Jobs in Health Informatics Are Becoming Plentiful

The way most doctors and health care professionals do their jobs has hardly changed over the past thirty to forty years. Contrast this with the enormous changes in, say, transport, manufacturing and telecommunications!

But hang on to your stethoscopes! Despite the fact that some doctors still have their heads buried firmly in the sand, the winds of change are blowing and most doctors are now using electronic communication technologies, if not enthusiastically, then at least regularly. The combination of technological change, the demands of business and the rise of consumerism are causing radical changes in the way healthcare is practiced around the world. Health Informatics experts are poised to revolutionize health practices by implementing the enormous changes needed in the health system, that have already occurred in other industries. These professionals typically have backgrounds in either healthcare, such as nurses and doctors, or information technology, and then receive cross-training so as to be able to work across both areas in the newly emerging electronic health systems of today and tomorrow.

The changes in healthcare will be the 21st century’s equivalent of the public health initiatives of sanitation and nutrition which revolutionized health care in the twentieth century. Integration of online technologies will see doctors and patients working together on electronic health records with patients having much more say in their treatments. The development of widely available broadband networks and video mail will bring electronic health into everyone’s home. Patients and doctors will work collaboratively on the internet as parters with the agreed mutual objective of health improvement.

Look at how fast the average adolescent can send messages on their phone – gone are the days when a telephone was just an audio device. The way we interact with communication systems is radically changing the way we behave and think in ways that are impossible to predict. And the computer literate children of today – the millenials and succeeding generations – will drive these changes. How many doctors want to interact with patients using instant messaging? Not many today, but the doctors of the millennial generation will probably think nothing of this approach. And these sorts of systems will be developed by experts who have been trained in health informatics, and who understand how to apply information technologies of all sorts to change and improve the way that we deliver patient care.

Knowledge has never been as important – and as accessible – as it is today.

Technology, and in particular, Internet technology, is transforming the academic medical landscape. A large number of institutions are moving to digital-only radiography and full electronic medical records. I no longer write any notes on paper – all my clinical work is electronically recorded. Residents now come to rounds armed with a vast array of reference information stored in hand-held personal digital assistants. The iPod is now a platform for lectures presented either as “podcasts” and “videocasts” and is also used as a mobile x-ray image viewer. Continuing medical education is increasingly available through the Internet. The digital revolution has greatly altered how academic health systems pursue education, research, and clinical care, and this is spreading through the rest of the health system.

The provision of clinical care is changing rapidly as health informatics technologies become increasingly used and accepted, with a move away from episodic care to concentrating on continuity of care, especially for patients with chronic disease who will create the greatest disease burden in the future. Care is gradually moving away from a focus on the service provider to that of the informed patient and from an individual approach to treatment to a team approach. Increasingly, less focus is placed on treating the illness and more is placed on wellness promotion and illness prevention: the model of the”Information Age care” first described by Dr Tom Ferguson MD. To move to this future of information age healthcare, the availability and use of information must be strengthened to facilitate changes in health service delivery, and a much greater focus must be placed on developing and refining the information technology infrastructure, and on training experts in health informatics who can create and develop the electronic clinical environments needed by both patients and doctors.

This is all occurring at a time of difficulty in our economy, but America is known for its capacity to thrive on challenges, and to rapidly change its industrial practices in the face of adversity. The health system needs large numbers of experts in health informatics, and training programs are being rapidly expanded. The University of California Davis Health Informatics graduate program, for instance, has doubled the number of Masters Health Informatics students in one year, and has enrolled 76 new students in a fully online Health Informatics certificate program within the last three months. The Obama Administration is putting billions of dollars into health informatics implementation and training with funds from the American Recovery and Reinvestment Act and increasing numbers of jobs in health informatics are already appearing. The jobs website, CareerBuilder has just marked health informatics as it’s number one emerging industry job opportunity, and is highlighting a number of jobs in areas as diverse as telemedicine, nursing information officers, clinical information technology liaisons, programmers, analysts, data integration experts and health service managers.

Business Analyst and Health Care Domain

Health Care is a very important industry that contributes to the growing world economy. Health Care and Pharmaceuticals sector have a certain way of working that is essentially different from the other sectors. There are a lot of norms and regulations set by governing authorities that are to be followed by health care professionals. This applies to a Business Analyst too, who has projects dealing with this domain. The basic principle of success of a Business Analyst (BA) is that he needs the right balance of information and technical knowhow to successfully complete his job in any sector. This dictum applies to the Health Care sector as well.

A BA should be well versed with the information that is needed for a professional to work in the Health care domain. Since he has to analyze the processes and then help in the development of essential software for the projects in the health care and pharmaceuticals sector, he needs to have both – the information required of a Health Care professional and the technical knowledge required for the establishment of software designed for this sector. With the adequate knowledge of both these pre-requisites, a BA can be confident of carrying out his job to the client’s satisfaction.

As is known to one and all, health care sector deals with clinics, hospitals, laboratories, medical tests etc. since these all lead to the safety of human life, health care professionals including Business Analysts need to be aware of every norm and have a complete know-how of how things work in the sector. The knowledge of the working of this sector, equipped with good sound knowledge of the techniques used in hospitals or laboratories or the concerned place of work, will make a Business Analyst in this domain stand in good stead. As mentioned above, compliance with many norms and regulations have to be taken care of. These usually pertain to legal, forensic medicine, political, social, and even economic ambits. Such care is essential since it is obvious that the end results of completed projects deal with human lives and so the consequences, if gone awry, can be fatal to life itself, not just loss of money.

Hence, technical knowledge should be sound and a complete know how of technical guidelines, processes, running and working of software packages, is quite essential for a BA. Most importantly, since these projects deal with human health and safeguarding of life itself, the time lines of the project and accuracy of the project must gain highest priority, but also keeping in mind the cost.

An important point relating to the technical know-how of a BA is knowledge of clinical trials – their procedures, laws, terminologies, and latest developments. Experience and expertise in Enterprise Content Management systems, Database Management Systems, tools like SAS, data mining, documentation, security, systems helping professionals to make informed decisions and faster data retrieval systems always helps a Business Analyst successfully complete a project. Ensuring there are no loopholes in the implementation of these projects is a must by a BA, since they concern human lives.

The Various Roles of a Business Analyst in Any Organization

As the name suggests, a business analyst is a person who basically studies different businesses for various purposes. This could be to find weaknesses in the business model or to simply find out whether it is running optimally or not. The one thing that is always apparent is that the role of such an analyst in any business is critical. This is because in all cases, the analyst has to study the business and then suggest ways of making it more profitable or efficient. It can therefore be said that the health of any business heavily depends on the work that such an analyst does, as they determine which direction the business will take.

This means that in order to become a good analyst, one has to be willing to be very critical at what they do. Any mistakes made during analysis or policy formulation (a process in which the analyst is heavily involved in) could lead to massive losses. In extreme cases, it could even lead to complete shutdown of the company.

In addition to analysis of the current business structures, such an analyst is also very useful when it comes to the design of a business process. This is important skill is useful when starting a new company or when restructuring an already existing one. As with analysis, the cost of mistakes when doing the design can also be costly. For instance when starting a business, any major mistake that the analyst makes means that the company would start operations on the wrong foot. Once the organization has gained impetus, such mistakes can be difficult and expensive to correct.

The other important role of such an analyst in today’s business environment is integration of technologies with the current business models. For instance, before implementing a new technology in any business, it is often necessary to get an analyst to study the current business set up, and then try to figure out the effect that the technology would have on business. In the same vein, the business analysts can also suggest modifications of current operations so as to ensure that implementation of the new technology is smooth. If the technology has to be modified in order to fit into the current business, it would be the role of the analysts to suggest how this should be done for maximum effect. As one can see, the role of business analysts is very important and should not be taken for granted.

The Benefits And Risks Of Self Funding Your Employee Health Benefit Plan

What Is Self Funding?

An employer who operates a self funded health plan assumes the financial risk for providing health care benefits for its employees. Self funded plans differ from fully insured plans in that employers do not pay monthly premiums for health care that employees might be given, the employers, rather, pay only those claims that employees actually receive.

To limit their liability most employers purchase stop-loss insurance. The stop-loss insurer agrees to reimburse the employer for health care costs that reach a certain threshold (usually $25,000-$100,000) in exchange for premium payments. Generally, the lower the threshold amount the higher the premium.

For example, assume a stop-loss threshold set at $25,000. The employer will pay employee health care claims up to and exceeding $25,000. However, the employer will be reimbursed for those paid claims over and above $25,000. The stop-loss insurer does, however, put annual and lifetime limits on coverage and will adjust premium costs accordingly. The higher the annual and lifetime max the more premium will be demanded.

The employer’s money may solely be used to pay claims or, alternately, it may be a shared expense with employees making some contribution. The money is typically placed in a trust account that is then debited to pay claims as they are incurred.

What Are the Benefits of Self Funding?

Typically, employers automatically save money in the first 12 months while self-funding. This occurs because claims payments are not processed until the second or third month. In the first year, employers have 12 months worth of money set aside to pay claims but they will only be paying 10 or 11 months worth of claims because of the time lag.

Employers also experience savings on direct costs that are included in fully insured medical insurance premiums such as overhead, taxes, profits and commissions. Most self funded plans use a third party administrator (“TPA”) to process and pay medical claims. Most TPA’s administration costs are significantly lower than those included in the premium by an insurer or HMO. And the premiums paid to a stop-loss insurer are usually much lower than those paid to an insurer for a fully insured plan.

Self funded employers also save on premium taxes that they would ordinarily pay if fully insured as they merely hold money in trust to pay for health claims. Self funded plans are not required to pay to the 2-3% premium taxes applicable to fully insured plans.

Mandatory benefits imposed by state law are also not applicable to most self funded plans, as federal law governs regulations of most self funded plans. These state mandated benefits are oftentimes expensive and cutting them out removes added expense.

Self funding provides employers the flexibility to design their health benefit plans. And they have greater control of the distribution of benefits as compared to a fully insured plan. In a self funded plan, employers have access to the money in the claims fund that is being used to pay current claims. This money produces interest income that can be added to the fund that would not otherwise exist in a fully insured plan.

What Are The Risks of Self Funding?

Despite these important benefits there are several risks that must be considered before the decision to self fund is made. The biggest issue in self-funding is the potential financial exposure.

Catastrophic events and high utilization by employees can lead to exorbitant claims costs. This can mitigated, as discussed above, by purchasing stop-loss insurance. But proper analysis of your company’s potential risk is essential when trying to determine the attachment points for stop-loss coverage.

Your company also must be aware of potential legal exposure. As a self funded plan you remain ultimately liable for claims decisions errors. In addition, labor relations problems could arise with employees in event that employee medical claims are paid late and this could lead to unrest, job dissatisfaction or a decrease in productivity. Both of these risks make choosing a qualified, competent TPA absolutely essential.

Finally, there are many legal complexities that impact self funded plans. Most self funded plans are regulated by the Department of Labor and are subject to federal law, specifically the Employee Retirement Income Security Act (“ERISA”). And there are several important tax law considerations that must be accounted for as well. Developing a relationship with an ERISA attorney well versed in self funding can save you time, money, and the headache of employee lawsuits.

Is Self Funding Right For Your Company?

In general, the decision whether to self fund is much easier for those employers with more than 200 employees. In fact, self funding is not widespread among small employers, only 12% of those with just 3 to 199 employees self fund their health plans, according to the 2007 Kaiser Family Foundation Survey of Employer Health Plans. The more employees you have the easier it is spread the risk. Medical claims tend to be quite volatile and smaller employers oftentimes cannot maintain the cash-flow necessary to fund those months where costs are excessive.

To determine whether self funding is the right option for your company, you should perform a risk analysis and cash-flow analysis, then examine employee demographics and covered dependents. You should also review the claims history of your company. You must know the age and distribution of the claims submitted by your employers in order to determine the risk that you will be accepting by self funding.

With this information you will have an idea about the general age of your employees and be able to identify what their aggregate health claims reveal. For example, if your employee population is older the data may reveal expensive conditions of age such as heart disease or cancer. Or perhaps your employees are disproportionately overweight, then you may see more diabetes claims or at least be put on notice that these types of claims are likely. On the other hand, if your employees are young they may have very little utilization but may be susceptible to sport injuries. At this point, you must review utilization rates for the last 3 to 5 years.

With this data in hand you should be able to determine whether you can reasonably afford self funding. Be realistic, however, about your company’s cash-flow. Claims do not arrive in an orderly fashion over a 12 month calendar period. Some months are more expensive than others. You cannot postpone claims payments you must have adequate cash-flow and enough reserves to immediately pay claims. The assistance of a qualified TPA, insurance broker, and/or ERISA attorney is essential at this point and a competent professional will be able to assist you to determine whether self funding is a viable option.

What Impact Will ERISA & Other Laws Have On Your Self Funded Plan?

Most self funded plans are subject to ERISA and the comprehensive bundle of regulations associated with this statutory scheme. ERISA, however, preempts state insurance laws including reserve requirements, mandated benefits, premium taxes, and consumer protection regulations. Self funding provides more freedom to create plans free from state mandates, which can result in substantial savings versus fully insured plans.

However, in addition to ERISA there are other federal laws that definitely impact your self funded plan including:

1. Health Insurance Portability and Accountability Act (“HIPAA”);
2. Consolidated Omnibus Budget Reconciliation Act (“COBRA”);
3. Americans with Disabilities Act (“ADA”);
4. Pregnancy Discrimination Act;
5. Age Discrimination in Employment Act;
6. Civil Rights Act;
7. Internal Revenue Code (“IRC”);
8. Tax Equity & Fiscal Responsibility Act;
9. Deficit Reduction Act; and
10. Economic Recovery Tax Act.

While this is no inconsequential list, a good TPA will be able to handle the administration and compliance with the most onerous of the statutes listed above including ERISA, HIPAA, and COBRA. However, be aware that while TPAs will provide compliance service they may not accept liability for violations of these laws (other than for gross negligence), which will rest squarely on the shoulders of you the employer.

Who Will Administer Your Self Funded Plan?

As you can see, choosing the right TPA is one of the most important if not the most important decision when deciding to self fund. A TPA can help with the cash-flow analysis and risk analysis and can administer much of the compliance requirements of a self funded plan.

Here are 10 steps to take when seeking a qualified TPA:

1. Look for a TPA that is capable of providing a customized health plan specific to your company’s needs;

a. Your chosen TPA should be flexible enough to create a plan that fits your demographics. Working with your TPA to customize coverage will cut costs and improve employees’ satisfaction with the benefits provided.

2. Check references from some of the TPA’s larger clients.

a. Ask for a list of the TPA’s larger clients then contact the clients to independently verify the client’s satisfaction with the TPA.

3. Make sure that the TPA uses and provides accurate legal information.

a. Look for a TPA that is communicative and up to date on changing regulations. It is essential that your TPA maintains a close relationship or employs an ERISA attorney due to the complexity and interplay of federal ERISA and state insurance regulation.

4. Understand how a provider (physician/hospital) network (PPO) figures into the equation.

a. TPA’s oftentimes have relationships with provider networks and can negotiate on your behalf.

5. Investigate how the TPA manages your funds.

a. ERISA requires self funded plans to prudently safeguard their assets. While not required by law, TPAs generally recommend that employers set up a trust account for their plans. This step fulfills the prudence requirement of ERISA. Many TPAs also offer client audit reports to verify that their financial practices prevent fraud and abuse.

6. Ask whether the TPA processes COBRA and HIPAA documentation.

a. COBRA and HIPAA, two federal laws, have several notification and compliance aspects that most TPAs will happily administer for you. Just ensure that your contract states that the TPA will be liable for COBRA and HIPAA administration errors and that the TPAs errors and omissions policy covers COBRA and HIPAA errors.

7. Learn all you can about the TPA’s cost-containment programs.

a. Ask how the TPA handles pre-authorizations, large case management, utilization review, and provider network evaluations.

b. Also determine how the TPA manages catastrophic claims. A good TPA is usually proactive: Detecting catastrophic claims early allows the TPA to reduce your costs without diminishing quality of care.

8. Find out how the TPA trains its claims analysts.

a. In addition to finding out how analysts are trained, inquiring about turnover rate is good idea as well.

9. Make sure that the TPA practices good management reporting.

a. Your chosen TPA should make available periodic reports explaining plan status. Reports should detail finances, number of employees served, medical costs, use of medical services, and savings realized from network providers.

b. These reports are invaluable and will provide you with the information you need to decide which services to add and whether you need to increase or decrease contributions from employees and put you on notice regarding other necessary changes or alterations.

10. Review bids from stop-loss insurance providers.

a. After you have chosen your TPA, it can contract for stop-loss insurance on your behalf. Be cognizant, however, that self funded plans are required by ERISA to obtain several bids.
b. Ensure that you are able to easily review the bids and make sure that you do some due diligence checking on the stop-loss carrier. You may not want to deal with a new company that is unfamiliar with the business and is inexperienced.

c. Lastly, ask your TPA their procedure when renewing or changing stop-loss carriers. A good TPA is aware and will put you on notice that the renewal procedures and claims definitions are often complex. These complexities are purposefully drafted by the stop-loss carrier to avoid claims liability.

d. A quality TPA will ensure that you are made aware of these complexities and will make sure that you are not left holding the bag with thousands of dollars of unpaid claims.

Conclusion

For those employers who have the size and available cash-flow, a self funded health plan can result in substantial medical claims savings. A self funded plan offers the flexibility to design customized benefit plans and provides much more control over plan benefits than the typical fully insured medical plan.

However, there are numerous risks and potential pitfalls including legal and compliance hazards, human resource and employee relation headaches, and potential liability for mishandling claims. Most large companies find that these risks can successfully mitigated with the help of a qualified, competent TPA.

Implementing a self funded health plan is not to be undertaken lightly, but failing to do so may mean wasting thousands of dollars every year on fully insured premiums. Performing the cash-flow analysis and risk analysis detailed above will give you a good idea whether your company is ready to self fund. At that point if you believe self funding is a viable option, contact a qualified TPA or ERISA attorney and with the assistance of a competent professional you can design a self funded plan that not only meets the needs of your employees but also bolsters your bottom line.

How To Help Yourself With Texas Health Insurance

If health care reform survives, residents could see a reduction in the cost of Texas health insurance premiums. That’s because a major part of health care reform requires insurers spend more on their members or give them a refund.

Texas insurance plans are now required to spend at least 80 percent of the revenue they bring in on medical care for members. The remaining 20 percent may be used for administrative needs, commissions to bring in business through agents and brokers, or advertising and marketing efforts. Because this new requirement limits profits, big business is fighting reform.

As long as health reform is not overturned, insurers that keep excessive profits or spend more than 20 percent of premiums for anything other than members’ health services will owe refunds. Such rebates could be returned to members by check or via a credit on premiums. These refunds will be due by August 1, 2012.

Because group health insurance for Texas plans typically retain less than 20 percent of members’ premiums, no refunds are anticipated on group coverage. Texans who have to pay for their own coverage in what’s known as the individual market are the ones who will receive rebates.

How Likely Are Refunds On Individual Texas Insurance Plans?

Rebates on health insurance in Texas are mandated by the reform law that is being challenged in the courts. Texas Attorney General Greg Abbott joined with 20 other state coalitions to file suit in the Federal District Court in the Northern District of Florida to oppose federal reform.

Judge Vinson rejected the federal government’s motion to dismiss the States’ case and in a sister lawsuit in the Commonwealth of Virginia, a federal judge ruled that the mandate to maintain minimal coverage is unconstitutional. This mandate is the model for universal health care seen in most developed countries, and it may be necessary to bring the U.S. up to the standard set around the world.

Can Texas Help Individuals Get Coverage?

Texas state government officials are facing a major monetary shortfall of up to a $24 billion. Yet, a recent public opinion poll shows the majority of voters support health care protection for children and low-income families.

A recent newspaper poll commissioned by the Austin American-Statesman of 819 Texas residents included 716 registered voters. They were polled by phone at the end of December 2010. Approximately 61 percent of the respondents wanted to retain current spending levels for programs that provide health care to children and families with moderate or lower incomes.

Even the most optimistic budget estimates require cutting the budget by 15 percent, according to analyst Eva DeLuna Castro. She’s with the Center for Public Policy Priorities that advocates for those with low-incomes in Texas. Without health care reform, Texas residents may be on their own to find health insurance in Texas.

Individuals Can Get Texas Health Insurance Coverage With Low Premiums

If you’ve lost your group coverage through employment, you need to know three things to find low-cost individual policies. First, high-deductible policies generally cost less. Before health care reform, these policies were criticized because policyholders tended to give up regular preventive care. This resulted in too many diseases progressing without treatment.

When health care reform passed in March 2010, insurers were required to cover recommended preventive services at 100-percent. Individuals who purchase Texas health insurance now can get yearly checkups, including screenings for common cancers, diabetes and high blood pressure with no co-pay charges whether they have met their deductible or not.

In Texas, health insurance for individuals under the age of 30 is especially inexpensive. A Blue Cross plan called Tonik offers three low-cost coverage options. Rates can be from $64 to $123 a month, depending on medical history and where you reside in Texas. The rates are good for those over 30, too, but the plans only cover healthy individuals.