HEALTHCARE

INSIGHTS
Top trends
driving the
US healthcare
industry
Volume # 1
 The changing pulse of the US
healthcare industry 04

Trend #1
Medicare and Medicaid Expansion 07

Technological imperatives 10

Trend #2
ACO and new payment models 16

Technological imperatives 19

Trend #3
Regulatory compliance and fraud 24
and abuse prevention

Technological imperatives 26

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With the introduction of new
healthcare acts and reforms,
the healthcare industry in the
US has undergone significant
transformations brought on by
challenges and solutions driven
by new technology. This year, the
industry can look forward to more
innovation and advancements
driven by new and existing trends,
powered by technology.

However, all of these trends and

technologies are made relevant by
yet another powerful and critical
driving force – the consumer, who
demands, adopts, and expects
nothing but the best, from
the healthcare industry.

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 The changing pulse of the US
healthcare industry

The healthcare industry in the US is healthcare. In surveys conducted forced to settle for consultations
facing numerous challenges. Ageing by the Economist Intelligence Unit with healthcare providers in
populations, chronic diseases, and PricewaterhouseCoopers their locality.
and new players in the market are 64% of respondents from the US
They are being provided with
among the top issues. Of these, new indicated that they were open to
alternate modes of consultation.
entrants – including the young and seeking medical attention through
If they want to discuss their health
existing technology companies, new and non-traditional ways. To
issues and get opinions from
and most importantly, retailers meet these changing expectations,
providers in other parts of the
– are creating the most impact. the healthcare industry, which is
country, or even the world, they
As consumers get comfortable increasingly becoming consumer-
can get it in a few clicks. Patients
with the one-click services driven, is transforming the way
are being empowered to seek
provided by other industries, the it operates.
expert medical advice – even if
healthcare technology companies Today, healthcare delivery has taken healthcare providers are miles away
and retailers are changing the on a new meaning in the US. For and unable to give face-to-face
way consumers experience instance, no longer are patients consultations – via e-visits.

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Patients too are responding and accommodate consumer care friendly payment methods to
positively to the new trends in anywhere. healthcare data analytics for
healthcare. Research shows that the more effective treatment plans
It is not just healthcare delivery
US$9.59 trillion global healthcare – everything is undergoing a
that is transforming. Almost every
market is receptive to these seismic shift.
aspect of healthcare is changing.
innovations that can supplement From insurance coverage to The common undercurrent
or replace traditional person- consumerization of healthcare, from passing through these changes is
to-person clinical interaction healthcare provider- and patient- technological disruption.

It is not just
healthcare delivery the market are fuelling this change The healthcare industry has come
with the technology-based tools a long way in how it has leveraged
that’s transforming. they bring to the market. For technology to provide better and
Almost every aspect instance, technology companies’ more cost-effective care for patients
mobile-based apps have made who have expensive treatment
of healthcare is it easier for healthcare providers requirements and understand the
changing. to share crucial information with population and its healthcare needs.
patients. Similarly, social media Traditional healthcare companies
platforms have bridged the huge are partnering with those who have
gap that had long separated patient, a strong knowledge of healthcare
Technology has now reached the healthcare providers, and insurance and deep expertise in technology
core of healthcare and is changing companies - it has helped create a to help offer services and develop
the way it evolves. New players in vital connect. new products better aligned with
patient needs.

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 Key trends transforming the US healthcare industry

Medicare and
Medicaid Expansion

Besides a shift in power, the

reform has brought a change in
the way primary care is delivered.

ACO and new payment

models

Achieving the triple goal that

the ACO has set out can be quite
challenging, when approached
independently or in siloes.
Regulatory compliance and
fraud and abuse prevention

Compliance is essential to not

just pass audits, but also to stay
relatively safe against
growing threats.
Retailization and digital
transformation

Public exchanges are getting

integrated in a stealthy but sure
manner into the insurance industry.

Population health and care

analytics

The aim of population health

management is to enhance
outcomes of a group’s health
by monitoring and tracking its
members. Legacy modernization, cloud,
automation, and outsourcing

To keep up with ever-evolving

needs of the healthcare industry,
organizations must undertake legacy
modernization.

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OVERVIEW

Empowering people with better

control over healthcare

TREND #1
MEDICARE AND MEDICAID EXPANSION

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 One of the key objectives of the To make the program more those who were previously not
Patient Protection and Affordable accessible for those who are below covered under a private health
Care Act (PPACA) is to reduce the the eligibility criteria, the ACA has insurance plan by their employer,
number of Americans who are given states permission to expand a new program was launched.
currently uninsured. In an effort the program to cover this section Also, the ACA established new
to meet this objective, the PPACA of people, too. This was achieved rules mandating insurers to extend
offered incentives to those who by creating uniform eligibility healthcare coverage to everyone
signed up for health coverage under standards across the country. For who applies.
the Medicaid healthcare program.

The PPACA and revenue, and a decrease in spend, healthcare organizations

unpaid care. In stark contrast, the and insurers are adopting new care
offered incentives to states that have not expanded their models that move patients to care
those who signed up insurance program, are witnessing settings that are less expensive,
for health coverage the opposite effects. and offer a more holistic approach
under the Medicaid At a time when the industry is to healthcare, rather than send
them to emergency rooms or
healthcare program. under pressure to reduce healthcare
inpatient care.
spend, the US has identified a very
small percentage of the country’s With Medicare and Medicaid
patients, whose healthcare expenses Expansion, the Affordable Care Act
make up a significant portion of (ACA) has given back consumers
the country’s healthcare spend. control over their healthcare
These efforts have made a
Compounding this issue are the dual and has brought significant
significant difference in a number
eligible, those who are eligible for transformations in the industry.
of areas. For instance, the states
both Medicare and Medicaid. Besides a shift in power, the reform
and districts where healthcare
organizations have carried out The money that the country spends has brought new entrants to
Medicare and Medicaid Expansions, on these patients continues to the economy, an increase in the
have seen an increase in volume rise. To counter the effects of this retailization of health insurance,

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and a change in the way primary be uninsured by 20163. And, by 2022, expenses in the coming years.
care is delivered. To keep pace with the states would have paid close to Fortunately there are a host of
these shifts, industry leaders should US$23 billion in payment towards new technologies and business
be flexible and forward-thinking. Medicaid3. Their expenses will models that can help them speed
continue to mount by about US$167 up the process.
This is especially necessary in states
that have not yet opted for Medicaid billion in enhanced payments
Expansion – in the coming years, towards Medicaid3, to counter the
they will experience a greater push reductions that they face from the
to move towards expansion. By federal government. Ever since the
2020, hospitals that serve in these
states will see a decline in federal
With insurance coverage at the heart
of the matter, hospitals interested in
ACA was signed
support, to the tune of US$39 billion. offering Americans the provision to in 2010, more
According to a research by the
Robert Wood Johnson Foundation
gain healthcare coverage, will soon
have to go down the Expansion
than 90 new
and Urban Institute, if the 24 states path. The sooner this transition is companies have
that have not yet opted for Medicaid
Expansion continue without change,
made, the faster a larger section of
the population can access better
been created4.
6.7 million of their population will healthcare while avoiding huge

Primary care physicians, surgeons, and other specialists in

Expansion states saw a higher percentage of Medicaid patients
during the first three months of 2014 than were seen in
non-Expansion states5.

Most will get coverage in the first few years of ACA Expansion
6

45
40
35
30
25
20
15
10
5
0
2014 2015 2016 2017 2018 2019 2020
Exchanges Medicaid Uninsured

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 Technological imperatives

Some of the challenges the – are generated under Medicare Reduce care-delivery cost
healthcare industry faces, and Medicaid across the country.
One of the biggest challenges
technologies that enable healthcare How can this information
the healthcare industry faces is in
organizations to overcome them be leveraged to benefit the
reducing the cost of care delivery.
and deliver benefits to providers, healthcare industry?
With the help of big data generated
payers, and patients, by leveraging
under the Medicare and Medicaid
Medicare and Medicaid Expansion: Solution Expansion, organizations will get
Big data in healthcare is the insights that will enable them
to understand where money is
Big data and analytics extremely valuable. Analyzed and
being spent. With this information,
interpreted the right way, it will
Challenge offer insights that can help take they can adopt the right tools and
the healthcare industry to the solutions that would be better
Every day, vast amounts of data – on suited to tackle problem areas.
billing, payments, treatments, etc. next level.

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Treatment effectiveness and types of treatments most effective information generated in the
physician dues for specific illnesses and identify past year and released by the US
healthcare providers who are government recently, shows that
Besides gaining insights on
not getting their dues. Big data specialists get paid more on a
expenses and cost reduction can show how different kinds of per-visit basis, while family practise
opportunities, organizations can providers are getting paid per visit physicians get paid better on a
also use big data to understand vs. on a daily basis. For instance, daily basis.

This level of big

data mining has Fraud control (CMS) started a Virtual Research Data
Center. This will provide researchers
helped authorities in The Department of Justice (DoJ),
anytime access to encrypted files that
the Federal Bureau of Investigation
the USA to prosecute (FBI), and the Department of
would otherwise have to be shipped
fraudsters and save Health and Human Services (HHS), to them on request. The data center
will contain all the information that
billions of dollars. have been using real-time big data
it collates from different sources.
to understand factors costing the
Medicare program money. The DoJ Researchers can analyze and interpret
has already identified fraudsters the data from their systems. This
Population health in the healthcare industry, initiative will help reduce costs,
responsible for draining resources. increase access, decrease time
For both healthcare providers of research, and increase overall
This level of big data mining has
and payers, knowing what ails efficiency of the process.
helped authorities in the US to
the country, is critical. To get this
prosecute fraudsters and save Since 2008, hospital outpatient
information, they can leverage big
billions of dollars. departments (HOPDs) and
data and get a better understanding
of the illnesses affecting specific age As part of the Big Data and ambulatory surgical centers (ASCs)
groups. This can then be used to Development Initiative by the have been taking on the role of
create awareness and urge people to government, the Centers for treating a large section of the
take preventive measures, if possible, Medicare and Medicaid Services country’s population. A research
especially if they are in a risk group. conducted by the Centers for

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 Medicare and Medicaid Challenge Solution
Services indicates that by 2008,
How can ASCs and HOPDs The best way to do this is to harness
3.3 million Medicare eligible
effectively meet the needs of these the power of data by analyzing it.
citizens were being treated by
ever-increasing number of patients A few areas that ASCs could direct
just 5,175 ASCs7.
with limited resources, while their analytic focus on, would
decreasing costs and increasing include the following:
revenue?

Data can help

identify trends and up a lot of most organizations’ medication and equipment.
changes in staffing, spend. Using analytics, Analyzing the organization’s
healthcare providers can metrics, based on aspects like
a critical area which identify organizational structure physician performance and
takes up a lot of weaknesses, alter staffing utilization of ancillary tests, will help
most organizations’ schedules for better efficiency, them stay more accurately prepared.
spend. and reduce spend on areas like
overtime Prevention of fraud and resource
drainage
Accurate forecasting
One of the biggest roadblocks
Optimizing labor cost
If an organization is able to healthcare organizations face when
These healthcare organizations predict supplies and medication it comes to precisely allocating
should leverage metrics to get requirements, their stock can be funds is fraud. Data analytics can
a better understanding of their more closely aligned with patient reveal departments into which
staffing capacity. Data can help needs. If not, the organizations money is being funnelled and
identify trends and changes in may have more of what is not highlight potential problem areas –
staffing, a critical area which takes essential, and less of crucial which act as hot spots for fraud.

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Telehealth and mobile patient health outcomes, they are remote patient-monitoring
on the lookout for smarter processes can help organizations
With healthcare organizations and tools. Mobile technology can decrease instances of hospital
facing increasing pressure to reduce be the answer to these problems. readmissions and extend care
hospital readmissions and improve Telehealth, mobile apps, SMS, and beyond the hospital.

Telehealth, mobile
interaction between a patient and bundled payments, wherein, instead
apps, SMS, and remote physician who is not located in the of a hospital focusing on gaining
patient monitoring same area. When a patient needs reimbursements, it works to get a
can help organizations follow-up consultations, he does share of the savings.
decrease instances of not have to visit the hospital and get
Mobile app developers should focus
hospital readmissions readmitted to get the healthcare
on creating paid solutions closely
and extend care attention she needs. It also helps
aligned with patient needs, to help
beyond the hospital. organizations avoid penalties for
them reduce hospital visits and
readmissions.
readmissions. Once app developers
Mobile too can help reduce are able to convince patients about
hospital readmissions – however, the benefits they gain with the
not by taking the traditional app, the uptake of these apps will
Medicare supports consultations reimbursement route that most increase. If successful, hospitals
provided via a two-way healthcare organizations like to will reduce readmissions, and get
telecommunication system take, as mobile is currently not a percentage of the savings, the
enabling real-time video and audio covered by Medicare. They will offer solution will generate.

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 Social media

Challenge Information sharing

There is a pressing need for Videos are short and easy-to- Videos also educate viewers on
Medicare and Medicaid programs understand. They present details how they can share this information
to reach the masses in an effective on most of the critical aspects of with friends and family through
and impactful way. How can this Medicare, like how to enroll for it, other social media platforms, too.
be achieved? when and how to use it, and how They encourage people to continue
the program is beneficial for them. the conversation with friends
Through the YouTube channel, and family on blogs, via Pinterest,
Solution Skype, and LinkedIn. This is an
Medicare Made Clear, people can
In an effort to reach the population, learn about enrollment in the effective way of increasing reach
drivers of the Medicare program program and know more about the and getting attention of people.
have created a channel on YouTube benefits they can receive through
that serves as a platform where online resources.
payers, providers, and most
importantly, patients, can get
information they need.

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Besides this dedicated channel, the videos take a look at why Connecting with and keeping track
there are more videos about Medicaid Expansion is essential of customers
Medicare and Medicaid Expansion for healthcare organizations, and
that other organizations have provide statistics on benefits other Medicaid agencies for states can
shared on YouTube. Both patients organizations and states have hire analytics service providers to
and physicians can benefit a experienced post-expansion. gather important information; for
lot from these videos. Some of instance, people’s opinion on the
programs, on social media.

Through the YouTube

This will help program drivers for the better. The way healthcare
channel, Medicare Made understand general perception industry uses social media is quite
Clear, people can learn of the population about the similar to how private companies
about enrollment in the programs. It will also provide do. They are connecting with
program and know more crucial insights into which users are customers, monitoring public data,
about the benefits they having problems with their health and interpreting it with analytics
can receive through online coverage. tools to get insights that can help
resources. Based on this information, deliver better care.
customer service can be changed

AHIP’s Coalition for Medicare Choices (CMC) – more than

1.8 million seniors and counting – are writing letters and emails,
making phone calls, attending events, and engaging on social
media to urge policymakers to protect Medicare Advantage as
lawmakers consider policies that could impact their coverage8.

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 OVERVIEW

Paving the way to more

rewarding experiences

TREND #2
ACO AND NEW PAYMENT MODELS

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Currently, leaders across one of the five key traditional when approached independently
organizations are trying to payment models based on a or in siloes. This is especially true,
create one payment model healthcare provider’s performance. for the US, where healthcare
that incentivizes physicians and The five models are: one-sided costs are rising and quality
motivates them to achieve the shared savings, two-sided shared of care varies drastically. The
three-pronged aim the ACO savings, episode payments, partial challenge is compounded further
has set: enhancing care quality, capitation, and global payments. for organizations in which the
improving patient outcomes, and fee-for-service model is deeply
reducing costs. Accountable Care Achieving the three-pronged
ingrained. The impact is felt most
Organizations (ACO) generally follow goal can be quite challenging
by healthcare payers.

Besides bringing
increased savings, Recent reports by HHS indicate benefits that the model brings
the model has that a payment model – Pioneer
Accountable Care Organization
are likely to convince the HHS to
integrate the model into other
continued to (PACO) that was developed as part programs under Medicare.
ensure that of the Affordable Care Act (ACA), has
The CMS developed another
patients get high brought significant savings of more
than US$384 million over two years.
program, the Advance Payment
quality care This means that over the course of
ACO Model, through which
organizations participating in the
the year, about US$300 has been
Shared Savings Program receive
generated per beneficiary each year.
payments in advance, which will be
Adding more credibility to this retrieved from the shared savings
They have to make the transition payment model is a finding by they generate. It was created to
to a model where the healthcare CMS that shows that this is the motivate more organizations
provider is reimbursed on the basis first patient care model to meet to participate and offer better
of quality of service provided, not expansion criteria of Medicare patient care, by offering advance
the quantity. If adopted the right beneficiaries. Besides bringing payments.Medicare Shared
way with the right technology, increased savings, the model has Savings Program was created to
payment models under the ACO can continued to ensure that patients encourage greater cooperation
bring financial benefits to payers. get high quality care. The dual and coordination

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 among healthcare providers, to offer better coordination of healthcare based on prepaid shared savings.
better healthcare to beneficiaries of services, and more investment It takes forward learnings that
Medicare Fee-for-Service and bring in new healthcare processes the CMS has with the Advance
down costs. Through this program, and infrastructure that improve Payment Model to provide new
ACOs can enhance healthcare physician efficiency. ACOs joining this year or in 2016,
value by promoting greater Another payment model by the ACO the motivation to move into areas
accountability among providers, is the Investment Model, which is that are under-served.

ACOs will be
offered savings prepayments at the beginning and
on an ongoing basis.
Pioneer ACO Model and Medicare
Shared Savings Program. The
in prepayments CMS, which largely oversees
The CMS recently introduced a new
at the beginning payment initiative for ACOs – Next-
different payment models and
and on an Generation ACO Model. This is best
their effectiveness, shares savings
generated from a program with
ongoing basis. suited for organizations with prior
experience in coordinating care for
the ACO that adopts it. The criteria
for this is: the ACOs should keep
different patient populations. This
their spend below a specific level
new model is more aligned with
– a benchmark – over the course
CMS’ focus on looking into payment
of three years. This is one of the
It also provides for current ACOs models encouraging healthcare
key factors that drives ACOs to
participating in the Medicare Shared providers to take on bigger financial
adopt new payment models –
Savings program to shift to systems risks while rewarding them well for
which may bring in better savings
with increased financial risks. These positive healthcare outcomes. The
than older models.
ACOs will be offered savings in new model is an alternative to the

Physicians say that their payment models are changing. 51% of clinicians said
that in five years, 3/4th of their total revenue will come through channels other
than fee-for-service9
24% of clinicians stated that their practice was likely to partner or merge with
a hospital, resulting in full employment by the hospital9

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Technological imperatives

Here are some of the challenges the healthcare industry faces, and the technologies that enable healthcare
organizations to overcome them and deliver benefits to providers, payers, and patients in the area of ACO payments.

Big data Solution it brings, the few that have adopted

it are seeing good returns
Challenge One of the technology-based trends
that has caught the attention of
How can big data be used to help the healthcare organizations is big Recommending the ideal model
the healthcare industry leverage data. While not many have the tools, Healthcare agencies like CMS
information about the ACO resources, or skills necessary to gather information about different
payment models? make the most of it and the benefits payment models used

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 by ACOs, money spent and saved, who can then retain existing providers for effectively delivering
and benchmarks for each ACO. models (if they are beneficial) or good patient outcomes. The
This information is then accessed, adopt new ones. programs will leverage big
analyzed, monitored, and interpreted data to create a better match
to get a better understanding of Developing outcome-based between healthcare providers and
which models work best. companies based on how positive
reimbursement models
CMS and other organizations can healthcare outcomes of the former
Organizations can create payment have been.
share this information with ACOs,
models that reward healthcare

This information
is then accessed, healthcare providers will be In the coming years, organizations
analyzed, monitored, rewarded by the companies. will have to invest more in
technology that will support better
and interpreted to get big data analysis, as penalties and
Reducing patient readmissions
a better understanding payment reductions for hospitals are
of which models work In 2012, the ACA started the increasing every year. Compounding
Hospital Readmissions Reductions
best. this issue are healthcare challenges
Program, to bring down incidences that plague the country. For
of patient readmissions that can instance, hospitals face a 3% penalty
be avoided. To align better with on reimbursement they receive
This will allow companies to pay less this program, organizations are regularly for excessive patient
on group insurance for employees, adopting big data tools that will readmissions within thirty days for
even for those who have preexisting enable them to aggregate data predominant health issues10.
conditions, as healthcare providers capable of providing insights to
who have been matched with them help them avoid unnecessary
show greater potential for delivering readmissions.
positive health outcomes. For the
quality of care they offer employees,

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Analytics and business intelligence

Big data
Challenge and kind of healthcare they deliver, Having learnt from inefficiencies of
Large amounts of patient data is organizations will be able to save this data, healthcare organizations
generated each day. Physicians will a specific amount of money. This are now integrating data analytics
not have time to look through all of money then gets split among the into the system to not only bring
it, understand what is essential, and organization’s members. greater coherence to payer and
leverage it to offer better healthcare provider data, but also bring in
This is in contrast to the capitation-
to patients. How can this data be efficiency into physician workflows.
based Health Maintenance Model
used by ACOs? Analytics will help organizations
that prevailed prior to the ACO
sift through mountains of data
model, according to which a
Solution generated and bring meaning to
healthcare provider is given a fixed
all that information. This means
Over the past few years, the concept revenue based on preventing
that physicians do not have to look
of accountable healthcare has illnesses and related costs. However,
through reams of data – just what is
made a significant impact on the this model failed, as healthcare
identified as essential.
industry. According to the ACO providers did not have data they
Model, the government allocates needed to measure performance.
specific funds for organizations to Data that was available was
care for their pool of patients. Based retrospective, and was neither
on the number of patients they see accurate nor timely.

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 Cloud
Challenge functions like health information information (ePHI) aggregated
exchange and credentialing more from companies and healthcare
Big-data-based insights generated
effectively. It also helps with providers, to ensure compliance
by analytics tools should be easily
case management and quality with the requirements Health
accessible to physicians. How can
performance registries. These Insurance Portability and
organizations make this happen?
capabilities come together as Accountability Act (HIPAA) has
viable alternatives to bring down set out. Organizations can opt for
Solution dependency on hosting systems for HIPAA-compliant cloud services,
ACOs to meet specific requirements. which will offer necessary flexibility
Healthcare organizations employ
without compromising on security
cloud-based services to make ACO To run payment-related programs,
or wasting resources.
payment alignment more seamless. healthcare organizations have to
With cloud, ACOs can carry out secure electronic protected health

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Mobile Solution
Challenge Payment model implementation

How can a healthcare provider, To help in implementation of Act – mobile apps have been
payer, or group ensure they are certain payment models – like developed for both healthcare
implementing a payment model the Open Payments that was started providers and payers. With such
right way, especially with the many as part of a move to increase apps, users can collaborate to
rules and regulations evolving and transparency in the industry record, track, share, and store
becoming complex with time? with adoption of the Sunshine important information.

The payments can be role in affecting health outcomes being developed to make the
captured and recorded is patients’ intake of prescribed payment process more seamless
in the system through medicines. and comprehensive. Healthcare
the app, which can also providers use these apps to safely
By using mobile apps to remind
send receipts to patients patients to take their medicines on
collect payments from patients.
acknowledging their time, healthcare providers increase
Payment collection is enabled at
payment. the chances of better healthcare
any interaction point – from an
emergency room to a home office
outcomes. This could in turn bring
– with mobile apps. Payments can
better reimbursements for them
be captured and recorded in the
through the new payment models.
system through the app, which
Better alignment with fee for quality
can also send receipts to patients
of service model
acknowledging their payment. The
Development of a seamless
Mobile technology can also be used information can also be synced with
payment pathway
in other ways to align healthcare other devices that the organization
providers better with their fee for Besides apps leveraging to uses for healthcare needs.
the quality of service provided. align with payment model
How? A factor that plays a big implementations, they are also

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 OVERVIEW

Ensuring effective and authorized

use of valuable resources

TREND #3
REGULATORY COMPLIANCE AND FRAUD AND ABUSE PREVENTION

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There is a rise in the integration of have to be complied with. Those factors too – like unnecessary
new rules and regulations at local, that do not comply, will be subject patient readmissions – health
national, and international levels. to penalties and enforcement organizations are feeling the
Organizations of all sizes are being actions. At a time when they are pressure to align more closely with
affected by these regulations, which facing penalty threats for other regulatory requirements.

Nearly 29 million
patient records that These figures indicate that there subsequently large amounts of data
have violated HIPAA is a pressing need for regulations are generated. Most organizations
to protect patients, payers, and want to leverage this data to
codes have been providers against security threats that increase returns and decrease risks.
affected, based leave critical information shared by However, achieving both outcomes
on a 2013 Redspin and among these players exposed. independently can be quite
Besides security threats, there are challenging and time-consuming
Breach report12. other issues that mandate the need for organizations.
for strong regulations – Fraud, Waste,
They can leverage technological
and Abuse (FWA). A direct implication
Regulatory compliance is essential innovations developed to comply
of FWA is an increase in healthcare
to not just pass audits, but also stay better with the regulations and
costs, which is borne by the
safe against growing healthcare- gain benefits that they bring. While
patient, payer, or provider. Other
information-related threats complying with rules can help
implications of FWA are resource
stemming from technological organizations avoid penalties and
and time wastage.
integration in nearly all aspects damage to their reputation, it also
of the industry. In 2009, over 800 To prevent this, healthcare provides opportunities to fortify
patient data breaches occurred organizations must align closely and make their structure stronger.
within five months of a new state with the latest regulations. This Organizations that take proactive
law11. Nearly 29 million patient can be quite an expensive deal for steps like employee training,
records that have violated HIPAA most healthcare organizations. The benchmarking, technology
codes have been affected, based on healthcare system in the US sees adoption, and best practices, will
a 2013 Redspin Breach Report12. millions of patients every year and be at an advantage.

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 A study by the Institute of Medicine estimates healthcare
fraud at a massive US$75 billion a year. Increasing litigation and
financial reimbursement models that pay per procedure have
increased wasteful expenditure13.

The top five security challenges in 2014 were identity

management and access control (35%), prevention of data
leakage (30%), cloud computing (30%), encryption during
transit and storage (27%), and regulatory requirements (23%).
The same year, security incidents soared to 60% and costs
related to this rose to an unprecedented 282%14.

Technological imperatives
Here are some of the challenges the healthcare industry faces, technologies that enable healthcare
organizations to overcome them and deliver benefits to providers, payers, and patients, in the area of
regulatory compliance and FWA:

Social media
Challenge information with a wide network protected, on social media, to
and maintain dialogues. The connect and discuss about the
What is an innovative method
healthcare industry too can follow latest in rules and regulations.
of sharing information about
in their footsteps. Employees can get updates
regulatory compliance across a
about ethics, address concerns,
healthcare organization? or answer questions about
Communicate with healthcare
this. Such internal channels
providers about compliance
Solution on social media will not only
and ethics connect people, but also
Organizations in several other provide the opportunity to start
Healthcare organizations can
industries across the globe conversations with each other.
start internal channels, which are
are adopting social media for
communicating important

In 2013, 41% Organizations said they communicate about compliance and

In 2014, 51% ethics topics through internal social media channels15.

In 2013, 45% Organizations said they review public social media and
In 2014, 40% other sources as part of pre-hiring due diligence15.

External Document © 2018 Infosys Limited

Cloud (compliant with
HIPAA)
Challenge the cloud should ensure that the l Data should be located / stored
provider is HIPAA-compliant. If the in the United States of America,
Cloud plays an important role in
provider has essential procedures not in foreign countries where
today’s healthcare industry, which
and policies in place to stay information may be analyzed by
generates large amounts of data.
compliant, organizations can other governments.
Organizations need the cloud to
worry less about security of data
store, retrieve, and share healthcare l Disaster recovery plan in the
either in transit or at rest. What are
and patient information. But how event of a calamity (natural or
the criteria that healthcare leaders
can they ensure that the cloud is man-made)
should look for in cloud providers
secure?
they are using, before initiating a l Operational procedures that
cloud strategy? monitor data round-the-clock
Solution for security threats
A few requirements that HIPAA-
Organizations covered under compliant cloud providers
l Data should be encrypted in
HIPAA and considering moving to should meet:
transit and at rest

External Document © 2018 Infosys Limited

 HIPAA-compliant cloud providers also create incident presented, especially in case of
service providers typically response processes that help them audits. They also have strong
have policies in place to meet take care of security breaches credentials that prove their
different challenges and tackle without much delay. Procedures expertise and are willing to
various situations, like change they follow are documented enter into a Business
management. The service thoroughly and are ready to be Associate Agreement.

The service
providers also create Business Intelligence is that it helps organizations
incident response Emergence of the Affordable Care
reduce healthcare costs and enable
compliance and adherence more
processes that help Act brings twofold mandates that
effectively. It brings big benefits for
them take care of organizations have to align with
– ACA, and existing requirements
patients, too – encourages them
security breaches that are part of the organization’s
to make healthier lifestyle choices,
stay educated about treatment
without much delay. systems. To achieve this, they have
plans, take ownership of their
to streamline all requirements into
health, and more. Below are other
one framework – a task that can be
benefits of integrating gamification
best performed only by business
intelligence tools. The right tools in healthcare:
Most cloud service providers who can positively impact their
are aligned with HIPAA compliance bottom line and experience Educating physicians
offer two factor authentication that patients have.
systems, where both healthcare According to a recent research,
providers and the service providers physicians who used specific
Gamification health-related video games to
have joint access to the stored
information. They also encrypt Besides EHRs, analytics, and big learn were able to deliver better
data (including patient, billing, data, gamification has become an patient care than most others
and payment information) with important element for stakeholders who used traditional methods of
latest techniques to ensure that in organizations. One of the reasons education. A game that the former
information is reasonably protected. gamification has gained importance used consisted of online trivia

External Document © 2018 Infosys Limited

which provided physicians their use these video games to practice also tells them best practices that
scores and ranking in terms of other anytime. It gives them a better edge can get them to their goals faster.
players. Such games can reduce to handle surgical instruments like One such instance of gamification
time physicians spend on learning laparoscopic devices, more precisely. helping patients is Packy and
and fast-track them to delivering Marlon, a game that was developed
better results. Influencing patient adherence to help children manage juvenile
diabetes. It has been successful in
With the help of patient-focused reducing the need for urgent care
Enhancing surgical precision
games, people can set health goals and emergency visits to healthcare
Video games targeted at surgeons for weight loss or gain. These games facilities due to diabetes-related
can help them increase their chart the path that patients take to conditions, by 70%16.
precision and aim. Surgeons can reach their goals more effectively. It

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http://www.pwc.com/gx/en/issues/cyber-security/information-security-survey/industry/
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 NOTES

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NOTES

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