brand recognition, according to Moody’s.
8. St. Louis-based Mercy Health has an “Aa3” rating and stable outlook with Moody’s. The health system has favorable cash-flow metrics, a solid strategic growth plan, a broad service area and improving operating margins, according to Moody’s.
9. Traverse City, Mich.-based Munson Healthcare has an “AA-” rating and positive outlook with Fitch. The health system has a leading market share in a favorable demographic area and a healthy net leverage position, according to Fitch.
10. Vancouver, Wash.-based PeaceHealth has an “AA-” rating and stable outlook with Fitch. The health system has a leading market position, robust reserves and strong cash flow, according to Fitch.
11. St. Louis-based SSM Health Care has an “AA-” rating and stable outlook with Fitch. SSM has a strong financial profile, and Fitch expects the system to continue growing unrestricted liquidity and to maintain improved operational performance.
12. Appleton, Wis.-based ThedaCare has an “AA-” rating and stable outlook with Fitch. The health system has a leading market share in a stable service area and strong operating performance, according to Fitch.
Glassdoor: 9 best hospitals to work for in 2019
Nine hospitals and health systems made Glassdoor’s annual Best Places to Work list in 2019.
Glassdoor compiled the list based on feedback from employees who chose to anonymously submit a company review to Glassdoor between Oct. 23, 2017, and Oct. 21, 2018.
Here are the nine hospitals and health systems that made the list:
1. St. Jude Children’s Research Hospital (Memphis, Tenn.) — No. 13
2. Northside Hospital (Atlanta) — No. 52
3. NewYork-Presbyterian Hospital (New York City) — No. 64
4. Memorial Sloan Kettering Cancer Center (New York City) — No. 66
5. MD Anderson Cancer Center (Houston) — No. 68
6. Phoenix Children’s Hospital — No. 83
7. Massachusetts General Hospital (Boston) — No. 84
8. Texas Health Resources (Arlington) — No. 89
9. Kaiser Permanente (Oakland, Calif.) — No. 98
Access the full list here. Access additional information on the methodology used for the list here.
6 Michigan physicians charged in $464M billing fraud scheme
A grand jury in Michigan returned a 56-count indictment Dec. 4 that charges six physicians in a $464 million healthcare fraud scheme, according to the Department of Justice.
Rajendra Bothra, MD, owner and operator of a pain clinic in Warren, Mich., and five physicians who worked at the clinic are accused of prescribing patients opioid pain medication to get them to come in for office visits. During the office visits, the physicians allegedly subjected the patients to unnecessary treatment, including facet joint injections. The physicians “sought to bill insurance companies for the maximum number of services and procedures possible with no regard to the patients’ needs,” the Justice Department said in a press release.
The fraud scheme, which occurred between 2013 and November 2018, allegedly involved more than 13 million unlawfully prescribed opioid prescription drugs.
“The damage that opioid distribution has done to our community and to the United States as a whole has been devastating,” said U.S. Attorney Matthew Schneider. “Healthcare professionals who prey on patients who are addicted to opioids in order to line their pockets is particularly egregious. We will continue to prosecute such individuals who choose to violate federal law and their ethical oaths.”
Partners HealthCare’s annual operating income soars 489%
Boston-based Partners HealthCare saw its operating income rise in fiscal year 2018 despite a decline in revenues, according to financial documents released Dec. 7.
Partners saw operating revenues dip 0.5 percent year over year to $13.31 billion in fiscal year 2018, which ended Sept. 30. The health system’s significant growth in provider revenues was partially offset by a decline in insurance revenue. Partners said the decrease in insurance revenue was attributable to the transition of members from Medicaid managed care programs into the new MassHealth ACO program in March.
After accounting for a 2.4 percent decrease in expenses, Partners ended fiscal 2018 with operating income of $309.9 million. That’s up 489 percent from a year earlier, when the health system posted operating income of $52.57 million.
Partners reported a 2.3 percent operating margin for fiscal 2018, up from a 0.4 percent operating margin in the year prior.
“While a 2-3 percent margin is slim compared to our peers across the nation, it enables us to reinvest in patient care and provide for the future capital needs of our hospitals and facilities,” said Peter K. Markell, treasurer and CFO of Partners.
After factoring in nonoperating income, Partners ended fiscal 2018 with net income of $826.6 million, up from $659.1 million in fiscal 2017.
HENRY KOTULA 