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The Year in Review: Healthcare in 2016

December 12, 2016
The end of the year is a time of reflection, and an opportunity to look forward to the future. Rapid changes have been happening in the healthcare world in general, and in the home healthcare world in particular. Here is a look back at the improvements and innovations that made 2016 one of the more interesting years in recent memory.

Make Healthcare Great Again

The election of Donald Trump to the presidency sent shock waves through the world, including the world of healthcare. On the campaign trail, Trump promised to “repeal and replace” the Affordable Care Act (Obamacare), and to roll back planned Medicaid expansion. Then, almost immediately after the election, Trump appeared to backtrack, suggesting that he would leave key elements of Obamacare alone, especially the provisions forbidding denial of coverage for pre-existing conditions. At the end of the year, it appears that the morning-after fears of a complete healthcare overhaul are less likely to be realized.

Tackling Fraud, Waste and Abuse

High above the political fray, health care policy makers have been hard at work trying to stem the tide of rising health care costs by reining in waste, fraud and abuse in health care, particularly in the home health sphere.

To begin to attack the problem, the federal government rolled out some initiatives designed to screen out potential fraudulent claims prior to money changing hands. Illinois is the only state currently required to do pre-claim review for home health claims.  Implementation in other states has been delayed because of the many problems experienced in Illinois, and with the new administration it is possible this could be rolled back entirely.  The initial plan was met with skepticism, as many stakeholders, including seniors, feared that delivery of needed home health services might be delayed or denied outright. It appears that many of those concerns were valid, which led CMS to delay further implementation for now. 
 
In 2016, the federal government expanded the competitive bidding program for suppliers of durable medical equipment, such as wheelchairs and walkers. To participate in the program, suppliers must now obtain licenses and submit financial documentation demonstrating that they are legitimate businesses

Bring on Data

Sophisticated data mining, referred to broadly as “predictive analytics”, resembles fraud detection techniques already employed by major credit card companies to identify suspicious charges. According to the Centers for Medicaid and Medicare Services (CMS), predictive analytics captured $42 billion in fraudulent claims between 2012 and 2014. Put in other terms, every dollar spent by CMS on “program integrity” resulted in $12.40 saved by averting fraud, waste and abuse.

Hotspotting

This year, big data was engaged not only to identify waste, fraud and abuse, but also to locate areas where money could be spent more wisely. The analytic technique, called “hotspotting”, identifies patients who require more resources on the basis of the complexity of their case, not simply the name of their condition. For example, many patients with diabetes have their disease well under control, expending fewer resources as a result. Other patients, by contrast, cost the system much more because of demographic and social factors that are invisible on a claim form. These patients visit emergency departments more often, and are admitted to the hospital more times per year than well-controlled diabetics. Hotspotting allows caregivers to focus attention on this high-risk population and help care for them at home.

Looking Forward

In 2017 we can anticipate an expansion of the use of big data to allocate healthcare dollars more wisely. Look also for expanding vigilance to root out fraud, waste and abuse. After all, the aspects of Obamacare that president-elect Trump appears to admire are those that promise to cut wasteful spending. In this respect, the healthcare world and the new president are on the same page.



 

Tags: abuse, affordable-care-act, fraud, Healthcare, regulatory, technology, waste

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