Healthcare in this United States is a lightning rod for debate. As Congress grapples with the future of the Affordable Care Act, the American people face uncertainty in medical care and costs.
To improve the efficiency, quality, and cost-effectiveness for patient care, hospitals have increasingly turned digital, using Electronic Medical Record (EMR) systems to store and share patient’s medical history. However, as the use of EMR systems increased, so did reported healthcare costs.
Since the adoption of the physician coding systems used to store and update EMRs in 2009, Medicare has experienced an estimated $380 million increase in reimbursements per year. Medicare accused hospitals of “upcoding,” or illegally overstating patients’ diagnoses and treatment, in an effort to receive a higher reimbursement. A 2012 study showed that hospitals in Utica, NY, and Nashville, TN, increased its patient reimbursement claims by 43% and 82% respectively after adopting EMR systems.
In response to this drastic surge in reimbursements, the Centers for Medicare and Medicaid Services conducted a pilot program, the Recovery Audit Program, from 2004 to 2010. Researchers at the Fox School partnered with researchers at McGill University to study how this audit program has been able to reduce illegal Medicare reimbursement claims, thus lessening the financial burden on American taxpayers.
The initial goal of implementing EMRs was to lower costs by reducing medical errors, over-testing, and re-admissions. But the findings of Dr. Kartik K. Ganju of McGill and Drs. Hilal Atasoy and Paul Pavlou of Temple University, confirmed that the adoption of the coding system is associated with an increase in Medicare reimbursements, particularly in the case of for-profit hospitals.
The research found an average of $217,745 in inflated reimbursements to Medicare per hospital per year, and even higher costs (nearly $370,000 in overages) at for-profit hospitals. After finding $693 million in overpayments by Medicare in six pilot states, the audit program was adopted nationwide in 2010.
The researchers looked into this “trillion-dollar conundrum” and found that the audit program successfully combated upcoding by using default templates and by identifying and removing cloned records of old patient that were erroneously copied into a new patient’s medical chart. After the audit became nationwide, the study found that it had corrected up to $2 billion in incorrect claims; yet for-profit hospitals were still reporting high reimbursement fees than their nonprofit counterparts.
The bottom line? While EMRs have enhanced coordination and information sharing, they also make it easier to report expensive and potentially inappropriate healthcare expenses.
As the first successful evaluation of the Recovery Audit Program, the researchers praise the work that has been done, but warn that stronger oversight by the government is still needed to combat ever-increasing costs, especially at for-profit hospitals.
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Molly Belmont, a Risk Management and Insurance student from Temple University’s Fox School of Business, has been selected as the winner of the 2016 American Association of Managing General Agents (AAMGA) Student White Paper Research Contest.
A junior, Belmont won the AAMGA competition’s Technology and Wholesaler category for her paper, “Internet of Things Insurance, Opportunities, and Threats.”
In her paper, Belmont focused on three distinct areas – the connected home, the connected car, and the connected self – and discussed benefits and potential flaws in the collection of data through the Internet of Things IoT.
“While these devices can help insurance companies price better premiums and lower risk, and can also better educate the consumer and help them identify exactly what they’re paying for, there is a cyber risk involved with these devices that most companies didn’t necessarily consider,” said Belmont, a native of Malvern, Pa. “These systems can be hacked and create unforeseen dangers.”
Belmont said the paper was the culmination of more than one month’s work, during which time she utilized more than 20 sources. She said it was the first writing competition in which she’s taken the top prize. Belmont credited Fox School Assistant Professor Storm Wilkins with the encouragement to enter the competition.
For her winning entry, Belmont will receive a scholarship totaling $1,000; an all-expenses-paid trip and registration for the 90th AAMGA Annual Meeting, to be held May 22-25 at the JW Marriott Desert Ridge Resort in Scottsdale, Ariz.; an opportunity to shadow an AAMGA member during his or her meetings at the conference; and publication of her paper in the May issue of Wholesale Insurance News magazine, which is distributed to more than 1.4 million insurance professionals in more than 40 countries globally.
“I’ve been looking into the schedule of events and the networking opportunities available at the conference,” said Belmont, who this summer will serve as a benefits intern in the Philadelphia office of Arthur J. Gallagher & Co. “I wasn’t expecting to win, so it’s a big thrill.”
Pharmaceutical companies would improve sales revenue by investing in commercial operations that promote business innovation, employee engagement, organization alignment, and ensure a reasonable ratio between district sales managers and frontline sales representatives, according to Fox School of Business research.
The study was commissioned by TGaS Advisors, a benchmarking and advisory services firm, and division of KnowledgePoint360®, a global leader in communications, information and workflow services to healthcare professionals and the pharmaceutical and biotechnology industries.
“We focused on factors likely to impact pharmaceutical sales because data for this area are more robust, but the value of investments in sales operations should be read as a proxy for a broad range of commercial operation functions,” said George Chressanthis, the professor of healthcare management and marketing at the Fox School of Business who led the study team with Eric Eisenstein, assistant professor of marketing, and Fox PhD student Patrick Barbro.
According to Chressanthis, this is the first such independent research study on the effects of qualitative versus quantitative measures of commercial operation functions on business performance. Internally reported data from 26 pharmaceutical companies were analyzed for the period 2005-2011 and was complemented with qualitative survey data on commercial operations’ cultural attributes assessed by strategic account executives at TGaS Advisors.
The research team was given complete access to their database, with all analyses, findings, and recommendations independently developed of TGaS Advisors. All company specific data elements and names in the research were kept confidential, in keeping with contractual obligations, but did not affect the course the analysis.
The research showed that three factors within a company’s commercial operations organization are particularly important in determining U.S. business performance:
- Commercial operations’ cultural attributes, specifically innovativeness and responsiveness, which drive employee engagement and organizational alignment, are critical. These attributes are most powerful in affecting sales when working synergistically and in concert with quantitative investments in commercial operations support.
- Company scale and spending to support sales professionals that allow for more products to sell and leverage specialized commercial operations functional support for sales representatives to be more effective in their role.
- The number of sales representatives whom district sales managers supervise has a direct bearing on their ability to provide necessary levels of sales force effectiveness activities such as coaching, mentoring, on-the-job training, and managerial support to representatives, which in turn has a quantifiable impact on business performance.
The findings suggest that executives can significantly improve commercial performance by investing resources to:
- Create stronger alignment between functions and foster a culture of commercial innovation, organizational alignment, agility, and urgency. Quantitative investments in commercial operations will yield sub-optimal returns without the right structure of cultural attributes to support these business activities.
- Support improvements in sales professionals (i.e., through information, systems, business processes, training, etc.).
- Ensure an optimal number of sales representatives reporting to each first-line sales manager.
The Fox School research team has presented study findings at the following conferences: Pharmaceutical Management Science Association Annual Conference in May 2013 (Bonita Springs, Fla.), International Health Economics Association 9th World Congress in July 2013 (Sydney, Australia), and the American Marketing Association Summer Marketing Educators’ Conference in August 2013 (Boston).
Further insights from the study can be found by reading, “What Aspects of Commercial Operations Impact Pharmaceutical Company Business Performance?” and TGaS Advisors’ “Reflections on a Research Study Conducted by the Temple University Fox School of Business,” both available at www.tgas.com.