/ en Sat, 26 Apr 2025 02:24:51 -0500 Thu, 05 Dec 24 14:26:53 -0600 /member-knowledge-exchange/2024-12-06/optimize-your-hospitals-revenue-cycle-efficient-patient-centered-operations <div> </div>header.jumbotron {display:none} <div> /* center_body */ .center_body { /*margin-top:50px;*/ /* margin-bottom: 50px;*/ } .center_body h3 {} .center_body p { font-size: 16px } p.center_Intro { color: #002855; line-height: 1.2em; font-size: 30px; margin: 10px 0 25px 0; font-weight: 700; font-size: 2em; } @media (max-width:768px) { p.center_Intro { line-height: 1.2em; font-size: 23px; font-size: 1.45em; } } .center_body .center_Lead { color: #63666A; font-weight: 300; line-height: 1.4; font-size: 21px; } /* center_body // */ /* Banner_Title_Overlay_Bar */ .Banner_Title_Overlay_Bar { position: relative; display: block; overflow: hidden; max-width: 1170px; margin: 0px auto 25px auto; } .Banner_Title_Overlay_Bar h1 { position: absolute; bottom: 40px; color: #003087; background-color: rgba(255, 255, 255, .8); width: 100%; padding: 20px 40px; font-size: 3em; box-shadow: 0 3px 8px -5px rgba(0, 0, 0, .6); } @media (max-width:991px) { .Banner_Title_Overlay_Bar h1 { bottom: 0px; margin: 0px; font-size: 2.5em; } } @media (max-width:767px) { .Banner_Title_Overlay_Bar h1 { font-size: 2em; text-align: center; text-indent: 0px; padding: 10px 20px; } } @media (max-width:530px) { .Banner_Title_Overlay_Bar h1 { position: relative; background-color: #63666A22; } } /* Banner_Title_Overlay_Bar // */ <header class="Banner_Title_Overlay_Bar"><img src="/sites/default/files/2024-12/VED_RI_RevenueCycle_banner_1170x250.png" alt="Banner Image" width="1170" height="250"><div><h1>Optimize Your Hospital’s Revenue Cycle for Efficient, Patient-Centered Operations</h1></div></header>/* CntMenuSub */ .CntMenuSub{ margin:20px 0px; padding-bottom: 5px; color: #afb1b1; letter-spacing: 1.5px; font-weight: 400; font-size: .7em; } .CntMenuSub .CntMenuBar{ border-bottom: 1px solid lightblue; } .CntMenuSub .CntMenuBar a:after{ content: "|"; padding: 0 3px 0 6px; color: #555; } .CntMenuSub .CntMenuBar a:last-child:after{ content: ""; } .CntMenuSub .CntMenuSubHome, .CntMenuSub .CntMenuSubParent{ text-transform: uppercase; color: #555; opacity: .9; } .CntMenuSub .CntMenuSubParent{ } .CntMenuSub .CntMenuSubChild{ } .CntMenuSub .CntMenuSubCurrent{ opacity: .7; } .CntMenuSub .CntMenuSubHome:hover, .CntMenuSub .CntMenuSubParent:hover{ text-transform: uppercase; color: #d50032; } /* CntMenuSub // */ <div class="container CntMenuSub"><div class="col-md-1"> </div><div class="col-md-10 row CntMenuBar"><a class="CntMenuSubHome" href="/education-events/aha-virtual-executive-dialogues">AHA Knowledge Exchange</a> <span class="CntMenuSubChild" id="CntMenuSubChild">Optimize Your Hospital’s Revenue Cycle for Efficient, Patient-Centered Operations</span></div><div class="col-md-1"> </div></div><div class="row spacer"><div class="col-sm-3"><div><a href="#DownloadFile" target="_blank"><img src="/sites/default/files/2024-12/KnowEx_RI_RevenueCycle_cover_910x1220_rev1.jpg" alt="AHA Knowledge Exchange | Optimize Your Hospital’s Revenue Cycle for Efficient, Patient-Centered Operations" width="100%" height="100%"></a></div></div><div class="col-sm-9 center_body">.sponsortype { color: #9d2235; font-size: 1.5em; margin: 0px; font-weight: 700; } <p class="sponsortype">AHA Knowledge Exchange</p> xxxxxx </p> --> Intro.............. </p> --><h2>Enhance critical KPIs via intelligent innovations using AI and automation</h2><p>As hospitals and health systems prepare for 2025, reinforcing financial stability and cash flow in the face of rising costs, declining reimbursements and workforce challenges is top of mind. Health care leaders need full visibility into key performance indicators (KPIs) and the drivers of performance in revenue cycle management (RCM) outcomes to make informed decisions.</p><p>By reducing redundant tasks, artificial intelligence (AI) streamlines documentation and processes, which in turn can help lower denial rates and boost patient satisfaction. This Knowledge Exchange e-book examines KPIs vital for revenue-cycle outcomes and focuses on how AI and other advanced technologies may drive RCM improvements and the delivery of high-quality patient care.</p><div class="row">@media (min-width:768px){ .EDsponsorFloat{ float:right; } } @media (max-width:767px){ .EDLinkFloat{ position:relative; left:27%; } .EDsponsorFloat { text-align:center } } <div class="col-sm-6"><a class="btn btn-wide btn-primary EDLinkFloat" href="#DownloadFile" title="AHA Knowledge Exchange | Optimize Your Hospital’s Revenue Cycle for Efficient, Patient-Centered Operations" data-view-context="top-level-view">Download the Report</a></div><div class="col-sm-6"><div class="EDsponsorFloat">Sponsored by: <a href="https://www.r1rcm.com/" target="_blank" rel="noopener nofollow"><img src="/sites/default/files/2024-03/Logo_R1_834x313.jpg" alt="R1 Logo" width="100%" height="100%"></a></div></div></div></div></div>.sp_CTA5_holder { margin-top:0px; border-bottom: solid 1px #555; padding-bottom: 50px; } .sp_CTA5_holder_last { border-bottom: solid 0px #555; } .sp_CTA5_holder >div{ overflow: auto; } .sp_CTA5_holder ul { list-style: none; /* Remove default bullets */ padding-left: 0px; /*width: calc(100% - 15%);*/ /*margin: 50px auto 0;*/ margin:auto 50px; } .sp_CTA5_holder ul li{ margin-bottom:7px; line-height: 1.5em; font-size:16px; } .sp_CTA5_holder ul li::before { content: " "; font-size: 1em; margin-right: 10px; display: inline-block; height: 12px; background-color: #9d2235; width: 12px; position: relative; top: 0px; -webkit-transform: rotate(45deg); -moz-transform: rotate(45deg); -o-transform: rotate(45deg); } .sp_CTA5_holder ul li{ padding-left:23px; text-indent:-23px; } .body ol>li, .body ul>li{ font-size:16px: } .sp_CTA5_holder h2 { color: #002855; /*! line-height: 2em; */ font-size: 2.15em; margin: 0 0 15px 0; /*! font-size: 30px; */ } .sp_CTA5_holder h3 { /*color: #002855;*/ line-height: 1em; /*font-size: 1.5em;*/ margin-bottom: 25px; margin-top:5px; font-size: 28px; } .sp_CTA5_section{ margin-top: 25px } .sp_CTA5_ImgShadow { /*background-color:green;*/ /* just a visual */ text-align: center } .sp_CTA5_ImgShadow { padding-bottom:75px; /* must match the padding on the img*/ margin: 0px; } .sp_CTA5_ImgShadow img{ width: calc(100% - 35px - 15px); -webkit-box-shadow: 50px -75px 0px 0px rgba(185, 217, 235, 1); -moz-box-shadow: 50px -75px 0px 0px rgba(185, 217, 235, 1); box-shadow: 50px -75px 0px 0px rgba(185, 217, 235, 1); position: relative; top: 75px; max-width: 490px; } @media (max-width:990px){ .sp_CTA5_ImgShadow img{ max-width: 350px;} } @media (max-width:990px){ .sp_CTA5_ImgShadow { padding-bottom:75px; /* must match the padding on the img*/ margin: 0px; margin-right: 40px } } <div class="row spacer sp_CTA5_holder sp_CTA5_holder_last"><div class="col-md-12"><h3>9 ways health leaders are leveraging automation and AI to improve financial performance and service quality</h3><div class="sp_CTA5_section"><ul><li><strong>Establish a team to analyze denial patterns</strong>. Consider utilizing robotic process automation (RPA) to keep up with changing payer and plan policies that may result in denials.</li><li><strong>Reduce days in accounts receivable by using predictive modeling</strong> based on historical data from payer denials and scoring of accounts to assign work to teams.</li><li><strong>Reduce denials by using automation in the electronic health record (EHR)</strong> to identify appropriate coding for particular services, which can be shared with specialist providers.</li><li><strong>Use RPA to automate eligibility verification and registration processes</strong> in order to optimize workflows and operations.</li><li><strong>Consider AI functionality to efficiently create clinical documentation improvement alerts</strong>, which will help staff identify accounts and claims in need of additional clinical information.</li><li><strong>Implement computer-assisted coding to drive down “Discharged Not Final Billed” accounts</strong> and consider autonomous where feasible to alleviate coding staff shortages and allow coders to focus on more complex cases.</li><li><strong>Utilize AI and RPA to assist with drafting appeal letters</strong> in order to streamline steps and reduce administrative burden on staff and clinicians.</li><li><strong>Employ a payer scorecard</strong> with denial analytics and predictive modeling to assist in Joint Operating Committee (JOC) meetings with payers.</li><li><strong>Craft a patient-centric financial experience</strong> using AI to create a transparent and flexible billing experience.</li></ul></div></div></div><h2>Participants</h2>/* people */ .people { margin-top: 50px; } .people img:nth-child(1) { border-radius: 200px; -moz-border-radius: 200px; -webkit-border-radius: 200px; margin-bottom: 10px; max-width:200px; /* for Transformation Talks */ display:block; /* for Transformation Talks */ margin:auto; /* for Transformation Talks */ } .people img:nth-child(1):hover { opacity: .7 } @media 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content:""; border-bottom: solid 1px #55555522; display: block; clear: both; width: 85%; margin: 5PX auto 10px; } <div class="people"><div class="row rowEqual_768"><div class="col-md-4 col-sm-6 ci_profile"><img src="/sites/default/files/2024-11/Ackroyd_Elizabeth_300x300.png" alt="Elizabeth Ackroyd" width="300" height="300"><p class="ci_profile_name">Elizabeth Ackroyd, MBA, CPC</p><p class="ci_profile_title">Senior Manager of Revenue Integrity</p><p class="ci_profile_company">Sarasota Memorial Health Care System</p> profile_combined </p> <p class="ci_profile_award"> profile_award </p> <div class="ci_profile_social"> profile_social </div> --></div><div class="col-md-4 col-sm-6 ci_profile"><img src="/sites/default/files/2024-11/Blakely_Marley_300x300.png" alt="Marley Blakeley" width="300" height="300"><p class="ci_profile_name">Marley Blakeley</p><p class="ci_profile_title">Vice President, Revenue Cycle Operations</p><p class="ci_profile_company">R1</p> profile_combined </p> <p class="ci_profile_award"> profile_award </p> <div class="ci_profile_social"> profile_social </div> --></div><div class="col-md-4 col-sm-6 ci_profile"><img src="/sites/default/files/2024-11/Cook_Jessica_300x300.png" alt="Jessica Cook" width="300" height="300"><p class="ci_profile_name">Jessica Cook</p><p class="ci_profile_title">Patient Access Supervisor</p><p class="ci_profile_company">Children’s Healthcare of Atlanta</p> profile_combined </p> <p class="ci_profile_award"> profile_award </p> <div class="ci_profile_social"> profile_social </div> --></div><div class="col-md-4 col-sm-6 ci_profile"><img src="/sites/default/files/2024-11/Hauser_Ruth_300x300.png" alt="Jackie Rouse" width="300" height="300"><p class="ci_profile_name">Ruth Hauser, RHIA, CDIP, CHPC</p><p class="ci_profile_title">Director, Health Information Management and Clinical Documentation Improvement</p><p class="ci_profile_company">Children’s Hospital Los Angeles</p><div class="ci_profile_social"> </div></div><div class="col-md-4 col-sm-6 ci_profile"><img src="/sites/default/files/2024-11/Johnston_Valerie_300x300.png" alt="Valarie Johnston" width="300" height="300"><p class="ci_profile_name">Valarie Johnston, BSHA, CPC, CRCR</p><p class="ci_profile_title">Director, Patient Financial Services</p><p class="ci_profile_company">Bryan Medical Center</p><div class="ci_profile_social"> </div></div><div class="col-md-4 col-sm-6 ci_profile"><img src="/sites/default/files/2024-11/Kirkland_Kathie_300x300.png" alt="Kathie Kirkland" width="300" height="300"><p class="ci_profile_name">Kathie Kirkland, MBA</p><p class="ci_profile_title">Director, Patient Financial Services</p><p class="ci_profile_company">Henry Mayo Newhall Hospital</p><div class="ci_profile_social"> </div></div><div class="col-md-4 col-sm-6 ci_profile"><img src="/sites/default/files/2024-11/Marqueira_Lisa_300x300.png" alt="Lisa Maqueira" width="300" height="300"><p class="ci_profile_name">Lisa Maqueira</p><p class="ci_profile_title">Vice President of Finance and Chief Revenue Cycle Officer</p><p class="ci_profile_company">Cedars-Sinai</p><div class="ci_profile_social"> </div></div><div class="col-md-4 col-sm-6 ci_profile"><img src="/sites/default/files/2024-04/Hoppszallern_Suzanna_300x300%20%281%29.png" alt="Suzanna Hoppszallern" width="300" height="300"><p class="ci_profile_name">Moderator:</p><p class="ci_profile_name">Suzanna Hoppszallern</p><p class="ci_profile_title">Senior Editor, Center for Health Innovation</p><p class="ci_profile_company">���������� Association</p></div></div></div><div class="raw-html-embed"> .SponsorMarketoForm { background-color: ; padding: 5px 25px; border: solid 2px #307FE2; margin: 50px 15px 0px !important; display: inline-block; width: -webkit-fill-available; margin-bottom: 25px; } .SponsorMarketoForm h3 { margin: 10x 0 0 0; color: #eaaa00; font-size: .7em; text-transform: uppercase; font-weight: 400; letter-spacing: 3px; max-width: 200px; /* Custom for the copy length */ 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views-field-field-page-title-background"> <div class="field-content sed-thumb"> <a href="/2024-09-26/transforming-behavioral-health-journey" hreflang="en"><img loading="lazy" src="/sites/default/files/styles/small_200x200/public/2024-09/Iris-Telehealth-banner-620x381.jpg?itok=QQ9C-7Mp" width="200" height="123" alt="Iris-Telehealth-banner-620x381" /> </a> </div> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-09-25T14:49:38-05:00">Sep 25, 2024</time> </span> </div><div class="views-field views-field-title"> <span class="field-content"><a href="/2024-09-26/transforming-behavioral-health-journey" hreflang="en">Transforming the Behavioral Health Journey</a></span> </div><div class="views-field views-field-body"> <div class="field-content">Transforming the behavioral health journey with strategic initiatives to build a sustainable and coordinated behavioral health services continuum.</div> </div></div> </div> </div> <div class="more-link"><a href="/aha-knowledge-exchange-archive">View All: AHA Knowledge Exchange</a></div> </section> </div> </div></div> Thu, 05 Dec 2024 14:26:53 -0600 Reimbursement <div class="container"><div class="row"><div class="col-md-8"><p>The Center for Medicare and Medicaid Innovation (CMMI) Nov. 26 <a href="https://www.federalregister.gov/public-inspection/2024-27841/medicare-program-alternative-payment-model-updates-and-the-increasing-organ-transplant-access-model" target="_blank">finalized</a> a new mandatory payment model that will begin on July 1, 2025 and test whether hospital performance-based incentive payments or penalties will increase access to kidney transplants while preserving or enhancing the quality of care and reducing Medicare expenditures. The rule also includes standard provisions that will apply to all CMMI models whose first performance period begins on or after Jan. 1, 2025.</p><div class="panel module-typeC"><div class="panel-heading"><h2>Key Highlights</h2><p>CMMI’s IOTA model will:</p><ul><li>Require participation from 103 eligible kidney transplant hospitals. Eligible hospitals include non-pediatric transplant hospitals in select markets performing 11 or more kidney transplants across all payers in a three-year baseline period. </li><li>Run for six years, from July 1, 2025, through June 30, 2031. </li><li>Assess performance across three domains: achievement (60% of score), efficiency (20% of score) and quality (20% of score). </li><li>Provide incentive payments or penalties based on hospitals’ aggregate performance scores. Hospitals will be eligible for incentive payments of up to $15,000 per case or penalties of up to $2,000 per case. </li><li>Provide a one-year glidepath to downside risk.</li></ul></div></div><h2>AHA TAKE </h2><p>We applaud CMMI for making adjustments to certain model design elements, as we <a href="/lettercomment/2024-07-16-aha-letter-cms-increasing-organ-transplant-access-iota-model" target="_blank">recommended</a>. For example, the agency increased the maximum incentive payment from $8,000 to $15,000 per case; withdrew certain burdensome transparency requirements; and removed three problematic quality measures from the performance scoring methodology. </p><p>However, we still have deep concerns about the IOTA model. Specifically, we believe the model may have unintended consequences by focusing so heavily on volume (possibly incentivizing subpar matches). Furthermore, a model based solely on three quality measures is not robust enough for either patients or hospitals. Additionally, we are concerned the model requires mandatory participation, thus negating organizations’ ability to assess whether a model is appropriate to best serve their patients’ and communities’ needs. Finally, while the agency did delay the start date to July 1, 2025, we are concerned that this still will not provide sufficient lead time to implement such a complex model, especially in light of the transformation already occurring in the organ transplant space. We look forward to continuing to work with the agency to address our members’ concerns. </p><p>Additional details are below:</p><h3>MODEL PERFORMANCE PERIODS </h3><p>CMMI finalizes its proposal that IOTA will include a six-year model performance period. However, the agency delayed the start date from Jan. 1, 2025, to July 1, 2025, with the model now ending June 30, 2031. </p><h3>PARTICIPATION AND MARKET SELECTION </h3><p><strong>Participant Eligibility. </strong>CMMI finalizes its proposal that eligible participants will include non-pediatric kidney transplant hospitals that perform 11 or more transplants annually across all payers across baseline years. </p><p><strong>Mandatory Participation.</strong> Despite AHA’s concerns, all kidney transplant hospitals meeting eligibility criteria in selected geographic areas will be required to participate in the IOTA model. The agency asserts that mandatory participation is necessary to ensure enough hospitals participate in the model, and that its low-volume thresholds will exclude smaller transplant hospitals that may not have financial resources to support the model. </p><p><strong>Geographic Selection.</strong> To determine which hospitals are required to participate, CMMI selected half of all donation service areas (DSAs) nationally using a stratified sampling method – all eligible hospitals in these DSAs will be required to participate. The agency posted a list of these 103 hospitals on their website (<a href="https://nam11.safelinks.protection.outlook.com/?url=https%3A%2F%2Flinks-2.govdelivery.com%2FCL0%2Fhttps%3A%252F%252Fwww.cms.gov%252Fpriorities%252Finnovation%252Ffiles%252Fiota-participant-dsa-list.xlsx%2F1%2F010101936a6edbbe-60e75cf8-c8f4-433c-9e59-3b1a241c42cd-000000%2Fa1bU4h7YjRScXjfuAdaUJfMIBgcKdRd6Xa1ahDWMK_o%3D381&data=05%7C02%7Cjholloman%40aha.org%7Cad23849b107e458f4e4108dd0e6936d7%7Cb9119340beb74e5e84b23cc18f7b36a6%7C0%7C0%7C638682567240761794%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=RK40EoIflD6B4sv3pcFnTPYiU1DLJaJi7ey7AFR6SN8%3D&reserved=0" target="_blank">list of hospitals selected to participate</a>). </p><h3>ATTRIBUTION </h3><p>CMMI finalizes its attribution methodology as proposed. Specifically, patients will be attributed to IOTA model participants based on their registration for waitlists, regardless of payer type or waitlist status, or based on completed transplant procedures. If a patient is on multiple waitlists, they could be attributed to multiple IOTA participants. Patients will be attributed through an initial attribution process and then quarterly. At the end of each performance year (PY), CMMI will create a final list of attributed and deattributed patients. </p><h3>IOTA PERFORMANCE ASSESSMENT </h3><p>CMMI finalizes its proposals to assess performance across three domains — achievement, efficiency, and quality. The agency also finalizes weights for each of the domains, with a final maximum possible score of 100 points. It did modify measures in the quality domain by removing three measures that were included in the proposed rule. Table 1 below summarizes the measures and points assigned to each domain.</p><p class="text-align-center"><strong>Table 1: IOTA Model Performance Score Domains, Points, and Measures</strong></p><table><tbody><tr><td>Domain</td><td>Points</td><td>Measures</td></tr><tr><td>Achievement  </td><td>60 </td><td>Number adult kidney transplants compared to a historical target. </td></tr><tr><td>Efficiency </td><td>20 </td><td>Organ offer acceptance rate ratio.</td></tr><tr><td>Quality </td><td>20 </td><td>Post-transplant composite graft survival rate.</td></tr></tbody></table><p> </p><p><strong>Achievement Domain. </strong>CMMI finalizes its proposal to include only one measure in the achievement domain — the number of kidney transplants performed on adults 18 years and older compared to a historical target. The agency did not finalize the health equity adjustment it had proposed. The Centers for Medicare & Medicaid Services (CMS) will use all-payer Organ Procurement and Transplantation Network (OPTN) and Medicare claims data to calculate the number of kidney transplants performed by the IOTA participant during a PY. Performance will be calculated inclusive of all payers. </p><p><u>Historical Target.</u> CMMI modifies the methodology for calculating the historical target for the achievement domain. Instead of using as the target the highest number of deceased and living donor kidney transplants per year during a rolling baseline period, the agency will use an average of annual deceased and living donor kidney transplants across baseline years. This number will then be projected forward using a national growth rate that CMS will calculate for all IOTA participants. Each baseline year will reflect 12 months and run from July 1 to June 30. </p><p>The national growth rate will be defined as the percentage increase or decrease in kidney transplants performed over 12 months by all kidney transplant hospitals (excluding pediatric kidney transplant hospitals). The agency modified one aspect of the methodology for calculating the national growth rate in that it will not exclude transplant hospitals falling below CMS’ low-volume threshold. </p><p><u>Scoring Approach. </u>CMMI made adjustments to the proposed scoring approach by reducing the threshold for a maximum score in the achievement domain. Specifically, instead of requiring hospitals to increase volume by 150% or more as compared to their target, the agency will require hospitals to increase volume by 125%. The agency also modified the rest of the scoring to create a more graduated scale as depicted in table 2.</p><p class="text-align-center"><strong>Table 2: Scoring Approach for Achievement Domain</strong></p><table><tbody><tr><td><strong>Performance Relative to Target Number</strong> </td><td><strong>Points</strong></td></tr><tr><td>Less than 75%  </td><td>0</td></tr><tr><td>75% to less than 85% </td><td>10 </td></tr><tr><td>85% to less than 95% </td><td>20 </td></tr><tr><td>95% to less than 105%  </td><td>30</td></tr><tr><td>105% to less than 115% </td><td>40 </td></tr><tr><td>115% to less than 120%  </td><td>50</td></tr><tr><td>120% to less than 125% </td><td>55 </td></tr><tr><td>Greater than 125% </td><td>60</td></tr></tbody></table><p> </p><p><u>Health Equity Performance Adjustment</u>. Due to stakeholder feedback and potential unintended consequences, the agency is not finalizing the proposed health equity performance adjustment at this time. The agency stated that it will monitor impacts to low-income individuals’ access and will consider new or updated policies in future rulemaking. </p><p><strong>Efficiency Domain. </strong>CMMI will use OPTN’s organ offer acceptance rate ratio as the sole measure in the efficiency domain. This measure is calculated by dividing the number of kidney transplant organs accepted by each IOTA participant by the riskadjusted number of expected organ acceptances. The measure uses logistic regression with risk adjustment for several characteristics, including donor quality and recipient characteristics; donor-candidate interactions, such as size and age differences; number of previous offers; and distance of potential recipient from the donor. Additional details on the measure are available on the e Health Resources and Services Administration (HRSA) <a href="https://optn.transplant.hrsa.gov/media/qfuj3osi/mpsc-enhance-transplant-program-performance-monitoring-system_srtr-metrics.pdf" target="_blank" title="Health Resources and Services Administration (HRSA)">website</a>, and risk adjustment models are available on the Scientific Registry of Transplant Recipients (SRTR) <a href="https://www.srtr.org/tools/offer-acceptance/" target="_blank" title="Scientific Registry of Transplant Recipients (SRTR) website.">website</a>. </p><p>To translate measure performance into a score, CMMI finalizes its proposal to calculate two separate scores for each IOTA participant: an "achievement score" reflecting its current level of performance and an "improvement score” reflecting changes in its performance over time. Participants would receive points equal to the higher of the two scores, up to a maximum of 20 points. </p><p>For achievement scores, CMMI will award points based on an IOTA participant’s national quintile of performance. CMMI will rank IOTA hospitals against national performance inclusive of all eligible kidney transplant hospitals regardless of whether they are included in the IOTA model.</p><p>For improvement scores, CMMI modifies its proposal for maximum points, although the scoring methodology comparing performance to a benchmark score remains the same. Specifically, a participant can receive up to 15 points for improvement scores (not 12 points). CMMI will calculate an “improvement benchmark rate,” which it defines as 120% of the IOTA participant’s performance on the organ offer acceptance rate measure during the third baseline year of each PY. CMMI will then compare the PY performance to the benchmark or performance during the third baseline year to determine eligibility for improvement points using the approach in table 3 below:</p><p class="text-align-center"><strong>Table 3: Improvement Scoring for IOTA Efficiency Domain</strong></p><table><tbody><tr><td>Performance </td><td>Points</td></tr><tr><td>At or above improvement benchmark rate </td><td><p class="text-align-center">15 </p></td></tr><tr><td>At or below measure rate for third baseline year </td><td><p class="text-align-center">0 </p></td></tr><tr><td>Greater than third baseline year but less than improvement benchmark </td><td><p class="text-align-center">Up to 15 points based on following formula: 15 x (Rate in Performance Year-Third Baseline Year Rate) (Improvement Benchmark Rate-Third Baseline Year Rate)</p></td></tr></tbody></table><p> </p><p><strong>Quality Domain.</strong> CMMI removed three of the four proposed measures from the quality domain measure set. </p><p><u>Composite Graft Survival Rates.</u> CMMI finalizes its proposal to include in the model the composite graft survival rates measure. This measure will be defined as the cumulative number of functioning grafts divided by the cumulative number of all kidney transplants performed by the IOTA participant. For the first model year, CMS will calculate the rate using only data from PY 1. However, the graft survival rate will be cumulative for the remainder of the IOTA model. </p><p>CMS will rank IOTA hospitals against national performance inclusive of all eligible kidney transplant hospitals regardless of whether they are included in the IOTA model. CMMI did receive concerns from stakeholders about the lack of risk adjustment in this measure. However, it asserts that since PY 1 is upside only, it will evaluate risk adjustment for future rulemaking. </p><p>In light of the fact that three measures were removed from the quality domain, as described below, the composite graft survival rates measure will account for all 20 points in the quality domain. Points will be awarded based on the national quintiles for performance as depicted in table 4.</p><p class="text-align-center"><strong>Table 4: Scoring Approach for Quality Domain</strong></p><table><tbody><tr><td><strong>Performance Relative to Target </strong></td><td><strong>Points</strong></td></tr><tr><td>Greater than 80th percentile </td><td>20</td></tr><tr><td> 60th to 80th percentile </td><td>18</td></tr><tr><td>40th to 60th percentile  </td><td>16</td></tr><tr><td>20th to 40th percentile  </td><td>14</td></tr><tr><td>10th to 20th percentile  </td><td>12</td></tr><tr><td>Less than 10th percentile </td><td>10</td></tr></tbody></table><p> </p><p><u>Other Quality Measures.</u> CMMI did not finalize its other proposed quality measures for the quality domain. Specifically, the agency will not include the CollaboRATE shared decision-making measure, colorectal cancer screening rate measure, or Three-item Care Transition Measure (CTM-3) in the IOTA quality domain. </p><p>The agency indicates that it will assess processes to add, remove or replace quality measures in future rulemaking. </p><h3>HEALTH EQUITY REQUIREMENTS </h3><p><strong>Health Equity Plan.</strong> CMMI modified provisions pertaining to the health equity plans. Specifically, submission of health equity plans will be voluntary across all PYs. </p><p><strong>Demographic and Health-related Social Need (HRSN) Data Reporting.</strong> CMMI did not finalize requirements for demographic and HRSN data reporting. The agency stated that it will continue to review feedback for future rulemaking. </p><h3>PAYMENT </h3><p>CMMI finalizes its proposal that IOTA will include both upside and downside risk for Medicare fee-for-service (FFS) payments for kidney transplants. </p><p><strong>Alternative Payment Model Design for Kidney Transplants. </strong>CMMI finalizes that payments to participants will be limited to Medicare FFS cases. Specifically, while aggregate performance for participants is based on attributed patients regardless of payer, the payment portion of IOTA will include kidney transplants furnished to attributed patients whose primary or secondary insurance is Medicare FFS (since payment is made on a per-case basis). </p><p><strong>Performance-Based Payment.</strong> Participants will be assigned to payment categories based on their performance score. As shown below in Table 5, incentive payments will be made to participants with a performance score of 60 or more. For PY 1, hospitals below this threshold will not receive a payment or be required to make a repayment. Starting in PY 2, hospitals with a score of 40 or lower will be required to pay CMS.</p><p class="text-align-center"><strong>Table 5: Performance Scores and Payment Methodology by PY</strong></p><table><tbody><tr><td><strong>Final Score</strong></td><td><strong> PY 1 </strong></td><td><strong>PY 2-PY 6</strong></td></tr><tr><td>60-100 </td><td>Payment to hospital </td><td>Payment to hospital</td></tr><tr><td>41-59 </td><td>Neutral Zone (no payment adjustment) </td><td>Neutral Zone (no payment adjustment) </td></tr><tr><td>0-40 </td><td>Neutral Zone (no payment adjustment) </td><td>Repayment to CMS</td></tr></tbody></table><p> </p><p><u>Payments to Hospitals.</u> CMMI increased the potential upside payments to participants in the final rule. Hospitals will be eligible for up to $15,000 per case based on their aggregate performance score (compared to the $8,000 per case that was proposed). Payment will be calculated based on the following formula: </p><p class="text-align-center">Payment = $15,000*((Final Performance Score-60)/40)*Medicare Kidney Transplants </p><p><u>Repayment.</u> As was proposed, CMMI finalizes that hospitals in the repayment category will be required to repay CMS up to $2,000 per case based on their aggregate performance score. This is estimated to be 8% of the average kidney transplant MSDRG cost. Repayment to CMMI will be calculated based on the following formula: Repayment = $2,000*((40-Final Performance Score)/40)*Medicare Kidney Transplants </p><p><u>Neutral Zone.</u> Hospitals scoring below 60 in PY 1 or from 41 through 59 in PYs 2-6 will be in the neutral zone and, as such, will neither receive payments nor be subject to repayment.</p><h3>TRANSPARENCY REQUIREMENTS </h3><p><strong>Publication of Patient Selection Criteria for Kidney Transplant Evaluation. </strong>The agency finalizes its proposal to require IOTA participants to publicly post by the end of PY 1, on a website, their selection criteria for evaluating patients for addition to their kidney transplant waitlist. </p><p><strong>Transparency into Kidney Transplant Organ Offers. </strong>The agency did not finalize its proposals that would require an IOTA participant to inform IOTA Medicare waitlist patients of the number of times an organ is declined on their behalf and the reason(s) for the decline on a monthly basis. </p><p>However, the agency did modify requirements for reviewing organ offer acceptance criteria (rather than acceptance criteria and organ offer filters) with IOTA Medicare waitlist patients at least once every six months. </p><p>The agency will consider additional requirements to increase transparency in future rulemaking.</p><h3>FRAUD AND ABUSE WAIVER AND OIG SAFE HARBOR AUTHORITY </h3><p>The Health and Human Services (HHS) Secretary has the authority per Section 1115A of the Social Security Act to waive specified fraud and abuse laws to test payment models. However, no fraud and abuse waivers are issued in the final rule. Therefore, as it stands, any arrangement or agreement under the model that implicates these laws would not be protected unless it falls under an existing exception or safe harbor. </p><p>The final rule notes that any fraud and abuse waivers would be promulgated separately. The AHA will work to ensure that CMS and the HHS Office of Inspector General (OIG) provide necessary waivers so that participating hospitals can pursue the program’s goals without running afoul of fraud and abuse laws. These legal protections are critical to hospitals’ ability to coordinate care among all caregivers. </p><p>CMMI stated that it expects that all financial relationships established between IOTA participants and providers or suppliers for purposes of IOTA would only be those permitted under applicable laws and regulations, including the applicable fraud and abuse laws and all applicable payment and coverage requirements. </p><p>CMS did make a determination that a federal anti-kickback statute safe harbor for CMSsponsored model arrangements and CMS-sponsored model patient incentives is available to protect remuneration exchanged pursuant to certain financial arrangements and patient incentives that may be permitted under the final rule. Specifically, the agency determined that the CMS-sponsored models safe harbor would be available to protect the following financial arrangements and incentives: the IOTA Model Sharing Arrangement’s gainsharing payments and alignment payments, the Distribution Arrangement’s distribution payments, the Part B and Part D immunosuppressive drug cost sharing support policy and attributed patient engagement incentives.</p><h3>GENERAL PROVISIONS FOR ALL INNOVATION CENTER MODELS </h3><p>CMS finalizes standard provisions that will apply more broadly to all CMMI models that begin on or after Jan. 1, 2025. Specifically, it finalizes sections pertaining to beneficiary protections, cooperation in model evaluation and monitoring, audits and record retention, rights in data and intellectual property, monitoring and compliance, remedial action, model termination by CMS, limitations on review and bankruptcy, reconsideration review processes and other notifications be applied across models. </p><h3>FURTHER QUESTIONS </h3><p>If you have further questions regarding IOTA, please contact Jennifer Holloman, AHA’s senior associate director of policy, at <a href="mailto:jholloman@aha.org" title="jholloman@aha.org">jholloman@aha.org</a>.</p></div><div class="col-md-4"><p><a href="/system/files/media/file/2024/11/2024-11-27_SB_IOTA-f.pdf" target="_blank" title="Click here to download the Special Bulletin: CMMI Issues Increasing Organ Transplant Access (IOTA) Model Final Rule PDF."><img src="/sites/default/files/2024-11/CMMI-Issues-Increasing-Organ-Transplant-Access-p1.png" data-entity-uuid data-entity-type="file" alt="Special Bulletin: CMMI Issues Increasing Organ Transplant Access (IOTA) Model Final Rule cover." width="600" height="779"></a></p></div></div></div> Wed, 27 Nov 2024 11:49:52 -0600 Reimbursement <div class="container"><div class="row"><div class="col-md-8"><p>Following the elections, lawmakers are returning to Washington, D.C., to tackle key funding issues, including Medicaid disproportionate share hospital (DSH) payment reductions and support for rural programs. They also will consider site-neutral payment proposals, oversight of health plans, continuation of telehealth and hospital-at-home waivers, and the prevention of violence against health care workers.</p><p>Before the lame-duck session ends and the 118th Congress adjourns, it is essential that federal lawmakers understand the challenges hospitals and health systems face and what is at stake for the patients and communities they represent. With several programs facing expiration at the end of this year, quick action is needed to preserve necessary funding and support for the nation’s health care organizations.</p><p>Here are the issues AHA leaders are <a href="/2024-11-12-aha-urges-congress-act-key-priorities-lame-duck-session" target="_blank" title="Issues AHA Leaders are calling on Congress to reinforce">calling on congressional leaders</a> to reinforce. Following is an overview of the issues and what you can do to assist these advocacy efforts.</p><h2>SUPPORT MEDICAID DSH DEAR COLLEAGUE LETTER</h2><p>At the beginning of the year, billions of dollars will be cut from the Medicaid DSH program, severely jeopardizing hospitals’ finances and threatening communities’ access to care. Contact your representative(s) and ask them to sign on to the bipartisan <a href="/system/files/media/file/2024/11/congress-dear-colleague-letter-to-stop-medicaid-disproportionate-share-hospital-dsh-payment-cuts-11-13-2024.pdf" target="_blank" title="House Dear Colleague Letter">House Dear Colleague letter</a> being circulated by Reps. Dan Crenshaw, R-Texas, Yvette Clarke, D-N.Y., Gus Bilirakis, R-Fla., and Diana DeGette, D-Colo., calling for Medicaid DSH cuts to be addressed. <a href="https://www.votervoice.net/AHA/Campaigns/118959/Respond">Click here</a> to send a message to your representatives.</p><h2><strong>LEGISLATIVE ACTION NEEDED</strong></h2><p><strong>Address the Medicaid</strong> <strong>DSH Payment Reductions. </strong>The <a href="/fact-sheets/2023-03-28-fact-sheet-medicaid-dsh-program" target="_blank" title="Medicare DSH Program Information">Medicaid DSH program</a> provides essential financial assistance to hospitals that care for our nation’s most vulnerable populations — children, impoverished, disabled and elderly. The fiscal year 2025 Medicaid DSH payment reductions are scheduled to be implemented on Jan. 1, 2025, when $8 billion in reductions take effect. The AHA calls on Congress to continue to provide relief from the Medicaid DSH cuts.</p><p><strong>Protect Rural Communities’ Access to Care.</strong> The AHA urges Congress to continue the <a href="/advocacy/advocacy-issues/2024-10-31-advocacy-issue-rural-mdh-and-lva-programs" target="_blank" title="Medicare-dependent Hospitals and Low-volume Adjustment programs">Medicare-dependent Hospitals and Low-volume Adjustment programs</a>. These programs provide rural, geographically isolated and low-volume hospitals additional financial support to ensure rural residents have access to care. These programs expire on Dec. 31, 2024. Congress should also enact a technical correction to remove barriers for Rural Emergency Hospitals to receive hospital-level reimbursement for outpatient services under Medicaid<strong>.</strong> </p><p><strong>Reject Site-neutral Payment Proposals.</strong> The AHA strongly opposes efforts to expand <a href="/advocacy/advocacy-issues/2023-09-11-advocacy-issue-site-neutral-payment-proposals" target="_blank" title="Site-neutral payment cuts information">site-neutral payment cuts</a> to include essential drug administration services furnished in off-campus hospital outpatient departments (HOPDs). Current Medicare payment rates appropriately recognize that there are fundamental differences between patient care delivered in HOPDs compared to other settings. HOPDs have higher patient safety and quality standards, and, unlike other sites of care, hospitals take important additional steps to ensure drugs are prepared and administered safely for both patients and providers. </p><p>The AHA also calls on Congress to reject legislative efforts requiring each off-campus HOPD to be assigned a separate unique health identifier from its provider as a condition of payment under Medicare or group health plans. Hospitals are already required to be transparent about the location of care delivery. This requirement would be duplicative and impose unnecessary and onerous administrative burdens and costs by needlessly requiring the overhaul of current billing practices and systems.</p><p><strong>Hold Commercial Health Plans Accountable.</strong> Certain health plan practices, such as inappropriate care denials and delayed payments, threaten patient access to care. These practices also contribute to clinician burnout and add excessive administrative costs and burdens to the health care system. The AHA urges Congress to pass the<a href="/lettercomment/2024-06-12-aha-support-house-improving-seniors-timely-access-care-act" target="_blank" title="Improving seniors timely access to care"> Improving Seniors Timely Access to Care Act</a> (H.R. 8702/ S. 4532), bipartisan legislation supported by more than half of the members of the House and Senate. The bill would streamline the prior authorization process in the Medicare Advantage program by eliminating complexity and promoting uniformity to reduce the wide variation in prior authorization methods that frustrate both patients and providers.</p><p><strong>Extend </strong><a href="/system/files/media/file/2024/05/fact-sheet-2024-telehealth-advocacy-agenda.pdf" target="_blank" title="Telehealth information"><strong>Telehealth</strong></a><strong> and </strong><a href="/system/files/media/file/2024/07/Fact-Sheet-Extending-the-Hospital-at-Home-Program-20240719.pdf" target="_blank" title="Hospitals-at-home information"><strong>Hospital-at-home</strong></a><strong> Waivers.</strong> During the COVID-19 public health emergency, Congress established a series of waivers expanding access for millions of Americans and increasing convenience in caring for patients. Telehealth provides a tremendous ability to leverage geographically dispersed provider capacity to support patient demand. The AHA calls on Congress to permanently adopt telehealth waivers and expand the telehealth workforce. </p><p>The AHA also urges Congress to pass the <a href="/lettercomment/2024-05-23-aha-support-house-bill-hospital-inpatient-services-modernization-act-2024" target="_blank" title="Hospitals Inpatient Services Modernization Act">Hospital Inpatient Services Modernization Act</a> (H.R. 8260/S. 4350), extending the hospital-at-home waiver for five years through 2029. Congressional action will reassure hospitals and health systems that are interested in developing such programs for their communities. </p><p><strong>Prevent Reimbursement Cuts for Physicians. </strong>Congress should take action to mitigate the scheduled physician reimbursement cuts for 2025 and to continue its work on broader reform for sustainable physician payment. Physicians have dealt with over two decades of conversion factor decrements, as well as significant staffing shortages and rising inflation in recent years. The scheduled 2.8% payment reduction in the 2025 Physician Fee Schedule would result in a significant risk to patients’ access to care.</p><p><strong>Protect America’s Health Care Workers.</strong> The AHA calls on Congress to enact the <a href="/system/files/media/file/2022/09/Fact-Sheet-Workplace-Violence-and-Intimidation-and-the-Need-for-a-Federal-Legislative-Response.pdf" target="_blank" title="SAVE Act information">Safety from Violence for Healthcare Employees (SAVE) Act</a> (H.R. 2584/S. 2768). This bipartisan bill would provide federal protections from workplace violence for hospital workers, similar to the protections in current law for airport and airline workers.</p><h2>FURTHER QUESTIONS</h2><p>Visit the <a href="/advocacy/action-center" target="_blank" title="AHA Action Center">AHA Action Center</a> for more resources on these issues and other priorities important to hospitals and health systems.</p><p>If you have further questions, please contact AHA at 800-424-4301.<br> </p></div><div class="col-md-4"><a href="/system/files/media/file/2024/11/aha-asks-congressional-leadership-to-fund-hospitals-protect-health-care-workers-alert-11-13-2024.pdf"><img src="/sites/default/files/inline-images/cover-aha-asks-congressional-leadership-to-fund-hospitals-protect-health-care-workers-alert-11-13-2024.png" data-entity-uuid="40f68d4b-dfe5-4e56-af78-6f8af97f13ca" data-entity-type="file" alt="Action Alert Cover Image" width="640" height="834"></a></div></div><p> </p></div> Wed, 13 Nov 2024 14:05:33 -0600 Reimbursement /2024-11-12-aha-urges-congress-act-key-priorities-lame-duck-session <p>November 12, 2024</p><table><tbody><tr><td>The Honorable Mike Johnson<br>Speaker<br>U.S. House of Representatives<br>Washington, DC 20515</td><td>The Honorable Hakeem Jeffries<br>Democratic Leader<br>U.S. House of Representatives<br>Washington, D.C. 20515</td></tr><tr><td>The Honorable Charles E. Schumer<br>Majority Leader<br>United States Senate<br>Washington, DC 20510</td><td>The Honorable Mitch McConnell<br>Republican Leader<br>United States Senate<br>Washington, DC 20510</td></tr></tbody></table><p><br>Dear Speaker Johnson, Leader Schumer, Leader Jeffries, and Leader McConnell:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) writes regarding the forthcoming government funding deadline.</p><p>Hospitals and health systems are experiencing significant financial pressures that challenge their ability to provide 24/7 care for the patients and communities they serve.  Increased expenses for drugs and supplies, inflation and the mounting burden due to certain commercial health insurer denial and delay practices continue to strain hospitals and health systems. At the same time, underpayments in reimbursements from Medicare and Medicaid do not keep pace with these mounting costs and exacerbate the problems hospitals are having.</p><p>As Congress begins to focus on its end-of-the-year work, America’s hospitals and health systems respectfully request that you consider the following priorities.</p><p><strong>Address the Medicaid</strong> <strong>Disproportionate Share Hospital (DSH) Payment Reductions. </strong>The Medicaid DSH program provides essential financial assistance to hospitals that care for our nation’s most vulnerable populations — children, impoverished, disabled and elderly. The fiscal year 2025 Medicaid DSH payment reductions are scheduled to be implemented on Jan. 1, 2025, when $8 billion in reductions take effect. Congress should continue to provide relief from the Medicaid DSH cuts.</p><p><strong>Protect Rural Communities’ Access to Care.</strong> We urge Congress to continue the Medicare-dependent Hospitals and Low-volume Adjustment programs. These programs provide rural, geographically isolated and low-volume hospitals additional financial support to ensure rural residents have access to care. These programs expire on Dec. 31, 2024. Congress should also enact a technical correction to remove barriers for Rural Emergency Hospitals to receive hospital level reimbursement for outpatient services under Medicaid<strong>.</strong></p><p><strong>Reject Site-neutral Payment Proposals.</strong> We strongly oppose efforts to expand site-neutral payment cuts to include essential drug administration services furnished in off-campus hospital outpatient departments (HOPDs). Current Medicare payment rates appropriately recognize that there are fundamental differences between patient care delivered in HOPDs compared to other settings. HOPDs have higher patient safety and quality standards, and, unlike other sites of care, hospitals take important additional steps to ensure drugs are prepared and administered in a safe manner for both patients and providers.</p><p>HOPDs provide care for Medicare patients who are more likely to be sicker and more medically complex than those treated at physicians’ offices. This is especially true in rural and other medically underserved communities. Additional cuts will directly impact the level of care and services available to vulnerable patients in these communities.</p><p>We also call on Congress to reject legislative efforts requiring each off-campus HOPD to be assigned a separate unique health identifier from its provider as a condition of payment under Medicare or group health plans. Hospitals are already required to be transparent about the location of care delivery. This requirement would be duplicative and impose unnecessary and onerous administrative burdens and costs by needlessly requiring the overhaul of current billing practices and systems.</p><p><strong>Hold Commercial Health Plans Accountable.</strong> Certain health plan practices, such as inappropriate care denials and delayed payments, threaten patient access to care. These practices also contribute to clinician burnout and add excessive administrative costs and burdens to the health care system. We urge Congress to pass the Improving Seniors Timely Access to Care Act (H.R. 8702/ S. 4532), bipartisan legislation supported by more than half of the members of the House and Senate. The bill would streamline the prior authorization process in the Medicare Advantage program by eliminating complexity and promoting uniformity to reduce the wide variation in prior authorization methods that frustrate both patients and providers.</p><p><strong>Extend Telehealth and Hospital-at-home Waivers.</strong> During the public health emergency, Congress established a series of waivers expanding access for millions of Americans and increasing convenience in caring for patients. Telehealth provides a tremendous ability to leverage geographically dispersed provider capacity to support patient demand. Congress should permanently adopt telehealth waivers and expand the telehealth workforce.</p><p>Hospital-at-home programs are a safe, innovative way to care for patients in the comfort of their homes. With over 300 hospitals with hospital-at-home programs, many other hospitals and health systems indicate they are interested in developing programs for their communities but are reluctant to do so without congressional action. We urge Congress to pass the Hospital Inpatient Services Modernization Act (H.R. 8260/S. 4350), extending the hospital-at-home waiver for five years through 2029.</p><p><strong>Prevent Reimbursement Cuts for Physicians. </strong>Congress should take action to mitigate the scheduled physician reimbursement cuts for 2025 and to continue its work on broader reform for sustainable physician payment. Physicians have dealt with over two decades of conversion factor decrements, as well as significant staffing shortages and rising inflation in recent years. The scheduled 2.8% payment reduction in the 2025 Physician Fee Schedule would result in a significant risk to patients’ access to care.</p><p><strong>Protect America’s Health Care Workers.</strong> Congress should enact the Safety from Violence for Healthcare Employees (SAVE) Act (H.R. 2584/S. 2768). This bipartisan bill would provide federal protections from workplace violence for hospital workers, similar to the protections in current law for airport and airline workers.</p><p>We appreciate your leadership and look forward to working together to ensure patients continue to have access to quality care in their communities.</p><p>Sincerely,</p><p>/s/</p><p>Richard J. Pollack<br>President & Chief Executive Officer</p> Tue, 12 Nov 2024 14:38:12 -0600 Reimbursement /news/headline/2024-08-13-aha-comments-medpac-2024-2025-cycle <p>The AHA Aug. 13 <a href="/2024-08-12-aha-comments-340b-drug-pricing-program-irf-payments-physician-fee-schedule-and-telehealth">commented</a> to the Medicare Payment Advisory Commission in anticipation of the commission’s 2024-2025 cycle. The AHA urged MedPAC to carefully consider the negative consequences for beneficiaries, providers and communities if Medicare payments to 340B hospitals are cut; reconsider its pursuit of inpatient rehabilitation facility-skilled nursing facility site-neutral payment policy; support updates to physician reimbursement that more adequately account for inflation; and recommend repealing in-person visit requirements for tele-behavioral health services.</p> Tue, 13 Aug 2024 14:16:15 -0500 Reimbursement /testimony/2024-05-16-aha-statement-senate-finance-committee-hearing-rural-health-care <p class="text-align-center"><strong>Statement of the</strong><br><strong>���������� Association</strong><br><strong>for the</strong><br><strong>Committee on Finance</strong><br><strong>of the</strong><br><strong>U.S. Senate</strong><br><strong>“Rural Health Care: Supporting Lives and Improving Communities”</strong></p><p class="text-align-center"><strong>May 16, 2024</strong></p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations; our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers; and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) welcomes the opportunity to comment on policies to ensure rural patients continue to receive access to high-quality care.</p><p>Hospitals and health systems are the lifeblood of their communities and committed to ensuring local access to health care. At the same time, many hospitals, including those in rural areas, continue to experience unprecedented challenges that jeopardize access and services. These include workforce shortages, high costs of prescription drugs, and continued severe underpayment by Medicare and Medicaid.</p><p>Rural hospitals make up about 35% of all hospitals in the U.S. Nearly half of rural hospitals have 25 or fewer beds, with just 16% having more than 100 beds. Given that rural hospitals tend to be much smaller, patients with higher acuity often travel or are referred to larger hospitals nearby. As a result, in rural hospitals, the acute care occupancy rate (37%) is less than two thirds of their urban counterparts (62%).</p><p>Below are a series of proposals and suggestions for the Finance Committee to consider as it seeks to ensure financial stability of providers, maintain critical flexibility to protect access and services, build the workforce of tomorrow and improve infant and maternal care in rural communities. </p><h2>FLEXIBLE PAYMENT OPTIONS </h2><p>To improve health care in rural communities, sustainable financing for rural hospitals and health systems is imperative. As a result, rural hospitals require flexible payment options to address barriers and invest in new resources in rural communities.</p><p>Providing certainty and stability in rural Medicare hospital payments is essential. Low reimbursement, low patient volume, sicker patients and challenging payer mix, common at many rural hospitals, puts added financial pressure on those facilities. <strong>The AHA supports policies that promote flexible payment options and address financial challenges faced by the full spectrum of rural hospitals, which will allow them to continue providing high-quality care for their patients.</strong></p><ul><li><strong>Making Permanent the Medicare-dependent Hospital (MDH) and Low- volume Adjustment (LVA). </strong>MDHs are small, rural hospitals where at least 60% of admissions or patient days are from Medicare patients. MDHs receive the inpatient prospective payment system (IPPS) rate plus 75% of the difference between the IPPS rate and their inflation-adjusted costs from one of three base years. AHA supportsmaking the MDH program permanent and adding an additional base year that hospitals may choose for calculating payments. The LVA provides increased payments to isolated, rural hospitals with a low number of discharges. AHA also supports making the LVA permanent. The MDH designation and LVA protect the financial viability of these hospitals to ensure they can continue providing access to care and AHA supports the <strong>Rural Hospital Support Act (S. 1110) </strong>and the<strong> Assistance for Rural Community Hospitals Act (H.R. 6430) </strong>to extend those important designations.</li><li><strong>Extend Telehealth Flexibilities.</strong> The expansion of telehealth services has transformed care delivery, expanded access for millions of Americans and increased convenience in caring for patients, especially those with transportation or mobility limitations. Given current health care challenges, including major clinician shortages nationwide, telehealth holds tremendous potential to leverage geographically dispersed provider capacity to support patient demand. AHA supports  the <strong>CONNECT for Health Act (S. 2016 / H.R. 4189)</strong> to make permanent coverage of certain telehealth services made possible during the pandemic, including lifting geographic and originating site restrictions, allowing Rural Health Clinics and Federally Qualified Health Centers to serve as distant sites, expanding practitioners who can provide telehealth, and allowing the continuation of audio-only telehealth services, among others.</li><li><strong>Reopen the Necessary Provider Designation for Critical Access Hospitals (CAHs). </strong>The CAH designation allows small rural hospitals to receive cost-based Medicare reimbursement, which can help sustain services in the community. Hospitals must meet several criteria, including a mileage requirement, to be eligible. A hospital can be exempt from the mileage requirement if the state certified the hospital as a necessary provider, but only hospitals designated before Jan. 1, 2006, are eligible. <strong>AHA urges Congress to reopen the necessary provider CAH program to further support local access to care in rural areas</strong>. </li><li><strong>Strengthen the Rural Emergency Hospital (REH) Model. </strong>REHs are a new Medicare provider type to which small rural and critical access hospitals can convert to provide emergency and outpatient services without needing to provide inpatient care. <strong>AHA supports strengthening and refining the REH model to ensure sustainable care delivery and financing.</strong> </li><li><strong>Rebase Sole Community Hospitals (SCHs). </strong>SCHs must show they are the sole source of inpatient hospital services reasonably available in a certain geographic area to be eligible. <strong>AHA supports the Rural Hospital Support Act (S. 1110) to add an additional base year that SCHs may choose for calculating their payments</strong>. </li><li><strong>Improve Access to Capital. </strong>Access to capital is important to stabilize a vulnerable hospital or advance innovations in others<strong>. AHA supports expanding the USDA Community Facilities Direct Loan & Grant Program and creating a new Hill-Burton like program to update rural hospitals to ensure continued access in rural communities. </strong></li></ul><h2>FINANCIAL STABILTY – FAIR, TIMELY AND ADEQUATE REIMBURSEMENT<strong> </strong></h2><p>Medicare and Medicaid each pay less than 90 cents for every dollar spent caring for patients — with Medicare hitting a historic low of 82 cents for every dollar — according to the latest AHA data. Given the unique financial challenges of providing care in rural areas, reimbursement rates across payers need to be updated to cover the cost of care.</p><p><strong>AHA supports the following policies to ensure fair, timely and adequate reimbursement. </strong></p><ul><li><strong>Medicare Advantage Payment Parity for CAHs. </strong>The Medicare Advantage (MA) program has grown significantly in the past decade. MA enrollment, which traditionally has grown slower in rural areas, is now surpassing the growth rate in urban areas. For example, MA enrollment quadrupled between 2010 to 2023 in rural counties, compared to metropolitan areas which doubled in enrollment during the same period. Yet, MA plans are not required to pay CAHs at the same cost basis as fee-for-service Medicare; and they are increasingly paying below costs, straining the financial viability of many rural providers. Further, MA plans have the additional burden of prior authorization and other health plan requirements with which rural providers must increasingly contend  requirements that do not exist to nearly the same extent in fee-for-service Medicare and add additional costs for rural providers to comply. <strong>We support legislation to ensure CAHs receive cost-based reimbursement for MA patients</strong>. </li><li><strong>Prompt Pay</strong>. Ensuring prompt payment from insurers for medically necessary, covered health care services is important for ensuring financial stability of rural hospitals and health systems. Delayed payments are particularly problematic for rural hospitals given their low patient volume and often challenging financial position. <strong>We support policies to increase oversight and accountability of health plans including establishing more stringent standards for timely payment to address certain commercial insurer tactics to delay and deny payment to health care providers.</strong> </li><li><strong>Make the Ambulance Add-on Payments Permanent. </strong>Rural ambulance service providers ensure timely access to emergency medical care but face higher costs than other areas due to lower patient volume. We support<strong>, </strong>permanently extending the existing rural, “super-rural” and urban ambulance add-on payments to protect access to these essential services<strong>. AHA asks Congress to pass the Protecting Access to Ground Ambulance Medical Services Act of 2023 (S. 1673 / H.R. 1666) to maintain those enhanced ambulance payments</strong>. </li><li><strong>Commercial Insurer Accountability. </strong>Systematic and inappropriate delays of prior authorization decisions and payment denials by commercial insurers for medically necessary care are putting patient access to care at risk. <strong>We support regulations and legislative solutions that streamline and improve prior authorization processes, including the Improving Seniors’ Timely Access to Care Act, which would codify many of the reforms in the Interoperability and Prior Authorization Final Rule. In addition, we support policies that ensure patients can rely on their coverage by disallowing health plans from inappropriately delaying and denying care, including by making unilateral mid-year coverage changes. </strong></li><li><strong>Wage Index Floor. AHA supports the Save Rural Hospitals Act (S. 803) to place a floor on the area wage index, effectively raising the area wage index with new money for hospitals below that threshold</strong>. </li><li><strong>Behavioral Health. </strong>Implementing policies to better integrate and coordinate behavioral health services will improve care in rural communities. We urge Congress to:<ul><li>Fully fund authorized programs to treat substance use disorders, including expanding access to medication assisted treatment.</li><li>Implement policies to better integrate and coordinate behavioral health services with physical health services.</li><li>Enact measures to ensure vigorous enforcement of mental health and substance use disorder parity laws.</li><li>Permanently extend flexibilities under scope of practice and telehealth services granted during the COVID-19 public health emergency.</li><li>Increase access to care in underserved communities by investing in supports for virtual care and specialized workforce.</li></ul></li></ul><h2>BOLSTERING THE WORKFORCE </h2><p>Recruitment and retention of health care professionals is an ongoing challenge and expense for many hospitals. Nearly 70% of the primary health professional shortage areas are in rural or partially rural areas. Hospitals and health systems need a robust and highly qualified staff to handle medical care in emergency situations. To achieve this goal, targeted programs that help address workforce shortages in rural communities should be supported and expanded. Workforce policies and programs also should encourage nurses and other allied professionals to practice at the top of their licenses. Below are listed a variety of different proposals and pieces of legislation Congress should consider enacting to tackle the workforce shortage crisis. </p><ul><li><strong>Graduate Medical Education. </strong>We urge Congress to pass the <strong>Resident Physician Shortage Reduction Act of 2023 (S. 1302 / H.R. 2389)</strong>, legislation to increase the number of Medicare-funded residency slots, which would expand training opportunities in all areas including rural settings to help address health professional shortages. </li><li><strong>Conrad State 30 Program. </strong>We urge Congress to pass the <strong>Conrad State 30 and Physician Access Reauthorization Act (S. 665 / H.R. 4942) </strong>to extend and expand the Conrad State 30 J-1 visa waiver program, which waives the requirement to return home for a period if physicians holding J-1 visas agree to stay in the U.S. for three years to practice in federally-designated underserved areas. </li><li><strong>International Workforce.</strong> The AHA urges Congress to pass the <strong>Healthcare Workforce Resilience Act (S. 3211 / H.R. 6205)</strong>, bipartisan legislation that would recapture 25,000 unused employment-based visas for foreign-born nurses and 15,000 for foreign-born physicians to help address staffing shortages. </li><li><strong>Loan Repayment Programs. </strong>We urge Congress to pass the <strong>Restoring America’s Health Care Workforce and Readiness Act (S. 862) </strong>to significantly expand National Health Service Corps funding to provide incentives for clinicians to practice in underserved areas, including rural communities. AHA also supports the <strong>Rural America Health Corps Act (S. 940 / H.R. 1711) </strong>to directly target rural workforce shortages by establishing a Rural America Health Corps to provide loan repayment programs focused on underserved rural communities. </li><li><strong>Boost Nursing Education. </strong>We urge Congress to invest significant resources to support nursing education and provide resources to boost student, faculty and preceptor populations, modernize infrastructure and support partnerships and research at schools of nursing. AHA also supports expanding the National Nurse Corps.</li><li><strong>Health Care Workers Protection. </strong>We urge Congress to enact the <strong>Safety from Violence for Healthcare Employees Act (S. 2768 / H.R. 2584) </strong>to provide federal protections for health care workers against violence and intimidation. </li></ul><h2>IMPROVING MATERNAL HEALTH IN RURAL COMMUNITIES </h2><p>The AHA and its hospitals and health systems are dedicated to eliminating maternal mortality and reducing maternal morbidity to provide mothers and babies with the opportunity to lead healthy and productive lives. Last year, we <a href="/system/files/media/file/2023/09/Federal-Public-Policy-Legislative-Solutions-Improving-Maternal%20Health_August%202023_Final.pdf">released </a>a comprehensive set of federal public policy and legislative solutions for improving maternal health. In addition, the AHA has <a href="/advocacy/maternal-and-child-health">shared </a>tools and resources and promoted the fields’ efforts through case studies, webinars and podcasts. </p><p>Over the last decade, more than 200 rural hospitals have closed obstetric (OB) units. The decision to close an OB unit is not made lightly. Hospitals and health systems consider various factors, including patient care, staffing challenges, declining patient volume and inadequate reimbursement, in addition to the important role they play in their communities and the lives of their patients. A recent Government Accountability Office study<a href="#_ftn1" title=""><sup>[1]</sup></a> estimated that half of all rural counties lack access to this essential care. </p><p>As Congress examines this issue more closely, we would encourage legislative approaches that focus on: </p><ul><li><strong>Increasing reimbursement for obstetric services.</strong> For example, some states have implemented add-on payments for labor and delivery - paid directly to the hospital - by their state Medicaid programs; a federal match could be helpful in maintaining and expanding the use of these payments. </li><li><strong>Reducing regulatory barriers to encourage partnerships and innovative approaches to delivering care</strong>. Partnerships between smaller rural hospitals and larger health systems can allow systems to share staff, connect patients with complex health needs to specialists, and in some cases, transfer high-risk pregnant women to other facilities. </li><li><strong>Encouraging state Medicaid graduate medical education (GME) programs to support expanding capacity of existing workforce.</strong> States have broad authority to create Medicaid GME programs that meet the needs of their state, including through fee-for-service and Medicaid managed care programs. In some states, primary care or family practitioners have received training in labor and delivery, including performing cesarean sections, to offer care as part of a broader clinical team that includes obstetricians and gynecologists. CMS could assist with guidance and encourage state Medicaid agencies to develop Medicaid GME programs focused on rural hospitals that provide maternity care.</li><li><strong>Requiring state Medicaid programs to cover telemedicine for maternal care.</strong> Telehealth can provide support throughout the perinatal period as well to allow for consultations with specialists and access to care for rural areas that do not have obstetric providers.<a href="#_ftn1" title=""><sup>[1]</sup></a> A study by the CDC examined work done by 13 state maternal mortality review committees to identify contributing factors and strategies to prevent future pregnancy-related deaths, which included addressing personnel issues at hospitals by providing telemedicine for facilities with no obstetric provider on-site.<a href="#_ftn2" title=""><sup>[2]</sup></a> In addition, the use of remote patient monitoring, such as with blood pressure cuffs weekly glucose review, both lowered pregnancy-related stress and improved patient satisfaction with their treatment. While the use of telemedicine for obstetric services has increased over the last few years, not all states may be requiring Medicaid to reimburse for these services. </li></ul><h2>CONCLUSION </h2><p>We thank you for the opportunity to comment on ways to improve rural health care and strengthen the communities that rely on the services provided by their local hospitals and health systems. We look forward to continuing to work with you on this important issue. </p><p>__________</p><p><small class="sm"><sup>1</sup> </small><a href="https://www.gao.gov/products/gao-23-105515" target="_blank"><small class="sm">htps://www.gao.gov/products/gao-23-105515</small></a></p> Wed, 15 May 2024 23:19:03 -0500 Reimbursement /news/perspective/2024-05-10-hospitals-face-financial-pressures-costs-caring-continue-surge <p>Hospitals hold an extraordinary place in our society by offering comfort and caring to all who walk through their doors, regardless of ability to pay.</p><p>While the commitment to serve, treat and heal never wavers, hospitals continue to face cost pressures that have increased throughout the past few years.</p><p>The AHA’s new <a href="/costsofcaring" target="_blank" title="Costs of Caring report">Costs of Caring report</a> highlights how hospitals and health systems continue to experience significant financial pressures that challenge their ability to provide 24/7 care for patients and communities. Simply put, the costs of providing care often outstrip levels of reimbursement … by a lot.</p><p>During the pandemic and in the years following, baseline costs have escalated dramatically in a number of essential areas, including workforce, drug and medication expenses, and administrative costs, to name but a few. These factors are creating headwinds and obstacles that threaten access to care for millions of Americans.</p><p>A closer look at the data reveals:</p><ul><li>Hospitals’ labor costs, which on average account for 60% of a hospital’s budget, increased by more than $42.5 billion between 2021 and 2023.</li><li>Economy-wide inflation grew by 12.4% during that period, more than double the 5.2% growth in Medicare reimbursement for hospital inpatient care. This makes it harder for hospitals to maintain access to care and invest in cutting-edge treatment and technology.</li><li>Significant underpayment by all payers was the norm for several essential and complex health care services. For example, payments for inpatient behavioral health services were on average 34% below costs, and in the outpatient setting, payments for burn and wound services were on average 43% below costs.</li><li>Certain commercial health insurer practices like prior authorization and denials have only added to mounting administrative burden, while health insurance premiums grew twice as fast as hospital prices in 2023.</li></ul><p>And if that wasn’t enough, these issues were exacerbated by the recent Change Healthcare cyberattack, forcing many hospitals and health systems to use diminishing cash reserves to maintain operations.</p><p>While some hospital and health system finances have experienced modest stabilization from historic lows in 2022, we are still far from where we need to be to meet the demand for care, invest in new and promising technologies and interventions, and stand ready for the next health care crisis.</p><p>That’s why we are continuing to call on Congress and the Administration to take action to strengthen hospitals and health systems and bolster access to care for all patients and communities. Among other priorities, we are advocating for rejecting funding cuts and extending key policies to ensure patients’ access to care; supporting and strengthening the health care workforce; holding commercial insurers accountable for practices that delay, deny and disrupt care; and bolstering support to enhance cybersecurity of hospitals and the entire health care sector.</p><p>No matter how big the challenges look — no matter how thick the fog is over the current political and policy landscape — we will answer the call to advance health in America.</p> Fri, 10 May 2024 10:23:52 -0500 Reimbursement /fact-sheets/2022-05-25-fact-sheet-majority-hospital-payments-dependent-medicare-or-medicaid <div class="container"><div class="row"><div class="col-md-8"><p>It is broadly acknowledged that Medicare reimburses hospitals less than the cost of providing care and their reimbursement rates are non-negotiable. The Medicare Payment Advisory Commission found that hospitals experienced a record-low -12.7% margin on Medicare services in 2022, and it projects that margins will continue to remain near -13% in 2024<sup>1</sup>. Combined underpayments from Medicare and Medicaid to hospitals were nearly $130 billion in 2022<sup>2</sup>, up from $76 billion in 2019. Exacerbating this pressure is the fact that Medicare and Medicaid account for most hospital utilization. In fact, 96% of hospitals have 50% of their inpatient days paid by Medicare and Medicaid, and more than 82% of hospitals have 67% Medicare and Medicaid inpatient days. Because of the fixed nature of these payments, hospitals are unable to fully absorb the tremendous inflationary forces they are currently facing.</p><p>A recent <a href="http://www.aha.org/costsofcaring" target="_blank" title="Cost of Caring Report">AHA report</a> highlights the significant growth in expenses across labor, drugs and supplies, as well as the impact that rising inflation is having on hospital prices. Further cutting Medicare payments to hospitals and health systems will threaten access to care for patients and communities.</p><p>__________</p><p><small class="sm"><sup>1</sup> </small><a href="https://www.medpac.gov/wp-content/uploads/2023/10/MedPAC-Hospital-payment-adequacy-Jan-2024.pdf" target="_blank" title="MedPAC Hospital Payment Adequacy - Jan 2024 pdf"><small class="sm">www.medpac.gov/wp-content/uploads/2023/10/MedPAC-Hospital-payment-adequacy-Jan-2024.pdf</small></a><br><small class="sm"><sup>2</sup> </small><a href="/2024-01-10-infographic-medicare-significantly-underpays-hospitals-cost-patient-care" target="_blank" title="Medicare significantly underpays hospital's cost of patient care infographic"><small class="sm">www.aha.org/2024-01-10-infographic-medicare-significantly-underpays-hospitals-cost-patient-care</small></a></p><p><img src="/sites/default/files/inline-images/fact-sheet-majority-hospital-payments-dependent-on-medicare-or-medicaid-congress-continues-to-cut-hospital-reimbursements-for-medicare-r-chart-1.png" data-entity-uuid="6e1f43c4-4984-416b-9093-113e6f3e10a1" data-entity-type="file" alt="Chart: Percent of U.S. Hospitals Treating Majority Medicare and Medicaid Patients, by Inpatient Days, 2022" width="561" height="434"> <br><img src="/sites/default/files/inline-images/fact-sheet-majority-hospital-payments-dependent-on-medicare-or-medicaid-congress-continues-to-cut-hospital-reimbursements-for-medicare-r-chart-2.png" data-entity-uuid="fb1121cd-1593-4601-b90e-86e632794235" data-entity-type="file" alt="Continuation of Chart: Percent of U.S. Hospitals Treating Majority Medicare and Medicaid Patients, by Inpatient Days, 2022" width="562" height="783"></p></div><div class="col-md-4"><div class="external-link spacer"><p><a class="btn btn-wide btn-primary" href="/system/files/media/file/2022/05/fact-sheet-majority-hospital-payments-dependent-on-medicare-or-medicaid-congress-continues-to-cut-hospital-reimbursements-for-medicare.pdf" target="_blank" title="Click here to download the Fact Sheet: Majority of Hospital Payments Dependent on Medicare or Medicaid PDF.">Download the Fact Sheet PDF</a></p><p> </p><p><a href="/system/files/media/file/2022/05/fact-sheet-majority-hospital-payments-dependent-on-medicare-or-medicaid-congress-continues-to-cut-hospital-reimbursements-for-medicare.pdf" target="_blank" title="Click here to download the Fact Sheet: Fact Sheet: Majority of Hospital Payments Dependent on Medicare or Medicaid."><img src="/sites/default/files/2024-05/cover-fact-sheet-majority-hospital-payments-dependent-on-medicare-or-medicaid-congress-continues-to-cut-hospital-reimbursements-for-medicare-r-5-6-2024.png" data-entity-uuid data-entity-type="file" alt="Fact Sheet: Majority of Hospital Payments Dependent on Medicare or Medicaid" width="510" height="659"></a></p></div></div></div></div> Mon, 06 May 2024 22:36:53 -0500 Reimbursement /news/headline/2024-05-02-new-aha-report-highlights-mounting-financial-challenges-hospitals <p>The AHA May 2 released a <a href="/costsofcaring">new report</a> highlighting how hospitals and health systems continue to experience significant financial pressures that challenge their ability to provide 24/7 care for patients and communities. <br><br>In 2023, data show that hospitals and health systems faced substantial challenges due to higher costs for labor, drugs and supplies. At the same time, reimbursements from Medicare and Medicaid did not keep pace with these mounting costs, and hospitals and health systems increasingly encountered challenges navigating onerous commercial insurer practices that delayed and denied payment for patient care. Those issues have been exacerbated by the recent Change Healthcare cyberattack, forcing many hospitals and health systems to use diminishing cash reserves to maintain operations.<br><br>“As this report clearly highlights, increased expenses, workforce challenges, and growing administrative burden are unsustainable and creating headwinds and obstacles that threaten access to care for millions of Americans,” <a href="/system/files/media/file/2024/05/Costs-of-Caring-2024-Report-Press-Release-20240502.pdf">said</a> AHA President and CEO Rick Pollack. “The AHA urges Congress and the Administration to take action to strengthen hospitals and health systems and bolster access to care for all patients and communities.”</p> Thu, 02 May 2024 15:13:22 -0500 Reimbursement /center/emerging-issues/market-insights/ai/building-and-implementing-artificial-intelligence-action-plan-health-care <div> /* Banner_Title_Overlay_Bar */ .Banner_Title_Overlay_Bar { position: relative; display: block; overflow: hidden; max-width: 1170px; margin: 0px auto 25px auto; } .Banner_Title_Overlay_Bar h1 { position: absolute; bottom: 40px; color: #003087; background-color: rgba(255, 255, 255, .8); width: 100%; padding: 20px 40px; font-size: 3em; box-shadow: 0 3px 8px -5px rgba(0, 0, 0, .6); } @media (max-width:991px) { .Banner_Title_Overlay_Bar h1 { bottom: 0px; margin: 0px; font-size: 2.5em; } } @media (max-width:767px) { .Banner_Title_Overlay_Bar h1 { font-size: 2em; text-align: center; text-indent: 0px; padding: 10px 20px; } } @media (max-width:530px) { .Banner_Title_Overlay_Bar h1 { position: relative; background-color: #63666A22; } } /* Banner_Title_Overlay_Bar // */ <header class="Banner_Title_Overlay_Bar"><img src="/sites/default/files/2019-09/AI_Top_Banner_1170x200.jpg" alt="Cover of Mobilizing Data to Improve Operational Efficiency " width="1168" height="200"><div><h1>Building and Implementing an Artificial Intelligence Action Plan for Health Care</h1></div></header></div> .container.spacer { padding-top: 0px } .t_menu { margin-bottom: 25px; font-size: 1.5em; padding-bottom: 25px; border-bottom: solid 2px lightgray; } .t_menu .col-sm-2, .t_menu .col-sm-10 { padding: 0px } .t_menu span { padding: 0 5px 0 15px } .t_menu .t_menu_child { padding-top: 3px; color: #818285 } @media(max-width: 500px) { .t_menu { font-size: 1em; } } <div class="row t_menu"><div class="col-sm-2 col-xs-6"><a href="/center" title="AHA Center for Health Innovation"><img src="/sites/default/files/2018-09/logo-aha-innovation-center-color-1000px.jpg" alt="AHA Center for Health Innovation Logo" width="1000" height="182"></a></div><div class="col-sm-10 col-xs-6 t_menu_child"><span>></span> <a href="/center/emerging-issues/market-insights" title="Market Insights">Market Insights</a> <span>></span> <a href="/center/emerging-issues/market-insights/ai" title="Market Insights">AI’s Impact on Health Care</a></div></div> h2{ color: #253b80; text-transform: uppercase; } h3 { color:#9d2235; } p.field_lead{ color: #63666A; font-weight: 300; line-height: 1.4; font-size: 21px; } <div class="row"><div class="col-md-12"><p class="field_lead">Staring at unlimited artificial intelligence (AI) use cases, hospitals and health systems need effective action plans for future health care delivery. AI has the potential to transform every aspect of health care delivery from the simplest administrative task to the most complex clinical procedures for less cost and improved organizational and patient care outcomes.</p></div> .y-hr3 div:nth-child(2){ border-top: solid 15px #9d2235; margin: 50px 0px; height: 0px; } <div class="row y-hr3"><div class="col-md-3"> </div><div class="col-md-6"> </div><div class="col-md-3"> </div></div><div class="col-sm-5 col-md-4"><a href="#DownloadNow" title="Sign up to download: Building and Implementing an Artificial Intelligence Action Plan for Health Care"><img src="/sites/default/files/2024-12/AI_cover_700x532.jpg" alt="Cover image of the report: Building and Implementing an Artificial Intelligence Action Plan for Health Care" width="1500" height="1140"></a><p><a class="btn btn-wide btn-primary" href="#DownloadNow" title="Sign up to download: Building and Implementing an Artificial Intelligence Action Plan for Health Care">Read More</a></p></div><div class="col-sm-7 col-md-8"><p>Health care AI is experiencing an influx of new technologies, algorithms and applications, leading to a dynamic landscape. Looking at unlimited possibilities with limited budgets, hospital and health system executives are learning strategically how and where to use AI technology for value creation. Their AI budgets are prioritizing patient access, revenue cycle management and operational throughput use cases that yield a tangible return on investment (ROI). Integrating AI into clinical care can enhance patient outcomes across health care settings and produce significant savings and improvements in health; however, challenges related to data privacy, bias and the need for human expertise must be addressed to implement AI responsibly and effectively.</p><p>The AHA Center for Health Innovation produced this Market Insights report for executives of hospitals and health systems to guide them as they journey into the use of artificial intelligence and AI-powered technologies to transform their organizations’ operations. This report is based on information and insights from interviews with 12 health care AI experts and leaders, published health care articles, presentations, reports, research and surveys on health care AI.</p></div></div><div class="row y-hr3"><div class="col-md-3"> </div><div class="col-md-6"> </div><div class="col-md-3"> </div></div> .t-data { margin-bottom: 25px } .t-data h2{ margin-bottom:25px } .t-data .t-dataBar-1 > div{ border-top: solid 25px #253b80; border-left:solid 3px #9d2235; padding-left:10px; padding-top:10px; padding-bottom:10px; min-height: ; margin-bottom: 10px; } .t-data .t-dataBar-1 h2{ display: block; clear: both; font-size: 1.1em; color: #5fa1d0; font-weight: 700; line-height: 1em; margin-bottom: 0px; /* If not Data # */ } .rowEqual { display: -webkit-box; display: -webkit-flex; display: -ms-flexbox; display: flex; flex-wrap: wrap; padding: 10px; } .rowEqual>[class*='col-'] { display: flex; } <div class="row"><h2>Foundational Building Blocks</h2><div class="rowEqual row t-data"><div class="t-dataBar-1 col-md-4"><div><h3>People</h3><p>Getting the people right is the hardest part of an effective AI action plan. The role of the CEO is critical to set the vision and lead an executive team that connects proposed AI pilots and projects with the overall strategic objectives of the organization. Changing the nature of work changes the culture of an organization.</p></div></div><div class="t-dataBar-1 col-md-4"><div><h3>Process</h3><p>With the right leaders and team in place, the health care AI action plan must have a system that determines how ideas for AI pilots and projects flow to the leaders and teams vetting them.</p></div></div><div class="t-dataBar-1 col-md-4"><div><h3>Technology</h3><p>Organizations must have strong data stewardship, governance and IT infrastructure. Data stewardship must be a criterion in an organization’s AI pilot and project vetting process. AI pilots and projects must meet an organization’s data governance standards.</p></div></div></div></div><div class="row y-hr3"><div class="col-md-3"> </div><div class="col-md-6"> </div><div class="col-md-3"> </div></div><div class="row"><div class="col-md-12"><h2>AI-powered Solutions Drive ROI and Use Cases</h2><p class="field_lead">Many hospitals and health systems look to improve financial stability and boost productivity by reducing staff time spent on administrative tasks with an ROI within one year. As health systems gain experience with AI initiatives, investments move beyond financial metrics and embrace a broader value proposition that AI offers in improving patient outcomes, patient experience, operational efficiency and reducing workforce burnout and turnover. Several tables and charts show the many AI use cases, the technology readiness level, the expertise required for deployment and the ROI impact.</p></div><div class="col-sm-5 col-md-6"><a href="/sites/default/files/2025-01/AI_clinical_use_cases_chart-1200x595.jpg" target="_blank" title="View the chart in a new window"><img src="/sites/default/files/2025-01/AI_clinical_use_cases_chart-1200x595.jpg" alt="AI clinical use cases planned | Percentage of surveyed health leaders in 14 countries who said they plan to implement AI within the next three years for clinical support." width="1500" height="744"></a></div><div class="col-sm-7 col-md-6"><h3>AI Administrative Solutions in Use Today</h3><p>One table identifies 17 areas within health care workflows that could benefit from AI-powered software and their ROI impact in patient access, revenue cycle management and operations.</p><h3>AI Clinical Applications in Use Today</h3><p>Another shows 11 areas in which AI can provide opportunities to improve patient outcomes, patient experience, operational efficiency and reducing workforce burnout and turnover.</p><p><a href="#DownloadNow" title="Sign up to download: Building and Implementing an Artificial Intelligence Action Plan for Health Care"><strong>READ MORE.</strong></a></p></div></div><div class="row y-hr3"><div class="col-md-3"> </div><div class="col-md-6"> </div><div class="col-md-3"> </div></div><div class="row"><div class="col-sm-5 col-md-6"><a href="#DownloadNow" title="Sign up to download: Building and Implementing an Artificial Intelligence Action Plan for Health Care"><img src="/sites/default/files/2025-01/AI_case_studies-700x300.jpg" alt="AI Case Studies: Atrium Health, Cleveland Clinic, Corewell Health, HCA Healthcare, Mayo Clinic, Providence, Sutter Health" width="700" height="381"></a></div><div class="col-sm-7 col-md-6"><h2>AI Case Studies</h2><p>Seven prominent hospitals and health systems have embarked on their own journeys into AI. They share how they are doing it, the benefits of incorporating AI, as well as the many lessons learned along the way.</p><ul><li><strong>Atrium Health</strong></li><li><strong>Cleveland Clinic</strong></li><li><strong>Corewell Health</strong></li><li><strong>HCA Healthcare</strong></li><li><strong>Mayo Clinic</strong></li><li><strong>Providence</strong></li><li><strong>Sutter Health</strong></li></ul><p><a href="#DownloadNow" title="Sign up to download: Building and Implementing an Artificial Intelligence Action Plan for Health Care"><strong>READ MORE.</strong></a></p></div></div><div class="row y-hr3"><div class="col-md-3"> </div><div class="col-md-6"> </div><div class="col-md-3"> </div></div><div class="raw-html-embed"> .SponsorMarketoForm { background-color: ; padding: 5px 25px; border: solid 2px #307FE2; margin: 50px 15px 0px; display: inline-block; } .SponsorMarketoForm h3 { margin: 10x 0 0 0; color: #555; font-size: .7em; text-transform: uppercase; font-weight: 400; letter-spacing: 3px; max-width: 200px; /* Custom for the copy length */ background-color: #fff; padding: 5px 15px; position: relative; top: -35px } .SponsorMarketoForm h2 { color: #002855; } .SponsorMarketoForm .SponsorMarketoFormHolder { background-color: ; padding: 15px; display: block; margin-bottom: 25px; max-width:700px; overflow:hidden; } .SponsorMarketoFormHolder form { margin: auto; display:inline /* xxxxxxxxxxx */ } /* Marketo Over-ride */ #contactus .mktoForm .mktoFormRow:nth-child(3) { float: left; } /*Center the last row */ @media (min-width:991px){ #contactus .mktoForm .mktoFormRow:nth-child(4) { margin-left: 15%; } #contactus .mktoForm .mktoButton{ margin: 0 0px; } } #contactus .mktoForm label { font-size: 0px; width: 0px !important; } #contactus .mktoForm input { height: 30px } #contactus .mktoForm .mktoButtonRow { float: left; } #contactus .mktoForm .mktoButtonWrap { margin-left: 20px !important; } #contactus .mktoForm .mktoButton { background-color: #002855 !important; border: 1px solid #002855 !important; color: #fff !important; padding: 0.4em 1em; font-size: 1em; background-image: none !important; min-width: 190px; margin: 0 15px; border-radius: 4px; /*padding: 10px 20px;*/ transition: all .25s ease-in-out; text-shadow: none; white-space: normal; height: 30px; font-weight: 700 } #contactus .mktoForm .mktoButton:hover { background-color: #fff !important; border: 1px solid #307fe2 !important; color: #307fe2 !important; } #contactus .mktoForm .mktoClear { clear: none; } <div class="container spacer" id="contactus"> <div class="row" id="DownloadNow"> <div class="col-md-1"> </div> <div class="col-md-10"> <div class="SponsorMarketoForm"> .FlipFlop{ display: flex; flex-wrap: wrap; flex-direction: column-reverse; } /*special for the Marketo form*/ .SponsorMarketoForm .FlipFlop .CTAkicker{ z-index: 1000; margin: 0px; color: #555; font-size: .7em; text-transform: uppercase; font-weight: 400; letter-spacing: 3px; top: -13px; position: relative; background-color: #fff; width: 200px; margin: auto; } <div class="FlipFlop"> <h2>Building and Implementing an Artificial Intelligence Action Plan for Health Care</h2> <div class="CTAkicker">Download Now</div> </div> <div class="col-sm-9"> <div class="SponsorMarketoFormHolder">   MktoForms2.loadForm("//sponsors.aha.org", "710-ZLL-651", 4337); MktoForms2.whenReady(function(form) { if (form.getId() == 4337) { form.onSuccess(function(values, followUpUrl) { form.getFormElem().hide(); document.getElementById("successAndErrorMessages").innerHTML = "<div><p>Thank you for downloading the latest AI report.<\/p><a class='btn btn-wide btn-primary' data-view-context='top-level-view' href='https:\/\/www.aha.org\/system\/files\/media\/file\/2025\/01\/Market_Insights_AI_Report-2025.pdf' target='_blank' rel='noopener noreferrer nofollow'>Download the Report<\/a><\/center><\/div>"; return false; }); }; }); <div id="successAndErrorMessages">   </div> </div> </div> <div class="col-sm-3"> <img src="/sites/default/files/2024-12/AI_cover_700x532.jpg" alt="Cover image of the report: Building and Implementing an Artificial Intelligence Action Plan for Health Care"> </div> </div> </div> <div class="col-md-1"> </div> </div> </div> </div> .mktoForm .mktoRequiredField .mktoAsterix { display: block; font-size: 18px; top: 10px; position:absolute; left:5px } Wed, 10 Jan 2024 15:00:00 -0600 Reimbursement