The Effects on Healthcare Information Technology Mark Lucido The University of Texas at Dallas HMGT 4321 Mehmet Ayvaci

Payment Model Reform:

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Table of Contents
Introduction .................................................................................................................................................. 5 Payment Model Overview ............................................................................................................................ 5 History of Payment Models .......................................................................................................................... 7 1900-1930 ................................................................................................................................................. 7 1931-1964 ................................................................................................................................................. 8 1965-1994 ................................................................................................................................................. 8 1995-2008 ................................................................................................................................................. 9 2009 Present ........................................................................................................................................ 10 Healthcare Reform and Effects ................................................................................................................... 11 Risk Reduction Overview ............................................................................................................................ 12 Risk Reduction by Payer Type ................................................................................................................. 13 Commercial Payers ............................................................................................................................. 13 Government Payers ............................................................................................................................ 13 Affordable Care Act..................................................................................................................................... 14 Coverage Options.................................................................................................................................... 14 Catastrophic ........................................................................................................................................ 14 Bronze (60%) ....................................................................................................................................... 14 Silver (70%) ......................................................................................................................................... 14 Gold (80%)........................................................................................................................................... 15 Platinum (90%) .................................................................................................................................... 15 Payment Models ..................................................................................................................................... 15 Macroeconomic Effects .......................................................................................................................... 17 Providers ............................................................................................................................................. 18 Vendors ............................................................................................................................................... 19 Healthcare Revenue Cycle .......................................................................................................................... 19 Revenue Cycle Management ...................................................................................................................... 20 Patient Access ......................................................................................................................................... 21 Patient Encounter ................................................................................................................................... 22 Billing Cycle/Payment Management ....................................................................................................... 22 A/R Management .................................................................................................................................... 23

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Collections Management ........................................................................................................................ 23 Conclusion ................................................................................................................................................... 24 Works Cited ................................................................................................................................................. 25

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Introduction
Since the introduction of Medicare in the mid-Sixties, healthcare costs in the United States have risen exponentially. In the decades that followed, each subsequent legislative action brings with it the promise of lower costs beginning with the passage of the HMO Act in the Seventies. Costs have continued to escalate; now upwards of $3 Trillion dollars, healthcare spending comprises nearly 18% of GDP. Now with implementation of the Affordable Care Act in full swing, the introduction of new payment models promises to change the incentives that drive healthcare costs and place the emphasis on quality and outcomes. These payment models will come at a price to providers however both in terms of risk and the technology outlay to manage day-to-day operations.

Payment Model Overview

There are a variety of payment models in use today in the United States. Most models fall under one of two categories: Retrospective, or Prospective. Retrospective payment models reimburse a provider after services have been rendered at the providers prevailing rates (Casto and Layman). Payment models that fall under this category include: Cost based reimburses the provider based on providers cost Fee For Service reimburses the provider based on a fee schedule or discounted fee schedule

Prospective payment models on the other hand, compensate the provider based on pre-established rates (Casto and Layman). Payment models in this category include: Per Diem/Per Case compensated on a per-day flat rate or on average resource levels for a particular diagnosis with variations for levels of severity

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Value Based Purchasing (VBP)/Pay For Performance (P4P) As the name implies, this payment arrangement rewards providers through incentive payments based on certain predetermined quality measures and patient outcomes. As opposed to some payment models that incent on cost reductions, VBP/P4P incents providers to improve patient outcomes thus delivering value for the healthcare dollar hence the name.

Episode of Care also known as bundled payment. This compensation method remunerates a group of providers for a single patients episode of care which spans the time horizon from initial diagnosis to post-acute rehabilitation

A newer trend in healthcare reform known as Population Health is beginning to gather momentum. Although this isnt a payment model per se, we chose to categorize a few models that technically fall under the Prospective Payment category, separately under Population Health for this research to emphasize the shift away from the per-patient reimbursement methods of our past. Under Population Health, the reimbursement rates are pre-negotiated based on a variety of variables such as quality, cost, and average care utilization however the underlying basis for remuneration is a group or population of insured members assigned to the provider. Shared Savings Bonus payments to ACO providers that incent coordination of care and cost reduction across a population of patients and healthcare services by meeting predetermined cost and quality measures Capitation a predetermined compensation amount paid to an individual provider or group of providers based on a flat per member per month arrangement for the number of covered members assigned to that provider

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History of Payment Models

To better put these various payment models into perspective, a historical review of the issuing legislature is important to understand. Exhibit 1 provides a graphical overview:

Retrospective Cost Reimbursement Fee For Service Per Diem/Per Case P4P

Prospective Episode Capitation

1900 3/23/2010 PPACA - Obamacare

2050

1929 Baylor Health Plan (Blue Cross)

1930 Blue Shield

1965 Medicare

1942 Stabilization Act of 1942 Employer Sponsored Health Insurance

4/20/1983 S.S. Amendments of 1983 Prospective Payments

12/8/2003 Medicare Prescription Drug, Improvement, and Modernization Act

Exhibit 1: Payment Model and Legislative Timeline

1900-1930
Prior to the 1920s, the medical field had very low overhead based on a low technology curve and the comparatively small amount of medical knowledge for the time. Because of these factors, a physicians only real cost was their time therefore payments to providers were for their cost. This changed starting in 1929 however when Baylor Hospital in Dallas, Texas developed the first form of Hospital insurance for Texas teachers which would become known as Blue Cross. The following year, Blue Shield plans began to emerge and the Health Insurance market was established which would form the basis for our existing system of misaligned incentives associated with third-party payers.

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1931-1964
The next significant development in Healthcare Reimbursement came during World War II when America was forced to make important economic tradeoff in both raw materials and labor. Specifically, on October 2, 1942, in an attempt to curve inflationary pressures, President Franklin D. Roosevelt enacted the Stabilization Act of 1942 which established wage price controls or wage ceilings. As is common with most attempts of Government to intervene, the unintended consequences became what we know and love today as Employer Sponsored Health Insurance. As our medical knowledge and technology grew, so did a providers cost curve. Providers fee schedules were implemented to reflect these changes and insurance companies reimbursed based on these fee schedules or variants of them discounted however for what was usual and customary within a region.

1965-1994
The 1960s brought about many social changes in American culture which extended into our politics and healthcare system. On July 30, 1965, President Lyndon Johnson signed into law the Medicare bill which would dramatically change the landscape of the American Healthcare system forever. From this point forward, healthcare spending in the United States would grow exponentially. The introduction of Medicare Insurance is important to note in a review of reimbursement models because since its introduction, Medicare not only serves as the gold standard in how commercial insurance companies reimburse providers but also the Medicare reimbursement affects Commercial payers through Hospital cost-shifting. When Medicare was first implemented, the system reimbursed at the prevailing Fee for Service rates. In the years and decades that followed there would be continued legislative attempts at controlling costs by controlling reimbursement. The first of these came on December 29, 1973 with the enactment of the

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Health Maintenance Organization Act of 1973. Although this regulation didnt directly affect the way providers were remunerated, it is important to mention here because the HMO model of Managed Care serves as the predecessor for our current ACO model which does have remuneration tied to it. From a reimbursement perspective, the more important legislation to note is the Social Security Amendments of 1983. This law became the milestone change in provider reimbursement through the creation of the Prospective Payment system which effectively eliminated a direct Cost-Based or Fee for Service reimbursement in exchange for one based on average costs across providers within a similar grouping. The other milestone event from this period that is important to mention in this research is the Health Security Act of 1993. The proposals originally offered by the Clinton Administration never actually passed to become law however, similar to the HMO Act of 1973, many of the elements from this reform were used as the foundation for the Patient Protection and Affordable Care Act.

1995-2008
The 1990s also saw another dramatic change in Healthcare with the passage of the Health Insurance Portability and Accountability Act in 1996. As part of this act, a demonstration project was approved for the Archer Medical Savings Account. This demonstration project however would not become mainstream until December 8, 2003 with the enactment of The Medicare Prescription Drug, Improvement, and Modernization Act which formalized the concept of Consumer Driven Health Care through the creation of the Health Savings Account (HSA) (United States Congress). As defined by the IRS, a Health Savings Account is a tax-exempt trust or custodial account that you set up with a qualified HSA trustee to pay or reimburse certain medical expenses you incur (U.S. Department of the Treasury, Internal Revenue Service). Funds can be directly contributed to an HSA

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either by you, on your behalf, or by your employer. Tax benefits apply provided they are used for qualified medical expenses as outlined by the IRS. All contributions by you, on your behalf, or by your employer are exempt from income taxes and excluded from Gross Income. Contributions are subject to annual contribution limits to qualify for deductions. For 2013, the maximum allowable amount is $3,250 for single coverage and $6,450 for family coverage. Interest and earnings on the assets in the account grow tax free. Funds remain in the account for future years. You own the account and account holdings; therefore the account is portable or transferrable if you should change jobs or employers. The importance of the HSA to Healthcare Reimbursement is that it was the first dramatic shift away from a provider-driven consumption and a third-party-payer reimbursement system to one of patient accountability. It places healthcare utilization in the hands of the consumer to determine their rate of consumption through rational decision making. It also creates more risk for the provider to collect a greater portion of their reimbursement directly from the consumer who is often stretched thin and is not accustomed to planning ahead for catastrophic events. In addition to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the 2005 Deficit Reduction Act established Quality Reporting standards that would later be built upon for Reimbursement Models adopted under the PPACA in 2010.

2009 Present
Fast forward our discussion now to March 23, 2010 and the passage of The Patient Protection and Affordable Care Act (PPACA). With the exception of Medicare creation in 1965, all subsequent legislature since has accomplished only small changes in healthcare primarily around reimbursement. That is until The Affordable Care Act, which is a sweeping overhaul to address access, coverage and quality of coverage and care. Additionally, there are both direct and indirect effects on provider remuneration. Briefly postponing the indirect effects for a moment, the direct reimbursement changes

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outlined in the legislature include the creation of Accountable Care Organizations, CMS demonstration project for the Shared Savings Program and the goals for Value Based Purchasing and Bundled Payments.

Healthcare Reform and Effects

Just as weve seen with the establishment of price controls in 1942, Government regulations usually involve some form of unintended consequences and considering the overarching goals of the PPACA, there are bound to be many. The three primary goals accomplished by The Affordable Care Act are: Improve Quality and Affordability of Coverage Increased Access and the role of Government programs Improved Quality of Healthcare Services

In addition to the direct reimbursement changes previously outlined, there are indirect effects on provider remuneration through the creation of inexpensive coverage options to expand covered lives. Many of those lives will be covered under CDHP options in the exchanges which will result in significant upside risk for providers to collect directly from patients.

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Risk Reduction Overview

Traditionally, the idea of insurance is to reduce the risk of an unexpected catastrophic event. By collecting variable premiums from many individuals, an insurance company is able to spread that risk across large groups of people. In our current system of reimbursement, provider remuneration comes from one of two sources; Government Insurers or Commercial insurers who assume nearly all the risk while the provider and patient or insured assumes very little risk. Over the years, with each change in reimbursement, whether direct or indirect, the balance of risk is shifted away from the insurer and onto both the provider and patient as illustrated in Exhibit 2 (Fleming, Forney W. MD, MBA).

Exhibit 2: Payment Models and Risk Transfer Over Time

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Risk Reduction by Payer Type

Commercial Payers Traditionally, Commercial payers have been able to shift the risk onto their members by increasing some combination of their premiums, copayments, deductibles or coverage limits. With the introduction of the Health Savings Account, an even greater portion of risk has been shifted onto patients directly through a combination of higher first-dollar deductibles, lower coverage limits and higher premiums. As this risk is shifted to patients, an equal amount of risk is shifted to providers in that it requires greater administrative processing and tools to collect directly from patients. Many of the providers Practice Management and Patient Accounting systems do not incorporate the necessary tools to verify coverage, verify propensity to pay and collect payment directly from patients therefore providers must rely on third-party vendors to provide bolt-on solutions. Government Payers Risk reduction for Government payers is significantly different from that of Commercial payers. Government payers are unable to simply raise prices on consumers as their overarching goal is a fair and equitable entitlement for all citizens. This leaves only the provider community from which to choose whom to shift the costs to. Traditionally, this has been managed by changing the payment models and how providers are reimbursed and with each change brings with it more risk assumed by the provider. This trend continues with the passage of The Affordable Care Act where three new payment models will be adopted across the industry. The legislation doesnt stop there however. With the introduction of the Insurance Exchanges and the five coverage options, many of the lower cost plans offered will be Consumer Driven, high-deductible plans. A large influx of previously uninsured patients will be entering the system who is constrained by income limitations. There is a strong probability that a substantial portion of the plans sold through the exchanges to the newly insured will fall under CDHPs creating a

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significant percentage of provider revenue that will need to be collected directly from patients who are not accustomed to planning for catastrophic events. In addition, as has been discussed in the media recently, many existing plans do not meet the minimum coverage requirements outlined in the PPACA due to their low cost. Due to the popularity and low-cost nature of CDHPs, there is a high likelihood those plans will be replaced with CDHPs further compounding the risk for providers.

Affordable Care Act

Coverage Options
There are 5 distinct health plan options offered through the Insurance Exchanges each ranging in premium costs and coverage levels based on the actuarial value of the plan (United States Congress). Catastrophic Catastrophic plans are the least costly of all plans offered in the exchanges however these plans are limited to only eligible individuals 29 and under or qualify for hardship exemptions. Plans in this level provide coverage that is designed to provide benefits that are actuarially equivalent to less than 60 percent of the full actuarial value of the benefits provided under the plan. Bronze (60%) Bronze plans are the lowest premium cost of the standard plan options but the highest cost for total out of pocket expense. Plans in this level provide coverage that is designed to provide benefits that are actuarially equivalent to 60 percent of the full actuarial value of the benefits provided under the plan. Silver (70%) Silver plans are the next lowest premium cost of the standard plan options with the next highest cost for total out of pocket expense. These plans provide coverage that is designed to provide benefits that are actuarially equivalent to 70 percent of the full actuarial value of the benefits provided under the plan.

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Gold (80%) Gold plans are the next most costly in premiums of the standard plan options with the next lowest cost for total out of pocket expense of all plans. These plans provide coverage that is designed to provide benefits that are actuarially equivalent to 80 percent of the full actuarial value of the benefits provided under the plan. Platinum (90%) The most costly in premiums of all plan options, however offer the lowest total cost for out of pocket expense. Platinum plans provide coverage that is designed to provide benefits that are actuarially equivalent to 90 percent of the full actuarial value of the benefits provided under the plan.

Payment Models
As previously mentioned, there are three distinct payment models introduced in the Affordable Care Act that should be considered: 1) Shared Savings Program, 2) Value-Based Purchasing and 3) Bundled Payments. Following is a closer analysis of each: Shared Savings Program - The CMS Shared Savings Program provides incentive bonus payments to ACOs based on their providers combined ability to meet predetermined cost reductions and quality performance standards (American College of Physicians) (RTI International). While this model attempts to realign incentives within the industry to facilitate care coordination, in order for providers to benefit from this model a clear and solid understanding of their colleagues performance is important when making care coordination decisions in order to maximize revenue potential. To participate, providers must organize under an ACO which is a group of providers and suppliers of services that work together to coordinate care for Medicare FFS patients. ACOs must meet all eligibility and program requirements and must serve at least 5,000 Medicare FFS patients and agree to participate for three years and cannot participate in any other shared savings program. Standard FFS payment arrangements continue however

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benchmarks are established that ACOs agree to perform against. There are 2 distinct benchmark models: 1) One-sided in which sharing savings, but not losses for the entire term of the first agreement and 2) two-sided model where both savings and losses for the entire term are shared. Under both models, an ACO must meet quality standards, achieve savings and also meet or exceed a Minimum Savings Rate. Savings are calculated based on the ACO quality score. There are 33 quality measures across 4 domains: 1) Patient/caregiver experiences (7 measures), 2) Care coordination/patient safety (6 measures), 3) Preventive Health (8 measures), 4) At-risk populations (diabetes, hypertension, Ischemic Vascular Disease, Heart failure, Coronary Artery Disease). Quality measures will be reported through a combination of CMS claims and administrative data, the ACO GPRO web interface for clinical quality measure reporting, and patient experience of care surveys. Value-based Purchasing Hospital providers who participate in the VBP incentive program will receive bonus incentive payments for delivering quality of care to Medicare patients. For participation in the program, providers must agree to an annual reduction in base operating DRGs, as illustrated in Exhibit 3, in order to fund the incentive payments (Centers for Medicare and Medicaid Services). To determine payment, hospitals will be measured on two domains, 1) Clinical Process of Care and 2) Patient Experience of care starting with a benchmarking period followed by subsequent performance periods. To measure hospital providers, CMS will use a combination of claims data and thirteen Clinical Process of Care measures which were selected from Hospital Inpatient Quality Reporting Program for Fiscal Year 2013. Subsequent Years 2.00%

FY 2013 DRG % Reduction 1.00%

FY 2014 1.25%

FY 2015 1.50%

FY 2016 1.75%

FY 2017 2.00%

Exhibit 3: Base Operating DRG Reduction Percentages

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Bundled Payments According to the CMS website, there are four models being tested for Bundled Payments (Centers for Medicare and Medicaid Services). They vary in nature from retrospective based to prospective based. Model 1 emphasizes the Acute Inpatient setting with a discounted prospective rate during the inpatient stay and separate payments to individual physicians. Providers are permitted to share gains under certain circumstances however. Model 2 has a retrospective basis that reconciles the hospitals costs against a target price for the particular episode of care. A single bundled payment is issued for the entire episode of care based on up to 48 different clinical conditions selected by participants. Model 3 emphasizes the post-acute episode of care and is triggered by an acute care discharge. A singled bundled payment is issued for the entire rehabilitation period based on up to 48 different clinical conditions selected by participants. Model 4 is a bundled payment that applies to all services furnished during the entire episode for an inpatient stay only. All physicians must submit zero dollar claims and will subsequently be paid by the hospital from the bundled payment based on up to 48 different clinical conditions selected by the participants.

Macroeconomic Effects
In order to understand what technology is affected by new payment models, one must first understand the macroeconomic impacts. Patients will assume new risks of higher prices; however they will have little influence over the technology other than the sheer increase in patient volumes coming from increased access. Therefore in our research we only considered the impact to certain groups such as to Providers and the impacts to software Vendors.

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Providers Providers are the most impacted by payment model reform for many reasons. First, they are assuming new risks of payment based on patient populations with little previous experience in actuarially calculating that risk. There will soon be demand to develop solutions that assist with these actuarial calculations. Secondly, providers are assuming more financial risk associated with a change in their payer mix; a greater portion of their revenue is coming now from patients as opposed to third-party payers. Stronger processes and solutions will be needed to reduce this risk through upfront eligibility and verification checking in addition to propensity to pay, upfront patient collections and payment plan solutions. Thirdly, when sharing revenue with multiple providers, a portion of that revenue is at risk based on the performance of other providers whom you have no control over. Solutions in the clinical setting will be needed to help identify and match high-performing providers/specialists in close proximity to the patients they serve when referring patients. Next, there is the risk associated with the technological constraints of these new models. Providers are increasingly becoming reliant on the vendor community to offer solutions to the new models which will require a thorough understanding of quality reporting and the types of data, mostly clinical in nature, needed to facilitate reimbursement while much of that is unknown. Also there are currently Contract Management systems that are not built to support these new contract types. Contract Management enables a provider to not only store the providers contracts from the various commercial payers, but also model what if scenarios as they approach contract renegotiations. These systems will have to be modified. Lastly, there has been a significant trend over the last few years to acquire and consolidate among providers. Physician practices have been consolidating while others have been acquired by hospitals to form larger ACOs. Each acquisition or consolidation brings with it the technical challenge of integration and interoperability. Solutions of all type will be needed to reduce this integration curve.

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Vendors As a result of the shifts in payment models, vendors too have been affected indirectly for many of the same reasons providers have. First, due to the bolt-on nature of the industry, many of the solutions are fragmented, not only across the revenue cycle but also between physicians and hospitals. There are many vendors who specialize serving the hospital market and others who specialize serving the physician market. As provider acquisitions and consolidations continue, this is creating an environment where some vendors are becoming disintermediated forcing them to make defensive moves into other verticals (vertical integration) or acquire and consolidate amongst themselves forcing solution integration. In both cases, this serves as a detractor from innovation and organic growth in solutions at a time when innovation and integration are both at a premium.

Healthcare Revenue Cycle

Considering most healthcare IT investments emphasize the billing process, the industry has created specific acronyms and terminology to describe this and communicate effectively. As illustrated in Exhibit 4, the Healthcare Revenue Cycle describes the cyclical process surrounding reimbursement for a patient encounter (Lucido, Mark). Since provider reimbursement and payment models are the core focus of reform, it is appropriate to understand the Revenue Cycle and Revenue Cycle Management to understand what systems are affected. The process often begins prior to a patients arrival, also called Patient Access, proceeds with the patient encounter and treatment, is followed by the billing cycle and concludes with payment and Accounts Receivables management.

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Exhibit 4: The Healthcare Revenue Cycle The Revenue Cycle is mostly similar between a physicians practice and a hospital however there are slight differences when comparing the two. For example, in the physicians practice, these tasks are consolidated across a select few individuals and handled within the four walls of the practice. In larger multi-physician/multi-office practices and hospitals, these tasks are often departmentalized due to the volume of patients and greater risk of revenue leakage.

Revenue Cycle Management

Administrative software in the healthcare environment is still predominantly a series of bolt-on solutions to the core Practice Management or Health Information System. Bolt-on solutions solve for specific niche problems and because of this, a more horizontal view of the Revenue Cycle, as illustrated

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in Exhibit 5, is necessary which allows Healthcare Administrators to consider each segment more granularly which subsequently enables deeper workflow analysis (Lucido, Mark).

Exhibit 5: Hospital Revenue Cycle Management

Patient Access
Patient Access is the providers process of Patient Intake which also includes pre-intake activities. Although these processes vary slightly between provider types, for the most part they are similar. Scheduling and pre-registration/pre-arrival tasks emphasize scheduling, benefit verification and preauthorization while registration and check-in serve as a stop-gap for any missed activities in scheduling and pre-registration. As a patient is admitted or checked-in to an office, there might be a few patient collection activities or establishment of a payment plan. This vertical is a high area of impact for payment reform.

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Patient Encounter
More recently because of healthcare reform, healthcare administrators are considering clinical tasks within the providers revenue cycle primarily in order to share clinical information which is becoming a required interdependency to making more sophisticated reimbursement decisions. This vertical is a medium to high area of impact for payment reform for several reasons. First, new quality reporting standards are required which is dependent on information generated during the patient encounter. Secondly, there is a greater need to share this information across the revenue cycle creating a strong demand for integration and new ways to use this information.

Billing Cycle/Payment Management

The most fragmented and sophisticated of the revenue cycle segments in terms of bolt-on solutions, the billing cycle encompasses all tasks associated with coding, claims processing, claim validation and payment tracking and can often include 7 or more different vendors servicing a single provider type. The process begins with charge entry and validates correct coding with ancillary solutions that audit coding practices to ensure revenue maximization. Once a patient encounter has been coded, a claim is often dropped from the appropriate patient accounting system and scrubbed with HIPAA and payer edits to ensure a high acceptance and first-pass payment by the payer. Once a claim has been submitted, automated processes routinely check the payment status and retrieve payment information to automatically post into the patient accounting system. More recently, comparative analytics is becoming more important to understand a providers performance against their peers of equivalent characteristics. Considering the solutions in this vertical are all developed to service a Fee For Service payment model and the trend is to move away from Fee For Service, this vertical is highly impacted by payment reform.

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A/R Management
The A/R Management segment of a providers revenue cycle is most prominent in large physicians offices and hospitals where greater revenue leakage is at risk and departmentalization is necessary to reduce that risk. Most notably, provider types of this magnitude incorporate contract management solutions into their revenue cycle so they can evaluate upcoming contract renegotiations and underpayment against the contract. Denials Management is also an important component for this segment to identify claims that require correction and resubmittal for reclamation of reimbursements that are rightfully owed the provider. When these solutions are not integrated into a providers revenue cycle, a greater portion of revenue is written off from receivables. Contract Management solutions are highly impacted by payment reform and will need to be redesigned to service new population health based payment models.

Collections Management
The last segment in the revenue cycle, Collections Management emphasizes the billing, collections and write-off process after remuneration from all responsible insurance companies. Patient direct billing usually involves frequent communications that are automated and timed throughout the revenue cycle. This implies a tightly integrated set of solutions to coordinate letters and statements, especially when a commitment to pay has been secured by the patient and a payment plan has been established. If a provider does not maintain sufficient staffing for internal collections, outsourcing to a third-party collections vendor is required which further demands integration externally with the vendor. Lastly, if a payment commitment cannot be secured from a patient, an automated and thorough write-off and charity process is necessary. This vertical is a medium to high area of impact for payment reform as there will be greater demand for charity screening to avoid fraud, and providers will emphasize a more efficient and stringent post-encounter patient communications and collection process.

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Conclusion
Over the last decade, the Healthcare IT field has seen a host of unlikely players entering the Revenue Cycle segment. In 2007, MedAssets, a leader in Group Purchasing, began its expansion with the acquisition of XactiMed for Claims Processing and later Accuro, a leader in Contract Management solutions. In 2008, Experian, a leader in Consumer Credit Scoring, acquired SearchAmerica, a leader in Healthcare Skip Tracing followed by its acquisition of Medical Present Value for Revenue Cycle Management solutions in 2011 and most recently the acquisition of Passport Healthcare an even more significant leader in Revenue Cycle Patient Access and Clearinghouse solutions. In 2011, Trizetto, a leader in payer membership and claim adjudication systems, acquired Gateway EDI followed by its acquisition of ClaimLogic in 2012 expanding its footprint into the Provider Revenue Cycle market. These are just a few of the most substantial consolidations occurring in the industry to address not only payment reform but more importantly innovative ways to consolidate a providers workflow processes for gains in efficiency, economies of scale and cash flow. While consolidation creates a strong competitive environment among vendors, the benefits to providers are substantial. Our Healthcare system may be the most expensive in the world and is fraught with waste, fraud and abuse resulting in low quality and outcomes. Payment reform addresses many of these problems, but at the expense of the provider. Ultimately, Providers in the end maintain the knowledge and skills required to treat, comfort and cure. If we remove all profit and marginalize the provider, there remains no incentive to practice medicine.

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Works Cited
American College of Physicians. "Accountable Care Organizations (ACOs)." n.d. PDF. 12 2013. <http://www.acponline.org/advocacy/where_we_stand/assets/aco.pdf>. Casto, Anne B. and Elizabeth Layman. Principals of Healthcare Reimbursement. Chicago: American Health Information Management Associations, 2006. Web. Centers for Medicare and Medicaid Services. "Bundled Payments for Care Improvement (BPCI) Initiative: General Information." Centers for Medicare and Medicaid Services, 2013. Web Page. 7 12 2013. <http://innovation.cms.gov/initiatives/bundled-payments/>. . "Frequently Asked Questions: Hospital Value-Based Purchasing Program." 2012. PDF. 7 12 2013. <http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospitalvalue-based-purchasing/Downloads/FY-2013-Program-Frequently-Asked-Questions-aboutHospital-VBP-3-9-12.pdf>. Fleming, Forney W. MD, MBA. "The American Healthcare System: Healthcare Payment Reform." Richardson: University of Texas at Dallas, 2012. Lucido, Mark. "Hospital Revenue Cycle Management." Richardson: Availity, LLC, 2012. RTI International. "Accountable Care Organization 2013 ." Baltimore: Centers for Medicare and Medicaid Services, 2012. PDF. U.S. Department of the Treasury, Internal Revenue Service. "Health Savings Accounts and Other TaxFavored Health Plans." IRS Publication 969. Washington: GPO, 2011. <http://www.irs.gov/pub/irs-pdf/p969.pdf >. United States Congress. "Medicare Prescription Drug, Improvement, and Modernization Act of 2003." United States Public Law. Washington: GPO, 2003. <http://www.gpo.gov/fdsys/pkg/PLAW108publ173/pdf/PLAW-108publ173.pdf>. . "Patient Protection and Affordable Care Act." United States Public Law. Washington: GPO, 2010.

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