Welcome to the Aegeus Strategy Blog, the blog and newsroom for Aegeus Strategy LLC., a leading provider of operational and information technology consulting to the healthcare marketplace.

 

Timm Tobin, Principal

By Timm Tobin

• Aegeus team charged with investigating and designing this data and EDI intensive effort. Responsible for submitting complete and accurate RAPS and EDPS files from this legacy claim adjudication system (Amisys) via an Enterprise Date Warehouse and associated Operational Data Stores. Worked with the Centers for Medicare and Medicaid Services (CMS), to develop the business process and technical plan.
• Led Amisys Claim Payment software implementations, conversions, and migrations for Managed Healthcare clients including Marketplace, Medicare, Duals, and Medicaid products. Implemented add-on software such as Market Prominence, Customer Service, Grievance/Appeals, Optum pricers for Medicare payments, Claim editing software ICES, ClaimCheck, ClaimsXten, and Cotiviti.
• Contracted to implement new data sources for multi-state All Payers Claim Database processes. Oversee a team responsible for integrating new Enterprise Data Warehouse as source to existing Government and Outsourced services. Responsible for overseeing design, development and test phases.
• For a major regional third-party payer, create and roll-out an Enterprise Data Warehouse and associated Operational Data Stores (ODS) and Data Marts. Providing key analytics to improve healthcare delivery and this insurer’s bottom line.
• Development of a Wellness Incentives Program, comprised of an Operational Data store (ODS), custom reward calculations, administrative UI, Single Sign On integration with WebMD (for user reward management).
• Clinical Implementation to transition from disparate legacy UM/CM/DM applications, to a web based distributed integrated platform reducing manual processes, and delivering a complete view of care. Create processes and configuration that is scalable for future growth and shared across lines of business. Enhance clinical data management and analytic core competencies.
• Design and manage the implementation of vendor 5010 solution including  responsibility of environments and testing for this complex project consisting of multiple teams. Manage local team as well as large offshore QA team. Develop processes and documentation across the Project including Charter, Work plan, and Contingency plans.  Adhere to client methodologies, and offer improvements. Extensive exposure to 837, 835, 270/271, 276/277 transactions.
• Provide Project Management for the Council on Accountable Quality Healthcare (CAQH) initiatives.  Quickly come up to speed on new requirements and work with all stakeholders to design and implement the solution. Develop project management plans and schedules for all phases of this initiative.
• Responsible for coordinating Trading Partner testing for this national payer.  Project consisted of developing scenarios, performing data mining, building the EDI transactions, and handling all defect management.  Extensive use of Quality Center to drive results.  Coordinate all players in end to end testing including Trading Partners, third parties, developers, test and business resources.

Dr. Kenneth L. Davis, president and CEO of Mount Sinai Health System

The United States spends far more on health care than any other nation on the globe: $10,348 per person, which amounts to nearly 18 percent of gross domestic product. That is eight percentage points above the average of the industrialized member nations of the Organization for Economic Co-Operation and Development.

Government-funded Medicare and Medicaid account for more than $1 of every $3 of U.S. health-care spending and $1 of every $4 in the federal budget. Medicare has been growing at more than twice the rate of inflation and is forecast to accelerate as baby boomers age, while the cost of Medicaid has grown as the Affordable Care Act has brought Medicaid coverage to more people.

So it is little wonder that congressional leaders are looking to chop Medicare and Medicaid spending, which have long been favorite targets of budget-cutters. As part of its effort to replace the ACA, Congress last year tried to eliminate full dollar-for-dollar sharing of Medicaid costs between the federal and state governments and replace it with finite block grants to the states.

The plan would have limited the federal government’s expenditures, leaving states with the lose-lose proposition of either paying more for Medicaid programs or slashing services and eligibility. Meanwhile, on a smaller level, Washington has delivered “death by a thousand cuts” to hospitals, engaging in a misguided effort to achieve savings by chopping hospital reimbursements time and time again. Most recently, the Trump administration and Congress have reduced Medicaid-funded disproportionate share hospital (DSH) payments, which assist hospitals that provide substantial charity care to residents of low-income neighborhoods.

Such budget-cutting strategies end up hurting the most vulnerable members of society — the millions of poor, elderly and disabled Americans who rely upon the government to provide their health care. The fact is, there have been too many efforts to cut costs rather than address the real source of the problem: America’s health-care delivery system, which is inefficient.

Medicine currently follows the capitalistic model of other American industries: A fee is paid whenever a service or good is delivered. This incentive-based approach works well in most every industry, but not in health care. Fee-for-service encourages more tests and treatments, some of which are completely unnecessary. More health care does not mean better health care.

Instead of volume, we need to incentivize value by rewarding better health outcomes resulting from efficiently delivered, proactive care that keeps patients healthy.

When providers are incentivized to maintain health rather than respond to illness, they treat patients earlier in low-cost environments, like neighborhood clinics, before health problems become serious and require expensive care in a hospital setting. Those who can deliver more value by keeping patients healthy should be able to share in the savings of the health-care expenditures they have reduced.

Providers who spend more than would normally be expected for a given patient should receive no incentive payments. Furthermore, in this shift to value, there is appropriate fiscal support and incentive for the care that needs to happen in between physician visits (for example, disease education, health coaching and other ongoing care-management work). In this kind of system, the interests of payers, providers and patients become aligned.

It can be done. Kaiser Permanente, which serves patients in eight states and the District of Columbia, combines hospitals and outpatient clinics with its own nonprofit insurance plan. Kaiser has a fixed annual amount to care for each member, so there is an inherent incentive to keep patients healthy and out of the hospital, where care is most expensive. Because its structure aligns the interests of payers, providers and patients, Kaiser operates efficiently and they are not alone. In fact, many other health systems, including the Mount Sinai Health System, are creating the same incentive model in partnership with private health plans.

By integrating the mobile and digital technology that is part of our everyday lives, medicine will be able to lower the number of hospital admissions.
Technology is facilitating this kind of value in health care. Laparoscopic surgery, using miniature digital video cameras and electronic tools, allows for small incisions that result in quicker recovery times and shorter hospital stays than traditional open surgery. Telemedicine services enable patients to talk to their doctors by remote video, saving time for both physician and patient and allowing for check-ins between office visits. Biosensors dramatically speed diagnoses by making it possible for doctors to monitor patients who are at home, reading their blood pressure, glucose level and electrocardiogram in real time and initiating treatment before a condition becomes serious.

Taken one step further, the Hospital at Home concept, which Mount Sinai Health System began in 2014, allows patients to be monitored closely from their own bedrooms and receive daily visits from a doctor or nurse practitioner, as well as home nursing care, lab services and medical equipment in their home, which is far less costly than remaining in the hospital.

Such money-saving programs are well established in England, Canada, Israel and Australia. In the Australian state of Victoria, every hospital offers hospital-at-home service, which accounts for 6 percent of all “hospital bed days.” This value-oriented hospital-at-home concept has great potential for expansion in the United States, particularly given the growth of telehealth and remote monitoring capabilities.

By integrating the mobile and digital technology that is part of our everyday lives, medicine will be able to lower the number of hospital admissions and substantially reduce costly readmissions. As hospital stays become shorter and surgical outpatient procedures advance, there will be less need for hospital beds and more reason to expand ambulatory services. Consequently, hospitals will continue to build the community medical practices and outpatient surgery centers that are needed for more value-oriented care.

To be sure, full-service hospitals will still be necessary — we all need to recognize there will come a time when most of us, particularly as we age, will need complex hospital care. Hospitals will simply be focused on management of chronic and complex illnesses, intensive care and high-level urgent conditions, such as thrombosis in the brain or a myocardial infarction (heart attack) requiring emergency treatment, with careful monitoring in an intensive-care unit. Smaller community hospitals will have to shift; more of them will become hospitals without beds, providing more ambulatory services and less-intensive inpatient care.

These changes in American health care aimed at improving value are under way. Now the shift toward value must accelerate because our fee-for-service approach is failing. We need a payment system that stops rewarding health-care providers as if they are factories and, instead, one that will be beneficial for providers, payers and patients. Rather than indiscriminate cost cutting, value-based care is the smart way to bend the health-care cost curve. It will improve patient health, as well as the nation’s fiscal and economic health.

By Mark Samuels

The specter of shadow IT continues to cast shade over enterprise technology operations, and chief information officers (CIOs) are in denial about the scale of the problem.

That is the key conclusion drawn from Symantec’s “1H 2017 Shadow Data Report,” which analyzed the main challenges organizations face when attempting to ensure that data held in cloud apps and services remains secure and compliant.

The survey, which evaluated more than 22,000 cloud apps and services, 465 million documents and over 2.3 billion emails, demonstrated how IT decision-makers must keep a watchful eye over the applications their employees use.

Understanding the Threat of Shadow IT

In a blog post, Symantec executive Deena Thomchick said that organizations use more cloud apps than most IT professionals would expect. The average business now uses 1,232 cloud apps, which is roughly one-third more than they did as of the second half of 2016.

Despite this number, the average CIO believes that his or her business uses between 30 and 40 cloud apps. These figures highlight how shadow IT poses a growing risk to the technology department’s ability to prevent data loss.

The survey also found that businesses “broadly shared” 20 percent of all files held in cloud-based file sharing apps and almost one-third (29 percent) of emails stored in on-demand email platforms. Symantec defined a “broadly shared” file as one that is distributed to the whole organization, an outside third party or publicly to any individual who holds a link to the file.

The Dangers of Sharing Sensitive Information

There is some good news, however. Thomchick reported that it was common in the past to find that 10 percent or more of these broadly shared files contained sensitive data. She suggested that security-conscious organizations are doing better today, since just 2 percent of shared files included confidential information.

While the reduction in the proportion of files containing sensitive data is encouraging, it is concerning that the data being shared includes details relating to compliance, such as personally identifiable information (PII), payment card data and protected health records. Of the 29 percent of broadly shared email assets stored in the cloud, 9 percent included compliance-related data. In total, according to SecurityWeek, Symantec found 207 million emails that it considered at risk.

Implementing Measures to Curtail Shadow IT

SecurityWeek noted that the survey results are based on companies using Symantec’s CloudSOC products. These businesses are therefore already striving to keep cloud data safe. Figures for firms not taking a proactive approach could be worse.

With the constant introduction of new productivity and communication tools, users are more inclined to collaborate outside of IT-sanctioned applications. IT organizations must evaluate existing solutions for their adherence to enterprise standards and either embrace them or replace them with viable alternatives.

When it comes to reducing the risk posed by shadow IT, Thomchick advised companies to implement a range of information security measures and implored executives to share threat intelligence across business platforms. She also pointed to the importance of other techniques, such as auditing, real-time detection, data loss protection and post-incident analysis.

Our local health insurance provider client needed to extract data from multiple sources, process it using a diagnostic grouper, then capture the output in a new data mart to be used for predictive analytics.

The broad goals were:
• create a data mart that was user-friendly for predictive analysts
• keep manual processing effort to a minimum
• ensure high data quality
• include 10 years of history for go-live
The main challenges were:
• upstream data quality issues
• multiple heterogeneous data sources that needed to be processed uniformly
Aegeus designed and developed a comprehensive solution centered around the Johns Hopkins ACG System using Microsoft SQL Server, SSIS and C#.NET. The solution provided an automated way to do the following:

1) Extract Transform and Load data from multiple heterogenous sources into the data mart, aggregating, de-duplicating, cleaning and conforming data to improve data quality while providing a uniform representation.

2) Invoke the Johns Hopkins ACG and process the newly formatted data through it using custom configuration options.

3) Load the diagnostic grouper’s output into the datamart, providing easy-to-use monthly snapshots and cumulative roll-ups.

The solution Aegeus delivered provided a stable, efficient platform for predictive analytics, as well as an extensible foundation for future development efforts.