How healthcare organizations can keep consumers engaged in the digital age

The pandemic has made healthcare virtual out of necessity. The success of healthcare companies lies in how they interact with digitally-savvy patients and consumers.

The pandemic has changed every facet of our lives and healthcare is no exception. While the healthcare industry was already tackling changes prior to the pandemic, the last two years have kicked into high gear the shift to digital.

Much of that shift stems from the changing needs of consumers and their evolving healthcare-related interactions. For many, those interactions are now remote and virtual. Healthcare organizations that stay several steps ahead of the needs of consumers are seeing success.

Let’s look at what healthcare leaders are focusing on as they address today’s digital healthcare consumer.

A Value Proposition Catering To Consumers

Even as healthcare becomes more digital, the need for a strong value proposition doesn’t change, especially if healthcare companies want to engage consumers and patients in the virtual sphere.

Sami Inkinen is the co-founder and CEO of Virta Health, an organization with a lofty goal. Virta Health aims to reverse Type 2 diabetes for a hundred million people.

But as Inkinen notes, you can’t force a treatment plan on patients. “People have to opt in,” he says. “Just to give you one statistic, half the people, for example, living with Type 2 diabetes, when a provider says, ‘you have to be on insulin,’ half do not want to do that.”

A better approach to engaging patients, Inkinen says, is through a value proposition that is the right fit for your consumer.

“You have to make sure that what you’re actually offering is so powerful [of a value proposition] that most people raise their hands and say, ‘are you serious? So, you can reverse diabetes? How can I do that? And you’re telling me it’s free? My employer helpline pays it?”

Sami Inkinen

CEO and Founder of Virta Health

Tom Waller agrees.

Waller is the SVP of Innovation at adidas and a keen observer of human behavior. He’s used those observations to improve the health, wellbeing, sports and fitness industries.

Waller says healthcare consumers are looking for ways to improve their health, but motivation alone isn’t enough. A value proposition that considers shifts in tiny human behavior goes a long way.

“It’s not quite as sexy, but it definitely works,” he says. He adds that healthcare organizations that use knowledge alone as their value prop are likely not going to entice consumers to engage. He sums it up with a sweet example.  “We all know we shouldn’t eat too much cake, but we still do.”

Keeping up with shifting digital healthcare trends

The one constant in the age of digital healthcare is that the industry is constantly changing. That’s predicated on the evolving needs of healthcare consumers.

“In healthcare, we’re so focused on how care has been delivered, we miss that consumers have totally moved on from the way they live their lives,” says Drew Schiller, co-founder and CEO of Validic. Schiller adds that the pandemic has been a catalyst in that move.

Organizations that continuously anticipate changes in the needs of their patients and consumers are the ones leading the innovation and disruption we’re seeing today in healthcare, says Sarah Richardson, SVP and CIO Tivity Health.

Richardson says that digital health involves the use of many devices, but the interactions between these devices offers opportunity for delivering a smooth consumer experience.

“We are seeing a huge shift from that patient experience to a human experience [and] there has to be a way for it to be pretty seamless and invisible to the user.”

Sarah Richardson

SVP and CIO at Tivity Health

Richardson says that digital health involves a continuous journey of making the consumer experience as benign as possible.

“You think about things like in-ear monitoring as well, so if you need a continuous monitoring of how well someone is doing, sure you can have it on your wrist, but you can put things into somebody’s ear so it’s even less invasive,” she says.

There’s also an opportunity to use voice command in digital health, Richardson says, and it has great potential for making digital health more accessible and convenient.

But the key is to make the digital healthcare consumer experience seamless and non-invasive in our day-to-day lives. “If it’s invisible, you’ll use it, or if it’s easy to use, you’ll do it,” Richardson says.

The shift to value-based healthcare

Providers are seeing the rise of value-based healthcare, which entails physicians and hospitals getting paid based on patient outcomes.

Inkinen says that value-based healthcare is helping not only patients see improved health, but also helping providers by reducing cost. He offers the example of Type 2 diabetes, which is currently costing the U.S. healthcare system billions of dollars each year.

“These diabetes drugs that people are on to manage their disease can easily be $500, $600 or $700 a month, like insulin and SGLT-2s, and GLP-1s,” Inkinen says.

“These are ridiculously expensive branded drugs, and we typically get patients off of them in 30 to 45 days,” he adds.

“And as an immigrant, this is one thing that’s been slightly painful for me to learn, but if you don’t make people money in U.S. healthcare, good luck trying to commercialize. So, when you align the outcomes with the money, magic happens.”

A New Era Of Healthcare

Healthcare is changing rapidly and staying ahead of these changes is necessary for organizations that want to remain competitive in the industry. At Emids, we help healthcare and life sciences organizations tackle these changes in a seamless manner for better outcomes.

The Health at Home Transformation: Delivering Care in a Space of Trust

The last two years were marked by fear, isolation and economic challenges brought on by the COVID-19 pandemic. But it was through these challenges we developed a need to interact with each other remotely.

In the healthcare ecosystem, we’ve seen a shift in how consumers engaged with their care providers—often through the use of technology in the comfort and safety of their homes.

Payers realized the benefits of Health at Home and began paying for services historically only reimbursed for in-person visits with a provider.

The result?

Consumers now have a choice of virtual or in-person care. Fears of leaving the safety of your home are eliminated, scheduling is convenient, and changes in patient health status are being captured while still manageable, preventing the need for hospitalization.

Even the Centers for Medicare and Medicaid (CMS) are now offering reimbursements for healthcare services being delivered remotely at home. This wasn’t conceivable prior to the pandemic.

As we grapple with COVID-19 becoming endemic, virtual access to healthcare and Health at Home remains a popular option for receiving care with technology playing a key role in making this a reality.

Home—a trusted space

While home care services are not unique to the pandemic, reimbursement models monetizing health at home became a reality during this time. Regulations suddenly supported a new model of care.

Our health needs were addressed within the four walls of our homes—a space of trust, convenience, and family support.

For the elderly, options for managing chronic care expanded into their homes, too. The concept of hospital at home was born out of the need to reduce potential exposure of vulnerable populations to COVID-19 while supplying the same level of quality care received in a hospital.

In addition to limiting potential exposures to the virus, an early study shows hospital-level care in the patient’s home resulted in fewer laboratory orders, less time lying down along with being readmitted less frequently within 30 days.

Technology—the driving force for health at home

The virtual care emergency department (ED)

Imagine waking up from your sleep with pain in your rib cage. You’re fearful something is wrong, yet afraid to drive to the ED. Do you call an ambulance? Ask a friend to drive you? What if you could simply use the telephone or computer and be visually connected with an ED doctor?

Imagine the video conference where you can describe what you are experiencing, what triggered it, medications you are currently taking and answer additional questions directly with the ED care professional.

Being told you would be safe to wait until morning to call your primary care provider allows you to avoid sitting in an overcrowded ED for hours.

It allows you to try to sleep until the morning. It keeps the ED open for those patients who truly require the emergent care. Scenarios like this are helping virtual care expand successfully into homes.

Wearables

Our lives happen between visits to our physicians. Between visits, wearables can support our health status by relaying important information to physicians. Many start out the day by putting a smart watch on or attaching a wearable to our body.

Our biological data such as heart rate, blood pressure, sweat sensing or blood glucose levels are some of the more common metrics monitored via our wearables.

New research and development addressing wearable electroencephalography (EEG) monitors for people with seizure disorders, or wearables for assessing lung function is providing more opportunities to focus on health at home.

The data from wearables supplies valuable feedback to the clinical teams helping to keep consumers in their homes and out of EDs or hospitals.

Healthcare apps

Healthcare apps are also making health at home a reality. Healthcare apps can support patient-physician relationships during the time we are not sitting face to face with our doctor. Apps can track physical activity, vital signs like blood pressure of blood sugars, provide medical reminders, and communicate with physicians.

The costs of apps range from a few dollars in a one-time payment to a monthly subscription fee of over $10. A quick check with your health plan could provide reimbursement or a discounted rate. 

Tracking carbs and macros provide insight for people managing weight and for people with diabetes.

For app developers, learning how to “onboard” new users is key to maintaining stickiness and growing successful apps. Combining the actions of several apps into an updated version where the consumer has a “one stop shop” experience to carry out several actions is driving change and new opportunities.

The consumer wins

Healthcare consumers now have choices in terms of how they receive care. Receiving care at home can reduce anxiety and fear. And that’s a win for the patient. After all, decreasing stress is key to a body battling an illness.

Improved outcomes, increased patient satisfaction, and lowered costs have been the battle cry for value-based care over the years. Are we closer to achieving this? Perhaps a change in venue for care might lead to innovation in the way care is delivered in the short term.

Expanding the options for health at home is trending up. Healthcare organizations are looking for the blueprints to build innovative programs that attract consumers who have had a taste of the future and are not willing to turn back.

Design Thinking: A UX Framework for Healthcare Apps

UX design has a direct correlation to user adoption, time to complete a task, reduction in errors (thereby decreasing the risk to patient safety), a decrease in support calls, and an overall increase in user satisfaction.

One of the most prominent issues facing clinicians and patients when trying to use a healthcare-related application is their inability to use the product efficiently or effectively (not to mention any patient-safety impacts).

In this post, we’ll explore the challenges of improving the design and usability of healthcare apps, and offers a solution to these problems with a five-step process called the Design Thinking Framework. This framework emphasizes that the keys to great design include iteration and collecting user feedback throughout the whole cycle, not just at the end.

Challenges of Designing a Better Product

The key challenges or barriers that healthcare vendors and hospitals face in terms of designing a better product (or improving the design and usability) usually fall into six main categories:

The Design Thinking Framework

When followed correctly the Design Thinking Framework helps clinicians and patients gain insights into the User Experience (UX) design process and ensure end users experience simple and meaningful interactions with the product. The framework focuses on these five components: Learn, Define, Ideate, Build, and Iterate.

Learn

When you listen, observe, and ask questions of your target users, product developers, designers, and system implementers, you will, in turn, learn to empathize with the user and understand their problems.

Define

Articulate and define what the problems and opportunities are based on the findings from the data/insights gained in the learning phase.

Ideate

As part of the ideation process, it is essential to get feedback on whether the design solution provides a better user experience, solves the problem, and addresses the user needs.

Emids Design Led Product Engineering

Create a Path for Consumer Experience Success​

See how Emids takes a design-led approach to product development.

Learn More

Build

At the build stage, designers/developers should be ready to use the feedback from users to iterate on the solution that worked best for them to create a prototype, test it with users (again) and start coding.

Iterate

Iterate the process, adjust when necessary and then advance to the next challenge. Check back with your users frequently throughout the design cycle, NOT just at the end, to make sure you are designing the “right” solution. This is a repeatable process that can be integrated with any product development process, regardless of the size of your organization.

Methodologies, Activities, and Deliverables to Consider

For each of the five principles, there are different methodologies, activities, and deliverables to consider.

  1. Learn
    • Activities/Methodologies: discuss the different types of design and user requirements research methodologies (e.g., on-site observations, interviews, workflow analysis)
    • Deliverables: personas, usage scenarios, task flow or hierarchical task analysis, journey maps
  2. Define
    • Activities/Methodologies: participatory design sessions with stakeholders, requirements definition, and validation
    • Deliverables: storyboards, workflows, usage scenarios
  3. Ideate
    • Activities/Methodologies: defining information and interaction design (via wireframing), formative testing
    • Deliverables: information architecture, concept designs, annotated wireframes, visual design and usability test report with recommendations
  4. Build
    • Activities/Methodologies: prototyping, detailed design, validation or benchmark usability testing
    • Deliverables: user validated product
  5. Iterate
    • Repeat the process and adjust when necessary and then advance to the next area or issue.

Usability Standards and the Design Thinking Framework

The Design Thinking Framework is based on two important standards related to usability: ISO 9241-11 and ISO 9241-210. ISO 9241-11 defines usability as “effectiveness, efficiency, and satisfaction with which the intended users can achieve their tasks in the intended context of product use.” The ISO 9241-210 standard provides guidance for designing for usability.

In addition, the Design Thinking Framework supports the Meaningful Use requirements for safety enhanced design and the test procedure for evaluating conformance of complete EHRs or EHR modules to the certification criteria defined in 45 CFR Part 170 Subpart C of the Health Information Technology: Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health Information Technology, Final Rule.

Tips for Following the Design Thinking Framework

Benefits of a UX Design Process

By following a UX design process, such as the Design Thinking Framework, healthcare vendors, and hospitals can realize business value and ROI. UX design has a direct correlation to user adoption, time to complete a task, reduction in errors (thereby decreasing the risk to patient safety), a decrease in support calls, and an overall increase in user satisfaction.

The Next Era of Emids

For the last 23 years, Emids has been built on innovation and the relentless pursuit of excellence. We have experienced incredible growth, with more than 3,300 associates and a footprint in six countries on four continents. Our customers span the healthcare ecosystem, including providers, payers, life science companies and technology firms. As a result of this influence, more than 150 million lives have been touched by Emids’ services and solutions. 

Today, Emids is at the confluence of healthcare’s digital transformation. Our associates and our capabilities will continue to play a vital role in helping our customers create a seamless, more interoperable, patient-centered ecosystem. 

However, Emids’ growth trajectory, fueled in part by our recent acquisitions, and the evolving demands of the marketplace compelled us to reassess our company’s story in a way that accommodates our scale and better reflects our culture, expertise and reputation. 

We wanted to meet the challenges and opportunities of healthcare transformation as a company united under a revitalized brand that sharpens our story and aligns us behind the singular mission of advancing the future of health through impactful technology solutions. 

This moment is the culmination of more than two years of hard work, iteration and reflection. We were focused on telling our story of partnership, domain expertise, nimbleness and our proactive approach to solving healthcare’s most pressing challenges. As we built our new brand, we aspired to distill the expanding capabilities of our organization and ground our identity in a common thematic vision.  

The result is Truth Seekers.  

This truth, in who we are and what the brand represents, is our North Star – it aligns and unifies us as a company, and differentiates us from our competitors. This new identity is not only representative of the technology solutions we create, but an embodiment of the ingenuity and innovation that runs through us all.  

This is a living statement and we are each tasked with building it, growing it and infusing it into our daily work. As Truth Seekers we are focused on digging deeper and going further to solve critical healthcare challenges. 

And we do so as one company and one brand: Emids.   

We’ve expanded our capabilities through five strategic acquisitions. By pursuing a new growth strategy, we introduced a new mix of capabilities in consulting, design, product engineering, systems integration and analytics. Our current portfolio is diverse and unparalleled, which welcomes new opportunities for Emids to play a larger role in our customer’s success.  

This brand won’t come to life with new colors and a logo – it will come to life by becoming a unifier built on action and aligned with our purpose. With time and a continued track record of customer success, we will shape and define ourselves as the new standard of excellence. 

This is a proud moment for all of us, showcasing who we are now and where we’re headed next. Welcome to the new Emids.  

Healthcare’s Growing Momentum: 4 Trends to Watch in 2022

As much of the entire world stood still (at a distance), healthcare was forced to rethink everything across the continuum of care. The aftermath of 2020 magnified the need to fast-track a normally slow pace of innovation. In response, healthcare sped ahead by decades.

With overdue clinical, financial and operational seismic changes occurring over the past 12-18 months, the momentum to truly transform healthcare has finally taken root. As we look back on 2021, we’re sharing four key trends that emerged and predictions for what’s on the horizon in 2022.

Healthcare Mashups For Better Health, Wealth & Well-Being

As we explored at the 8th Annual emids Healthcare Summit, the unexpected mashup of organizations, technologies, care delivery and payment models is perhaps the most talked-about development today. While the shock of the pandemic required companies to invest, partner or evolve their capabilities and revenue streams to better face an unpredictable future, this new landscape promises the incredible potential to dramatically change how care is delivered.

More than any other area, digital health has seen the most investment over the past year from within and outside healthcare.

Startups, longstanding payers and providers needed to differentiate themselves with vertical integrations across care journeys. With a vertical approach to funding, healthcare players can meet consumer demand for a consolidated, accessible care journey with new product offerings and capabilities.

$3.1B

The necessity to address mental health led investors as the top-funded therapeutic focus in 2021, topping at $3.1B by the end of Q3.

At emids, we were not exempt from this trend. In the past year, we welcomed design-led software engineering firm Macadamian and Quovantis, an award-winning user experience design and software development company. This growth of emids over the past year serves to scale client growth and enhance our offerings. As complements to our existing expertise, these acquisitions added specific capabilities that have compounded value, both near- and long-term, for our clients.

Data: The Key to Optimizing Operations

Innovation continues with cloud computing, artificial intelligence (AI), 5G connectivity and the Internet of things (IoT), but it’s data that has quickly become the central currency of healthcare. Finally, the entire industry sees and understands how data delivers financial and clinical success by enabling real-time decision making, precision medicine and population health management.

We’ve witnessed how global healthcare systems managed personal protection equipment (PPE), payers addressed social determinants of health (SDOH) and providers leveraged remote vitals to inform treatment to transform care with real-world insights. To transform care and optimize operations, leveraging predictive analytics allows leaders to make more precise and valuable data-driven decisions in real-time. Data lakes, predictive analytics, big data and AI will continue to unlock disruptive innovation across the entire ecosystem.

No one organization in healthcare has a complete set of digital transformation tools, but success in 2022 hinges on becoming a data-driven organization. Today, approximately 30% of the world’s data volume is generated by healthcare. By 2025, healthcare’s data volume will reach 36%. Adopting future-focused solutions like our CoreLAKE data management platform can create the capabilities and flexibility healthcare enterprises need to deliver care at the right place and time. Embracing secure, omnichannel platforms in a connected ecosystem will earn consumer trust, drive operational efficiencies and enhance the consumer experience.

Embracing a Patient-Centric Reality

A hybrid landscape of in-person care, remote monitoring, telemedicine and omnichannel experiences requires patients and providers to navigate and adapt to a new baseline of engagement. In future planning, organizations must undertake an agile transformation of their people, processes and technologies to embrace a patient-centric reality.

The pandemic swiftly cemented patient expectations around convenience, flexibility and security in digital patient access. In a 2020 survey, Experian Health found that 73% of patients wanted to self-schedule appointments online. Prompting providers to oblige, with 93% electing to improve the patient experience as a top priority. As our world adopts a mashup of digital and analog, local and global healthcare delivery, demand for an improved patient experience isn’t going anywhere. Organizations that choose to modernize technologies and build their entire operation around the patient experience will find themselves at a competitive advantage over those that do not.

As the pandemic reshaped care delivery through nontraditional platforms, healthcare recognized the need to create value-rich experiences for consumers in a digital world. Changing the way consumers interact with the healthcare system means embracing human-centered design thinking. By doing so, healthcare organizations can leverage a deeper understanding of patients to solve problems, achieve better clinical outcomes, improve the patient experience and lower costs along the way.

In 2022, there is a powerful opportunity before healthcare to not disintegrate in the face of disruption and instead break legacy thinking to raise the bar on consumer engagement.

Automation at Scale: A New Necessity

Soon intelligent automation will reach virtually every part of the industry across payers, providers and healthcare systems. The demand to cut costs will continue, requiring healthcare leaders to implement technology and methodologies in both clinical and administrative functions. Luckily, implementing AI and automation at scale can save time, money and empower the workforce by providing an environment free from mundane tasks.

AI and intelligent automation will continue to be prized for the positive impact it can have on operational efficiency and more importantly, the patient experience. While big data continues to grow, the next step is to layer in intelligent automation and make insights broadly accessible to providers, payers and consumers.

From our personal discussions with more than 80 customers, only 40% have initiated an automation journey. With a deep understanding of healthcare and years of experience implementing a range of solutions, our Automation offerings include our ideation framework and a business library of 400+ automation use cases for customers to review and adopt the right fit for their business needs.

The immediate and positive impact of automation has moved the technology from a nice-to-have to a necessity in healthcare’s digital transformation. In the coming year, healthcare leaders must employ today’s technology to do more in the future.

A Year of Recovery and Renewal

Healthcare is, and always will be, ripe for disruption. When we focused on pursuing innovation for the sake of bettering our industry, it became clear that digital transformation is not only helpful but crucial to eliminating what has held us back for so long. In 2021 we focused on learning and implementing new processes into a long-standing, outdated system. From our vantage point, healthcare needs to continue on this path to recovery while simultaneously pursuing ways to improve efficiency, intelligence and connectivity for tomorrow. The truth is – 2022 will require all of us to continue to innovate as our new normal will continue to be ever-changing. We can only progress if we commit to scaling digital transformation to improve continuity, quality and access to care.

A New Call to Action: Omnichannel Experiences in Pharma

With a growing number of communication channels, the need for big data and pandemic-spawned shifts, omnichannel excellence has become the only way to effectively communicate in an overcrowded marketplace. Omnichannel is emerging as the way forward by enhancing engagement across all channels and multiple stakeholders. For pharmaceutical and medtech organizations, the shift to an omnichannel model promises personalized engagement, improved revenues, quality of care and most importantly, patient outcomes.

At the 8th Annual Emids Healthcare Summit, Andy Corts, SVP of Research and Digitization at SignalPath joined Calyx CEO Gavin Nichols for an in-depth discussion on how pharma has eliminated long-standing silos and adopted holistic engagement models that puts patients first.

The Shift to Omnichannel

Over the past several years, digital transformation has proliferated and opened new mechanisms – including online portals, text messaging and telehealth – to support remote interactions. Pharma is shifting to an omnichannel model that promises a rising quality of care, patient outcomes, revenues and innovation.

“The omnichannel approach creates both a challenge and an opportunity for pharma. Now, no matter what channel you interact with there will always be context on the patient and their needs. This puts a responsibility on organizations to properly communicate with patients in an accessible way.”

Gavin Nichols

Calyx CEO

To adapt to changing preferences, the way people consume information and improve decision-making to benefit patients, new tools, resources and efficient communications are required. Pharma and medtech organizations are ushering in new leadership focused on patient engagement and being deliberate about investments. Simultaneously, technology companies are entering the arena to drive the omnichannel experience.

“Technology [in pharma] is now in the scaling phase and more than a novel idea; but rather, a common way we do business. There’s a new level of breadth and depth of research thanks to a digitally scaled model.”

Andy Corts

OneOncology Chief Technology Officer

Recognizing that they have lagged behind other industries in deploying digital solutions, both constituents – technology and pharma – are making incredible progress to remedy this gap.    

The Value of Data

Panelists agreed that in the shift to an omnichannel world and decentralized trials, one of the greatest success factors will be data. Walls are finally coming down around data liquidity and fragmentation, making data analytics equally as important as security and compliance. Because without extracting any meaningful value, data is just data.

On one hand, thanks to the advent of wearables and other tracking technologies, mechanisms exist to capture and support the terabytes of data needed to gain meaningful insights. Investments in tokenization will enrich data sets and connect valuable stakeholders like physicians and pharmacies. Articulating what does and doesn’t work will help pivot resources and accelerate the development of personalized medicine. For most organizations, it’s paramount to rely on both internal and external partnerships to develop an integrated data analytics strategy.

The Patient

The patient will always be at the center of healthcare. Healthcare doesn’t exist without them and the industry wouldn’t be learning, advancing or discovering new drugs without them either. Moving forward, organizations must undertake an agile transformation of their people, processes and technologies to embrace a patient-centric reality.

As a bright side of the pandemic, patients are equally savvy and more open to remote monitoring and care delivery at home. They are also vastly attuned to their individual needs and forging digital connections via online support groups, discussion boards or other forums. With a successful omnichannel model, pharma can empower patients through trial recruitment and education, broadening accessibility to treatments and methods that exist. In the end, decreasing the complexity and go-to-market time for new drugs will positively affect the patient experience.

Omnichannel engagement is about embracing a new model where agile teams combine human-centered design thinking, digital engagement and analytics to help deliver the right message at the right time through the right channel.

Getting Started With Emids

As pharma pursues the omnichannel experience, Emids is uniquely positioned to enable data and help accelerate value. By leveraging a wealth of experience specific to healthcare, Emids helps clients improve the lives of patients by enabling data insights and executing a data infrastructure ready for value creation. 

 Sriraman Nagarajan leads the Life Sciences business unit at Emids. He brings more than 28 years of industry experience leading high-performing teams responsible for driving digital transformation in the life sciences industry. Previously, he was the vice president at Cognizant, helping grow the life sciences business to the second largest in the industry. He led a significant portion of North American business that delivered solutions across technology, operations and digital business, including defining the strategy for medical devices business. Sriram’s entrepreneurial spirit was also recognized when he was named as one of top 100 inspiring leaders in the industry by PharmaVOICE in 2019. Be sure to connect with Sriram on LinkedIn. 

Download our Whitepaper

Moving Forward with the No Surprise Billing Requirements

In the first rule, Part I of the no surprise billing requirements, health plans were required to implement protections against balance billing and out-of-network cost sharing for emergency services, non-emergency services rendered by non-participating providers at specific facilities, and air-ambulance services by non-participating providers.  This rule, Part II, does not change that but offers clarification on the independent dispute resolution process, good faith estimates for uninsured (or self-pay) individuals, and expanded rights to external review.

As we stated in our August 13, 2021 blog, “No Surprises Act Interim Final Rule: Understanding the Implications,” health plans and insurers are required to disclose information on items and services covered by the No Surprises Act as follows:

A key step for payers to consider is assessing implementation readiness of current state for internal and delegated processes and technology.  All relevant processes, technology, and documentation such as websites, policies, internal standard operating procedures, provider and member portals, member rights and responsibilities, provider manuals, training guides, contracts, summary of benefits and coverage documents, call center scripts, internal training manuals and broker resources should be reviewed to help avoid readiness gaps.

Independent Dispute Resolution (IDR) Process

Members of Congress reacted to the Department of Health and Human Services (HHS) interim final rule (IFR) filed on September 30, 2021 entitled “Requirements Related to Surprise Billing; Part II”.   In a November 5, 2021 letter to the HHS Secretary, Xavier Becerra, the members urged HHS to amend the IFR to reflect the Independent Dispute Resolution (IDR) process as it was specified in the No Surprises Act that Congress passed in December 2020.

The IFR as written does not reflect the balanced process for settling payment disputes, rather, it makes the median in-network rate the default factor considered in the IDR process.  This approach is contrary to the statute as the IDR process should consider all the factors outlined in the statute without disproportionately weighting one factor.  It does not seem that there will be any near-time changes coming with the No Surprises Act and organizations need to be ready by January 1, 2020.

Implications to the IDR Process if Revised

As stated by the Congressman in the letter to HHS:  The No Surprises Act specified an IDR process that allows providers and payers to bring any relevant information to support their payment offers for consideration, except for billed charges and public payer information.  This includes:

Median in-network rates is only one consideration, not the default.  The certified IDR entity is to consider each of the above factors if they are submitted and not any single piece of information to be a default consideration.

Background on the No Surprise Billing Rules

The government has to date filed three rules to implement provisions in the No Surprises Act (Division BB, Title 1 of the Consolidated Appropriations Act, 2021).

The rules are about protecting consumers from excessive out-of-pocket costs resulting from surprise billing and balance billing.  Beginning January 1, 2022, the rules ban surprise billing for emergency services and certain non-emergency care provided by out-of-network (OON) providers at in-network facilities, and limit high out of network cost-sharing for emergency and non-emergency services for patients.  They will ensure uninsured and self-pay consumers know how much health care will cost before getting care; and that providers, health plans, and health insurance issuers have a process to settle payment disputes.

Requirements Related to Surprise Billing; Part II

Following is a description of the four main provisions covered in the third rule, IFR Part II:  the independent dispute resolution (IDR) process, good faith estimates for uninsured (or self-pay) individuals, the patient-provider dispute resolution process, and expanded rights to external review.

Independent Dispute Resolution

The Requirements Related to Surprise Billing, Part II, establishes a federal independent dispute resolution process that will be used by out-of-network providers, facilities, air ambulance services, group and individual market plans and issuers if there is an unsuccessful open negotiation.  This process will apply only for services where balance billing is prohibited under Part I of the Rule.

The independent dispute resolution process in Part II provides for a 30 day “open negotiation” for those in dispute to determine a payment rate.  Either party may initiate the independent dispute resolution process during the 4-business-day period beginning on the 31st business day after the start of the open negotiation period.  The parties may also jointly select a certified independent dispute resolution entity to resolve the dispute.  If a certified independent dispute resolution entity cannot be agreed upon, the Departments (the Department of Health and Human Services [HHS], the Department of Labor [DOL], and the Department of the Treasury) will make the selection.

Once a certified independent dispute resolution entity has been identified, the disputing parties will submit their payment offers and the supporting information to them.  After review of the submitted information, the certified independent dispute resolution entity will issue a binding determination by selecting one of the payment offers submitted by the disputing parties.  In 2022, each party will pay a $50.00 administrative fee for having used the independent dispute resolution process.  The non-prevailing party will be responsible for payment of the fees.

The Departments will certify independent dispute resolution entities on a rolling basis beginning January 1, 2022 with applications due by November 1, 2021.  Quarterly reporting will be required by the independent dispute resolution entities to help ensure transparency.

Important Open Negotiation and Independent Dispute Resolution Deadlines

Independent Dispute Resolution Action Timeline
Initiate 30-business-day open negotiation period 30 business days, starting on the day of initial payment or notice of denial of payment
Initiate independent dispute resolution process following failed open negotiation 4 business days, starting the business day after the open negotiation period ends
Mutual agreement on certified independent dispute resolution entity selection 3 business days after the independent dispute resolution initiation date
Departments select certified independent dispute resolution entity in the case of no conflict-free selection by parties 6 business days after the independent dispute resolution initiation date
Submit payment offers and additional information to certified independent dispute resolution entity 10 business days after the date of certified independent dispute resolution entity selection
Payment determination made 30 business days after the date of certified independent dispute resolution entity selection
Payment submitted to the applicable party 30 business days after the payment determination

Good Faith Estimates for Uninsured (or Self-pay) Individuals – Requirements for Providers and Facilities

A provider or facility must provide a good faith estimate when an item or service is scheduled or when it is requested by an uninsured or self-pay individual.  An uninsured or self-pay individual is one who:

The expected charges for each of the items or services that would reasonably accompany the primary item or service must be included in the good faith estimate.  For the period of January 1, 2022 through December 31, 2022, HHS will exercise enforcement discretion.  Enforcement discretion will allow time for providers and facilities to develop the necessary processes and procedures for receiving and providing information.

Patient – Provider Dispute Resolution

When an uninsured or self-pay individual is charged substantially in excess of the good faith estimate that was provided, the Patient – Provider Dispute Resolution process may be initiated within 120 calendar days of the patient receiving the bill.  Substantially in excess is defined by HHS as billed charges that are at least $400.00 more that the good faith estimate for any provider or facility included in that good faith estimate.

A Select Dispute Resolution (SDR) entity will resolve disputes through the Patient – Provider Dispute Resolution process.  The SDR entity will determine the payment as a component of the process.  An administrative fee will be charged to participating individuals.  The fee for the first year has been set at $25.00.

External Review

This rule expands the scope of adverse benefit determinations by amending the 2015 rule related to external reviews issued by the Departments.  The external review now includes the Surprise Billing and cost-sharing protections under the No Surprises Act and the related regulations.  Under this Interim Final Rule, grandfathered plans that are not subject to external review requirements will now be included for coverage decisions regarding whether a plan or issuer is compliant with the No Surprises Act billing and cost-sharing protections.

Cost and Burden Estimates

The Departments have provided estimated costs to comply with the No Surprise rulings.

In summary, the Departments estimate the total cost burden associated with these interim final rules to be $760.95 million in the first year, with $38.43 million attributable to the Federal IDR process for nonparticipating providers or nonparticipating emergency facilities or group health plans or health insurance issuers offering health insurance coverage; $4.02 million attributable to the external review process; and $706.7 million attributable to the patient-provider dispute resolution process.

The HHS has also provided additional cost information in the rule by the four areas:  independent dispute resolution (IDR) process, good faith estimates for uninsured (or self-pay) individuals, the patient-provider dispute resolution process, and expanded rights to external review.

Closing Thoughts

With the requirements taking effect beginning in January 2022, we’ll be watching for HHS’ response to the letter from Congress and potential amendments to implementation guidance for the IDR process.  Additionally, we can expect to see more rule-making requirements to implement other provisions in the No Surprises Act.

Sources

Acronyms

Advanced Explanation of Benefits (A-EOB); Centers for Medicare and Medicaid Services (CMS); Emids Regulatory Review Board (EMRB); Department of Health and Human Services (HHS); Department of Labor (DOL); Employee Retirement Income Security Act of 1974 (ERISA); Independent Dispute Resolution (IDR); interim final rule (IFR); out-of-network (OON); Public Health Service Act (PHSA); Select Dispute Resolution (SDR).

About Emids Regulatory Review Board (EMRB)

Collaboration of content for this blog was provided by EMRB subject matter experts, covering important regulatory program topics for our customers and partners.  Points of view and interpretation were relevant at time of authorship; however, they are subject to change over time.  For more information about these changes, contact us at engage@emids.com.

Keeping Up With A Shifting Healthcare Landscape: Emids Healthcare Summit 2021 Review

Like every facet of our lives, healthcare has experienced dramatic shifts due to the pandemic.

What we thought was normal—from how we work, to how we learn, to how we access healthcare—has been disrupted. In healthcare specifically, we’re seeing more organizations joining forces to tackle new challenges popping up in the healthcare landscape.

During the 8th Annual Emids Healthcare Summit, which we just wrapped up, industry leaders dived into several notable topics across the landscape. This includes getting the right healthcare messaging across; considering whole person care; centering the patient in your care delivery model and thinking about human behavior in the healthcare experience.

Let’s take a closer look.

Getting The Right Healthcare Messaging Across

The healthcare industry depends on science, research and standards of care to guide the industry towards truth. But in a politically charged environment, this can pose a challenge.

“Regardless of your politics, the current COVID-19 situation has created a difference of opinion.”

Dr. Jonathan B. Perlin

HCA Healthcare’s Chief Medical Officer

To address the chasm between opinions, healthcare industry leaders need to lean on the community and on trusted clinicians to get their messaging across.

This was echoed by Pat Geraghty, President and CEO of GuideWell and Florida Blue. Geraghty said his organizations are looking to get hyper local as they continue to grow, to build trust with the communities the companies serve.

Geraghty and Perlin also agreed that messaging around behavioral health needs a revamp. The pandemic has put mental health at the forefront of healthcare-related conversations.

“We’re all fighting against the stigma around behavioral health,” Perlin said.

“There’s no physical health without mental health and no mental health without physical health. These have to go together,” he added.

Conversations around mental health need to be reframed so that the stigma emanating around the subject ends, both Geraghty and Perlin said.

Whole Person Care: The Future of Healthcare Delivery

Mental health was a hot topic during this year’s Summit in part due to the mental health epidemic. We’re seeing a rise in the concept of whole person health, which entails bringing together the realms of mental and physical health, among other things.

“We are a fragmented system of care. How did we get here? For a person, their mind and body aren’t two separate things.”

Veeneta Lakhani

EVP of Growth and Operations at Vida Health

“When you see that one in four young adults considered suicide [over the summer], we need to really consider health holistically—the physical and the mental,” said Dr. Mohamed Diab, CEO at ActiveHealth Management.

The rise of mental health challenges we’ve seen in the past year and a half are, however, working as a catalyst to shift healthcare, albeit slowly.

“The perception and the approach in the industry is changing,” Diab said, noting that the industry needs to become more holistic in its approach to delivering healthcare.

Gyre Renwick, Chief Operating Officer at Modern Health, added that for the shift over to whole person health to happen in the industry, payers will need to make mental health coverage as ubiquitous as medical coverage.

“You have medical and dental offerings, but you don’t have mental health as an offering, traditionally,” Renick said, noting that healthcare companies will be slow to make that change.

Centering The Patient In Your Care Delivery Model

Along with payers and providers, life sciences and pharmaceutical companies have faced added challenges in terms of launching new drugs into the market.

The pandemic made it difficult to reach the right people at the right time. But the healthcare industry is looking to tackle that with omnichannel customer experiences—with patients taking center stage.

“Multichannel is everywhere. When we use omnichannel, we are doing it in the right places at the right time,” said Michele Schimmel, President at Real Chemistry.

Omnichannel experiences need to be seamless and personalized. This can be done through the strategic use of patient data.

“Data has been around for a while but it’s about bringing all the pieces together, said Gavin Nichols, CEO of Calyx.

“With an omnichannel experience, because you inherit the metadata that comes with the experience, it’s a much more meaningful conversation that you’re having,” Nichols added during Summit.

Regardless of the type of healthcare experience you develop, keeping patients and members top of mind is key.

“We’re seeing lots of different changes in how care gets delivered. Ultimately, we want to put the consumer in the center of it.”

Rajeev Ronanki

President of Digital Platforms at Anthem

“There are digital care options, and there’s always going to be the need for in-person care options,” he adds. “Let’s create a common experience where data becomes more interoperable—where it’s ultimately up to the patient and the caregiver in how care gets delivered,” Rajeev said.

Why It’s Important To Consider Human Behavior When Developing Healthcare Experiences

The last 18 or so months have shown us that both healthcare, and our lives, have become largely virtual, said Validic CEO, Drew Schiller, during the Summit.

“Healthcare was having fits and starts before the pandemic began,” but has since begun the march towards digital transformation, Schiller added. And that makes sense, seeing that most of society is also going digital.

“Consumers have totally moved on in the way they’re living their lives, and healthcare needs to connect with consumers there,” Schiller said.

Whether virtual, in-person or hybrid, when it comes to delivering healthcare experiences, it’s important for healthcare leaders to consider human behavior.

And understanding human behavior can often be complemented using data, said Tom Waller, an industry innovator.

“Tiny nudges next to tiny behavior changes really work,” if you’re developing digital healthcare experiences for users, Waller said. But he noted that data is not the be all and end all of healthcare user experiences.

“It has to be done in a thoughtful way,” without overwhelming the health app user, for example.

Final Thoughts

The 8th Annual Emids Healthcare Summit is over, but we hope you’ve taken with you valuable insights on the changing healthcare industry. We also hope you keep the conversation going with your colleagues and industry partners. If you need assistance at any point in your journey, Emids is here to help.

We hope to see you for the 9th Annual Emids Healthcare Summit in 2022.

Must-See Panels at The 8th Annual Emids Healthcare Summit

Now in its 8th year, the annual Emids Healthcare Summit has welcomed refreshing perspectives, new ideas and actionable insights from over 190 Healthcare Industry executives and 90+ companies for an event that’s meaningful, memorable and anything but run-of-the-mill. 

This year, we’re virtually welcoming cross-industry leaders for exclusive conversations on healthcare’s mashup to unpack the new landscape, share stories from the frontlines, predict behaviors and forge novel relationships. In anticipation of this year’s event on November 10-11th, register today and bookmark your favorites from these must-see panels.

November 10th

The Intersection of Physical & Mental Health

The question remains: with a rising mental health epidemic, has the time finally come for Whole Person Health? Leaders from Vida Health, Active Health Management, Groups Recover Together and Modern Health dive into practical ways to address physical and mental comorbidities, leverage technology and improve clinical outcomes.

Hybrid Isn’t Just a Solution for Cars

Healthcare’s mashup of in-person and virtual care delivery is a proven solution for real-world access: social, emotional, mental and physical. We’re opening healthcare’s digital front door for an important discussion with executives from Availity, Tivity Health, Maven Clinic and Russell Street Ventures.

Developing Omnichannel Experiences in Pharma

Gavin Nichols, CEO of Calyx, discusses how life sciences and pharmaceutical companies pursued research, drug development and clinical trials in a socially distanced world. And, how pharma has adopted holistic engagement models that put patients first. 

Fireside Chat: Pandemic Economy

Returning Summit speaker and SVP, Health Innovation of Walmart, Marcus Osborne joins Anthem’s President of Digital Platforms Rajeev Ronanki for a candid discussion on the business of healthcare post-pandemic and how digital transformation will build the foundation for innovation in the decades to come.

November 11th

Launch Pad: We’re Really Just Getting Started with Consumer Experience Design

From our own research, 78% of healthcare organizations feel their digital initiatives are not yielding results. To execute truly effective digital transformation, the question is, “how is my consumer having their needs met on their own terms?” Learn about the new approaches and emerging technologies needed to meet the digital consumer’s needs and expectations in healthcare. 

SDOH: Widening the Lens, Bridging the Digital Divide and Making the Business Case 

Following a proliferation of novel solutions and partnerships created to address the underlying Social Determinants of Health (SDOH), hear from leaders about what’s working, what’s not and how to drive new strategies with technology that considers access, inclusion and community impact for greater wellbeing.  

The Expanding Ecosystem of Direct-to-Consumer Healthcare 

Consumer demands for fast, quick and easy experiences related to healthcare are resulting in next-level innovations in all aspects of healthcare. Thought leaders from Orangetheory, WW and Relatient discuss how they digitally transformed their own companies and how to meet demands for a modern, integrated customer experience. 

Fireside Chat: Leadership & Health Misinformation

Tune in for a fireside chat between Glen Tullman, CEO of Transcarent, Pat Geraghty of GuideWell and Florida Blue and HCA Healthcare’s CMO Dr. Jonathan Perlin, who will share their lessons in leadership amidst so much mis- and dis-information in society and healthcare.

RSVP Today

If you haven’t already, register for the 8th Annual Emids Healthcare Summit on November 10-11th to hear how forward-thinking leaders are turning the unexpected into progress. This year’s brand new virtual experience is a can’t miss! 

P.S. Follow Emids social for real-time updates and join the conversation with #EmidsHCsummit

A Look at the Finalized 2022 IQR and PI Programs

On August 2, 2021, the Centers for Medicare and Medicaid Services (CMS) filed its annual Inpatient Prospective Payment System (IPPS) final rule. As continued effects of the COVID-19 public health emergency (PHE) spill over into the quality reporting programs, CMS is focused on closing gaps in public health services, emphasizing interoperability and intentions to incorporate more health equity and social determinants of health (SDOH) factors into their programs.

The Biggest Implication

In our review of the Promoting Interoperability (PI) Program updates, the most striking implication to prepare for in the calendar year (CY) 2022 is that eligible hospitals (EHs) and critical access hospitals (CAHs) will be required to report four Public Health measures.

Highlights

Our focus is on the finalized updates to the Promoting Interoperability Program, the electronic Clinical Quality Measures (eCQMs) for the Inpatient Quality Reporting (IQR) and PI Programs; and briefings on CMS’ requests for information to advance digital quality measures (dQMs) and close the health equity gap in CMS hospital quality programs.

Promoting Interoperability Program Updates

CMS Requests for Information (RFIs) on Digital Quality Measures (dQMs) and Health Equity

Digital Quality Measures (dQMs): CMS intends to fully transition to dQMs by 2025 and is considering defining and developing dQM software as end-to-end measure calculation solutions. These solutions will retrieve data from primarily Fast Healthcare Interoperability Resources (FHIR)-based resources maintained by providers, payers, CMS and others, calculate measure score(s) and produce reports.

Health Equity: CMS intends to close the health equity gap in CMS programs and policies by making the reporting of health disparities based on social risk factors, race and ethnicity more comprehensive and actionable for hospitals, providers and patients.

eCQM Updates

To explore more, download our latest white paper for further details on the changes, including clarifications and considerations of the requirements.

Sources

  1. IPPS Final Rule Full Title: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2022 Rates; Quality Programs and Medicare Promoting Interoperability Program Requirements for Eligible Hospitals and Critical Access Hospitals; Changes to Medicaid Provider Enrollment; and Changes to the Medicare Shared Savings ProgramUnpublished version filed on 8/2/2021; Published in Federal Register on 8/13/2021.
  2. CMS Fact Sheet, 8/2/2021: Fiscal Year (FY) 2022 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) Rates Final Rule (CMS-1752-F)
  3. QualityNet Webinar: Reporting the Hybrid Hospital-Wide Readmission Measure to the Hospital IQR Program; Tuesday, May 18, 2021.

Acronyms

Calendar Year (CY); Centers for Medicare and Medicaid Services (CMS); Certified EHR Technology (CEHRT); Critical Access Hospital (CAH); Digital Quality Measures (dQMs); Electronic Case Reporting (eCR); Electronic Clinical Quality Measures (eCQMs); Electronic Health Record (EHR); Electronic Laboratory Reporting (ELR); Eligible Hospital (EH); Fast Healthcare Interoperability Resources (FHIR); Fiscal Year (FY); Health Information Exchange (HIE); Hospital Harm (HH); Hybrid Hospital-Wide Mortality (Hybrid HWM measure); Hybrid Hospital-Wide Readmission (Hybrid HWR measure); Inpatient Quality Reporting (IQR); Inpatient Prospective Payment System (IPPS); Office of the National Coordinator for Health Information Technology (ONC); Promoting Interoperability (PI); Public Health Emergency (PHE); Query of Prescription Drug Monitoring Program (PDMP); Request for Information (RFI); Safety Assurance Factors for EHR Resilience Guides (SAFER Guides); Social Determinants of Health (SDOH).


About Emids Regulatory Review Board (EMRB)

Collaboration of content for this blog was provided by eMRB subject matter experts, covering important quality reporting topics for our customers and partners. Points of view and interpretation were relevant at time of authorship; however, they are subject to change over time. For more information about these changes, contact us at engage@emids.com.