Creating a “Clinancial” Model: Bridging the Gap Between Clinical and Financial

Posted on July 25, 2018 I Written By

The following is a guest blog post by David Dyke, VP Product Management at Ciox.

Healthcare at a broad level divides its business into two types of work: The clinical, and the financial. The groups that serve each effort are traditionally siloed. Doctors and nurses, for instance, focus on the clinical health of their patients.  Clinical pathways define the day: What is the plan of care? How do we improve the quality of care? How do we deliver the right course of treatment for this patient in the time we have, based on all of their individual variables?  And how do we apply that broadly to entire conditions and communities?

Separate from clinical practices are the equal and opposite financial forces within the business of healthcare. Healthcare CFOs, for example, are chartered with caring for the financial health of their organization.  Financial pathways rule the day: Ensuring administrative processes, patient experience and strategic plans align to the best operational outcomes.  How can we survive until tomorrow if reimbursement, risk, denials, cash, collections, debt and financing issues are not addressed today?

Yet, for all the division of labor and effort in the healthcare space, the reality is that the two sides of the business exist as the heads and tails of the same coin. When a patient walks into a healthcare provider’s office, clinical and financial pathways alike are opened up, and their relationship is far less siloed and far more symbiotic than the current model of care reflects. What if we approached these two traditionally separate parts of the healthcare system as two halves of the same? How do we break down the paradigm that these are two separate pathways? How do we connect the clinical and the financial?

Perhaps what we need is a new word; one that better reflects the concurrent pathways in healthcare. Maybe we are not laboring along two separate clinical and financial pathways, but a single “Clinancial” pathway.

cli·nan·cial (adjective)

Relating to both clinical and financial pathways in healthcare.

As the cost model in healthcare has shifted, the patient’s interest level in the financial side of the healthcare continuum has shifted dramatically. Health plans are increasingly prescriptive in their services.  Whether specifically defining limitations on choices, options, and access to specific providers, or implicitly influencing behavior through out-of-pocket cost motivators, the financial aspects of healthcare are increasingly top-of-mind.

Even for patients, the Clinancial pathway to care is here already. It’s not just simple decisions that intersect financial and clinical pathways. These meet again at the intersection of in-network, copays and out of pocket expenses, year to date costs, and whether a patient has a flex plan. All of these financial decisions have bearing on the patient’s end clinical pathway and could be better understood earlier in the process by those whose traditional focus is strictly clinical.

What clinical choices would be different if the outlook included financial realities and variables. What choices would be made in a Clinancial model? Similarly, what financial choices could be made with better clinical information?

From the way we code clinical services to the way we seek to manage reimbursement activities and claims, from denials to audits and at every point where Clinancial lines cross, we in healthcare have an opportunity to improve both our patient experiences and our bottom lines by better rolling together our clinical and financial information for all involved.

If case managers aren’t approaching patient care from the perspective of preventing denials, then they are missing a huge opportunity to improve not only the patient experience and clinical outcomes but also the organization’s ability to do the same thing systematically again tomorrow, and the day after that.

The landscape is continuously changing. Health Insurance Plan Designs vary widely today, and will have more variabity tomorrow. Medical guidelines are always evolving too. The barriers to adopting Clinical Guidelines are well documented, it’s most often a factor of information or population overload.  For example, in 2017 the guidelines for High Blood Pressure changed, effectively “giving” High Blood Pressure to 30 million more Americans.  It’s a business model where we need to know how to be continuously adaptive, how we are engaging with all parties involved, from the healthcare recipient to the insurers, and building a trust network around risk. Yet we traditionally do not evolve, or change, or update ourselves particularly efficiently.

Some organizations are doing this better than others – integrating even just their reporting structure. They ask themselves questions like “Are medical records part of the clinical or the financial operations of a hospital?”

Groups that see the shift have moved within their organizations to form teams with names like ‘Revenue Integrity’, and because of those new delineations they are more closely aligning the “how” and “why” of the clinical process with the “what” and “when” of the financial workflows. And as they have shifted into Revenue Integrity teams, they are looking at things more holistically to uncover key findings. Much like an integrated care team takes a holistic look at a patient, their direct conditions and their social situations. These integrated Clinancial teams can find connections between coding workflows and reimbursement speed, and can design and implement Clinancial Workflows to measure and improve their outcomes.

No matter the structure, integrated Clinancial Teams are doing three things well: They communicate regularly across the siloes, they collaborate across teams on opportunities that affect both the clinical and financial aspects of the business, and they share data, findings and ideas.

The victories are twofold: Organizations have a chance within a Clinancial model to improve patient satisfaction and outcomes, while at the same time better flowing clinical data through into reimbursement. We have entered a new financial reality where the patient’s experience has an increasingly material impact on a provider’s bottom line. By unifying around Clinancial Pathways, we can make strides to improve patient outcomes and experiences, while at the same time gaining operational efficiencies to drive margin improvement now, when we need it most.

And all we needed to do was invent a new word for it.  #easy

About Ciox
Ciox is a health technology company working to solve the clinical data illiquidity challenge by providing transparency across the healthcare ecosystem and helping clients manage disparate medical records and a proud sponsor of Healthcare Scene. When stakeholders do not have timely access to the complete clinical picture of patients, critical decisions about patient care, medical outcomes research, disease prevention, reimbursement, and payments are sub-optimized. Ciox’s scale, expertise, expansive provider network and industry leading technology platform make it the most reliable clinical data company in the US. Through its standards based technology platform, HealthSource, Ciox helps clients securely and consistently solve the last mile challenges in clinical interoperability.  Learn more about Ciox’s technology and solutions by visiting www.ciox.com