Health Information Management Careers

Healthcare is a booming industry. After all, even people in the best of health need a check-up periodically. Although most people envision bustling halls full of doctors and nurses, a host of other professionals work behind the scenes to make sure day-to-day operations go smoothly.

Health information management (HIM) has become essential to all avenues of healthcare. Health information records include every bit of data that relates to patient care and managing it successfully paves the way for top quality treatment. Examples of health information include X-rays, lab results, medical histories and even the notes your doctor or nurse takes during appointments.

HIM professionals operate on multiple levels. Protecting and maintaining the quality of individual health records are a significant part of HIM responsibilities, but health information managers may also use aggregate data to analyze high-level health trends and changes within a population.

The Evolution of HIM

A hundred years ago, health information management just meant filing records and keeping them safely locked away in the office. With no digital aspect, keeping track of physical files didn’t require much more than basic literacy and a robust filing system.

Today, no aspect of healthcare has escaped digitization. For every paper copy of a health record, there is at least one digital counterpart that must be secured, stored and recalled at the right moment. Navigating databases as they expand in real time requires specific training and technical skill. Enter the revamped field of health information management.

HIM’s importance has only appreciated as the move toward digitized medicine accelerates. In the past five to 10 years, the number of specific roles in the HIM careers field has skyrocketed. To succeed in the increasingly technical field of health informatics, professionals need specific training and certifications. Here are some of the career branches HIM professionals with a bachelor’s degree may choose:

  • Data Quality Manager
  • Departmental Director
  • System Manager
  • Chief Privacy Officer

HIM education requirements don’t always include a four-year degree. These roles require an associate’s degree to get started:

  • Records Technician
  • Health Data Analyst
  • Coding Specialist
  • Patient Information Coordinator
  • Insurance Claims Analyst

Primary Disciplines of HIM

In such an immense field, professionals can choose from a number of primary disciplines that govern their daily work. Check out this snapshot of the seven main health information management career paths

  • Informatics and Data Analysis: If you love in-depth analysis, informatics and data is the HIM field for you. Health informatics governs how patient information is stored, transmitted and used within an organization. This discipline analyzes the logistics of health information and draws actionable conclusions from large sets of data.
  • Compliance and Risk Management: Emerging technologies inherently carry some risk to patients and staff. Healthcare risk managers use data to reduce the chance of anyone in the organization incurring an injury. They work proactively to prevent harm, but also react quickly and decisively to keep damage to a minimum after an incident. Risk managers do this in part by ensuring staff members follow relevant healthcare regulations to a tee. Compliance is crucial to safety in healthcare.
  • IT and Infrastructure: The IT side of health information management is responsible for maintenance and diagnostics of the systems or software used to store and transmit data. The best candidates for this discipline have a background in information technology. Health IT career paths are ideal for someone who wants to transition their IT skills to a new industry.
  • Education and Communication: HIM professionals aren’t all ultra-technical wizards. Communication is critical when working with so many moving pieces, and large organizations need one or more managers to keep information flowing smoothly between departments and individuals. Organizations also need someone to educate other staff members on processes and compliance for recordkeeping.
  • Operations and Records Management: Keeping up-to-date records is an essential role of HIM professionals. Health organizations can’t operate safely or effectively without accurate, accessible patient records. Records managers ensure the integrity and protection of paper copies as well as digital files.
  • Revenue Cycle Management: Healthcare is big business, and maintaining the financial health of an organization is key to keeping things going. Revenue cycle management (RCM) is the process providers use to track incoming and outgoing costs related to patient care. An RCM manager oversees the patient’s progress through the system, from creating an account to the final bill payment.
  • Coding and Billing: Medical billing and coding professionals bridge the gap between providers and patients. They submit accurate codes for insurance reimbursements and create the final bill for services. Coding and billing represent the front line of health information management.

What’s It Like to Work in HIM?

For the most part, all health information management career options lead to work in an office-like setting with other professionals in the field. You’ll generally enjoy a standard nine-to-five workday, with overtime becoming more common as you grow in HIM roles and responsibilities.

General skills needed for health information management are broad. Computer literacy and technical ability are fundamental as HIM continues to become more technological. You may be working closely with others or independently, and strong communication skills will serve you well in either case.

Training for health information management careers requires certifications you can obtain by completing exams. A bulk of certifications come from the American Health Information Management Association (AHIMA). The Registered Health Information Administrator (RHIA) is the most fundamental of the HIM certifications. It provides a launching pad for many HIM careers.

One of the perks of an HIM career is the ability to take a branching path to whatever position you’re ultimately after. Many HIM professionals start out as medical coders and then use that foundational knowledge to pursue management positions. Career growth and stability make HIM a premier field for those who want a good job as well as those looking to climb the ladder.

Where HIM Professionals Work

You may be wondering how versatile HIM career paths actually are. At its core, health information management is necessary to ensure accurate information is coded, transmitted and stored correctly.

General job duties include the classification of reimbursement data and protection of patients’ privacy in relation to their health data. You may also analyze data, whether to support providers or to assist in research that informs public policy. Some career paths involve improving the collection methods or quality of data to improve its application in any healthcare setting.

The typical workplaces for HIM professionals are hospitals, long-term care centers, behavioral health facilities and managed care organizations. But you’re not limited to healthcare providers alone. These organizations also have a growing need for HIM professionals:

  • Law and consulting firms
  • Rehab centers
  • Government agencies
  • Insurance companies
  • HIM Agencies

5 Fast-Growing HIM Careers

Demand for professionals in every discipline is steadily climbing, and the health information management career outlook remains bright. Read on to find out more about the duties, education and the national average salary for the fastest-growing HIM careers:

1. Medical Coder

A medical coder takes completed patient notes and translates them into medical code. The coder evaluates diagnoses and any treatments or medication given to a patient and uses the International Classification of Diseases (ICD) or another code book to assign the appropriate codes. Each code translates into insurance billing information, which is how patients get reimbursement for treatment. Medical coders may earn extra certifications for a specialty, such as anesthesia and pain management, cardiology, rheumatology or others.

To be successful, medical coders need to build up an extensive working memory of diagnoses as they relate to codes. Quick and accurate data entry is also a must.

Degree & Certifications

Most medical coders enter the field with an associate’s degree. Certifications for medical coders include the Certified Professional Coder (CPC), which greatly increases earning power. Professionals interested in acquiring one of the many specialty credentials should visit the American Academy of Professional Coders (AAPC) website to view the full list of possible specialties.

The average salary is typically around $40,618.

2. Credentialing Specialist

Credentialing specialists work internally within medical facilities. Rather than handling any patient data, they are tasked with ensuring staff information is up to date. Because the medical field hosts so many types of professionals, the credentialing specialist ensures all those licenses and credentials remain valid. The specialist may also maintain a variety of records relating to licenses and credentials.

Credentialing specialists must be comfortable coordinating hundreds or thousands of staff credentials. This HIM career option requires the ability to communicate effectively and enforce deadlines.

Degree & Certifications

There is no hard-and-fast rule degree requirement to become a credentialing specialist. Some smaller organizations may only require a high school diploma, but most mid-size and large organizations do want to see a bachelor’s degree. All specialists must earn the Certified Provider Credentialing Specialist (CPCS) certification to start.

The average salary runs about $43,135.

3. Coding Compliance Auditor

Someone needs to make sure coding professionals comply with all medical billing and coding laws. Failure to remain in compliance with the long list of regulations surrounding health information management can expose an organization to undue risk, loss of revenue and perhaps even legal consequences. Auditors may work on teams or independently, and they review documents and conduct process inspections. If any noncompliance emerges, the auditor outlines the necessary steps for resolution and follows up afterward.

Compliance auditing is one of the more demanding healthcare informatics careers, requiring an analytical mind and unshakable ethics. Attention to detail is paramount.

Degree & Certifications

Most employers require a bachelor’s degree, and a master’s degree is preferred. Candidates must have extensive medical coding experience and may benefit from obtaining Certified Professional Compliance Officer (CPCO) status.

The average salary for this type of position runs about $55,464.

4. Revenue Cycle Manager

Revenue cycle managers oversee patient billing and provide high-level resolution of any revenue cycle issues across departments. The revenue cycle manager keeps all things billing running smoothly. This position may also involve automating billing communications and implementing other innovative solutions to improve billing processes. If any discrepancies arise within the revenue cycle, this manager is the one to solve them.

Revenue cycle managers have to think quickly and creatively when problems arise. Because this position frequently requires problem-solving for other departments and individuals, it helps to be a people person.

Degree & Certifications

Employers want a bachelor’s degree for this position — preferably in finance or a related field. Successful candidates need extensive experience with and knowledge of billing, coding and Medicare among other insurance providers. The American Association of Healthcare Administrative Management (AAHAM) offers multiple certifications for revenue cycle managers, from the Certified Revenue Cycle Specialist up to the Certified Revenue Cycle Executive.

Average salaries for this position are about $65,059.

5. Director of HIM

If you’re ambitious and want one of the top HIM careers, you might want to set your sights on a Director of HIM position. The director oversees medical coding and records and may be responsible for more than one department. Depending on the organization, the HIM director may be indirectly in charge of hundreds of employees. Productivity, workflow and comparative performance are all in the director’s wheelhouse. The director also leads compliance efforts to make sure no rules or regulations fall by the wayside.

As top-level managers, HIM directors must be comfortable with a vast volume of communication. They also have to stay on top of changing healthcare laws, so a passion for continued learning will speed up career advancement.

Degree & Certifications

A bachelor’s degree is the minimum level of education required to become an HIM director. Although there is no specific set of HIM career qualifications for this job, you do need Registered Health Information Administrator (RHIA) certification along with a minimum of three to five years of experience in medical coding and records.

The average salary is about $70,188.

Specializations within the HIM field are developing rapidly as the need for data management rises. In addition to the specific duties within each role, HIM professionals fulfill other critical functions such as:

  • Setting the standard for emerging technologies in digital health records
  • Educating patients on accessing, protecting and interpreting their healthcare information
  • Using data to support the best outcomes for patients and providers

Health Information Management Career Outlook

If this is all sounding pretty good so far, you’ll be pleased to know that the field of HIM is still growing faster than average. According to the Bureau of Labor Statistics (BLS), employment for medical and health services managers will increase by 20% between 2016 and 2026. This increase far outstrips the 8% growth of management jobs in general, and the 7% of all occupations combined.

Because baby boomers are such a large population, they will continue to drive demand for healthcare overall. Of course, the need for healthcare means the need for organization and management of all that new information pouring into the system. Digital health records are here to stay, and so is health information management.

The Future of HIM

As new technologies emerge in healthcare, the roles of health information management professionals will change. The shift from paper records to electronic health records (EHRs) is almost complete, so anyone entering the HIM field will be part of an exciting new revolution in the cutting edge of healthcare.

Today’s HIM training and education programs are focused on the future and preparing professionals for the growing decentralization in their roles. Because digitization requires fewer physical resources than the hard copy system, individuals are expected often expected to oversee information in multiple departments. HIM is one of the most dynamic careers available, and even more new roles may emerge shortly.

If you want to dive into a career with immense potential and room to succeed, visit Healthcare Resolution Services. Learn more about HIM careers and check out our open positions to see how far your career can go.

Understanding the Transition from PQRS to MIPS

Understanding PQRS to MIPS Transition

Since the Physician Quality Reporting System (PQRS) ended in 2016, healthcare providers have been faced with the challenge of transitioning to the new Medicare payment initiative program — the Merit-Based Incentive Payment System (MIPS). The MIPS transition brings with it expanded requirements for reporting performance data across a variety of quality and cost metrics. Physicians and practices must meet these new requirements if they hope to earn incentive payments and avoid financial penalties. In this piece, we will outline the primary differences between PQRS and MIPS and offer guidance for staying compliant and performing well on MIPS in 2019.

What Is MIPS, and What Does It Mean for the Healthcare Industry?

The Merit-Based Incentive Payment System is a national incentive system that offers payments to Medicare Part B providers for high-quality and cost-effective care. MIPS was introduced in 2017 by the Centers for Medicare and Medicaid Services (CMS) as one of two options within the Quality Payment Program (QPP). This performance-based incentive system is designed to reward eligible physicians and groups for providing quality and cost-effective care. It also aims to drive improvements in the healthcare field, lower the overall cost of care and increase healthcare information use.

MIPS streamlines several other Medicare incentive and payment programs into one system, so clinicians and group practices can better monitor their performance across various measures. The financial incentives provided to physicians and practices that perform well in MIPS are also meant to encourage improvements in the level of care provided.

This means all Medicare Part B providers should plan to participate in MIPS and must submit their data before the submission deadline to avoid penalties.

The implementation of MIPS means individuals and practices in the healthcare industry must now collect and report data in four different performance categories outlined in the MIPS requirements. Eligible individuals and groups that fail to participate in MIPS or fail to report in a category for which they are eligible can result in financial penalties. Providers that receive a low MIPS score may also receive a negative payment adjustment on their Medicare Part B reimbursements.

To earn a high MIPS score and positive payment adjustment, healthcare providers must adopt new data collection practices and commit to improving the quality and cost of their care in 2019.

Why Did PQRS End?

Why Did PQRS End?

The Physician Quality Reporting System was first introduced as the Physician Quality Reporting Initiative (PQRI) under the Tax Relief and Health Care Act of 2006 (TRHCA). PQRI was a voluntary payment initiative for reporting quality data and was the first national incentive program of its kind to be introduced by the Centers for Medicare & Medicaid Services (CMS). In 2008, PQRI became permanent under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), and the incentive payments increased from 1.5 percent to two percent. In 2015, participation in PQRS became mandatory for all eligible providers.

The aim of PQRS was to collect data from physicians and group practices about the quality of care provided to Medicare. Based on these quality scores, providers were eligible for a positive or negative payment adjustment. PQRS Feedback Reports were issued to all participating clinicians and group practices so they could assess the quality of their services and identify ways to improve their care.

In 2017, the Physician Quality Reporting System ended when it was replaced by the Merit-based Incentive Payment System. The final program year for PQRS was 2016, and the final payment adjustments were distributed in 2018.

MIPS was designed to integrate and update various Medicare incentive and payment programs into a single system. MIPS consolidates PQRS, the Value-based Payment Modifier (VM) Program, also known as Value Modifier, and the Medicare Electronic Health Record (EHR) Incentive Program, also known as Meaningful Use. By merging these programs into a single system, MIPS provides a more comprehensive picture of provider performance and quality of care.

How Is MIPS Different From PQRS?

Because MIPS streamlines PQRS, the VM Program and the Medicare EHR Incentive Program, it is more comprehensive and extensive than PQRS alone. MIPS performance is measured by four categories — Quality, Improvement Activities, Promoting Interoperability and Cost. The Quality category of MIPS encompasses the performance measures previously reported through PQRS as well as the quality portion of the VM Program.

When transitioning from PQRS to MIPS, providers may notice similarities between the quality measures reported in PQRS and the performance measures of the MIPS Quality category. However, one of the primary differences between MIPS and PQRS is that, under MIPS, providers and groups are able to select their own quality measures. This update aims to address one of the biggest criticisms of PQRS by allowing clinicians and groups to select the most meaningful quality measures for their practice, as well as choosing their preferred reporting mechanism.

MIPS also requires fewer quality measures that must be reported, reducing the requirements from nine under PQRS to six under MIPS. By easing this requirement, MIPS allows physicians and groups to concentrate better on improving their chosen quality measures.

The other major difference between MIPS and PQRS is that MIPS includes the additional categories of Cost, Promoting Interoperability and Improvement Activities. The Cost category of MIPS replaced the VM Program, while the Promoting Interoperability, which was previously called Advancing Care Information, replaced the Medicare EHR Incentive Program.

The Improvement Activities category is a new category introduced with MIPS that is not rooted in a previous Medicare program. The Improvement Activities category measures how practices are working to improve their care processes, increase patient engagement with care and increase patient access to care. As with the Quality measures, physicians and groups can choose their own improvement activities that best suit their practice.

MIPS Participation

Who Needs to Participate in MIPS in 2019?

Participation in MIPS is mandatory for all eligible clinicians and practices, and those who fail to participate will receive a financial penalty. Beginning in 2019, eligibility for MIPS is determined twice each year instead of once, so practices that are not eligible at the start of the determination period should continue to monitor their eligibility throughout the Performance Year.

For the 2019 Performance Year, clinicians are eligible for MIPS if they:

  • Identify as a MIPS eligible clinician type on Medicare Part B claims
  • Have enrolled in Medicare prior to 2019
  • Exceed the low-volume threshold for 2019
  • Are not a Qualifying Alternative Payment Model Participant (QP)

The low-volume threshold includes three aspects — allowed charges for covered professional services, the number of beneficiaries for those services and the number of covered professional services provided. For 2019, providers are excluded from MIPS if they meet any of these low-volume thresholds:

  • Bill Medicare Part B allowed charges of $90,000 or less
  • Provide covered professional services to 200 or fewer Medicare Part B patients
  • Offer 200 or fewer covered professional services to Medicare Part B patients

Providers that fall under the low-volume threshold are not required to participate in MIPS but may choose to opt-in if they exceed at least one of the low-volume thresholds. For example, a physician who serves 250 Part B-enrolled individuals can choose to participate in MIPS even if their allowed charges and provided services do not exceed the low-volume thresholds.

Physicians and practices that are eligible for MIPS can choose between three participation options — as an individual, as a group or as a virtual group. These participation options also make it easier for low-volume physicians and practices to participate in MIPS.

MIPS Compliance Tips

MIPS Compliance Tips and Best Practices

To ensure Merit-Based Incentive Payment System compliance, providers must take steps to prepare for collecting and submitting MIPS data. Physicians and group practices can choose the best MIPS measures for their practice and then take steps to improve their performance. Providers can follow these steps for MIPS compliance to improve their performance scores and earn a greater MIPS incentive payment:

1. Determine If You Qualify for Special Status or Other Exemptions

Some MIPS eligible providers can receive a special status designation if they fall under the 2019 special status qualifications. Providers with special status may receive reduced reporting requirements in some of the performance categories or have performance categories reweighed. For 2019, clinicians, groups and virtual groups can receive special status if they:

  • Practice in a Health Professional Shortage Area (HPSA)
  • Practice in a rural area
  • Are a small practice
  • Are hospital-based, non-patient facing or ambulatory surgical center-based

A provider that qualifies for special status will receive the designation automatically and does not need to apply.

Providers also have the option to apply for two exceptions that will reduce their reporting requirements if their application is approved. For 2019, providers can apply for the Promoting Interoperability Hardship Exception and the Extreme and Uncontrollable Circumstances Exception. If you believe your practice may qualify for an exception, explore the exception criteria and submit an application for approval before the end of the Performance Year.

2. Choose Your Participation Type

Once you have determined that your practice is eligible for MIPS participation, you can then select the right MIPS participation option for you. If you choose to participate as an individual, you will report your MIPS data under your National Provider Identifier (NPI) number and a single Associated Taxpayer Identification Number (TIN). Your MIPS scores and payment adjustment will reflect your individual performance.

If you choose to participate as a group, you will submit MIPS data from each group member under a single TIN. Groups must contain at least two clinicians, one of whom is eligible for MIPS. When you report as a group, your MIPS scores and payment adjustment will be based on the performance of the entire group across all four performance categories.

The third participation type — a virtual group — was introduced in the 2018 MIPS Performance Year and allows clinicians to form a group with other practitioners who do not share the same TIN. Virtual groups must contain two or more unique TINs and can be made up of solo MIPS eligible practitioners, groups of 10 or fewer clinicians who share a TIN or a combination or individuals and groups. The virtual group participation option allows solo providers and groups to join virtually, regardless of their physical location or specialty.

3. Select Your Quality Measures, Improvement Activities and Promoting Interoperability Measures

MIPS participants are able to select their own Quality measures and Promoting Interoperability measures, as well as their own activities for the Improvement Activities performance category. This allows physicians and practices to choose the measures and activities that are most relevant to their practice, but it also requires more planning in advance for MIPS compliance and success.

Providers who hope to earn high scores in these categories should determine their performance measures and activities before the start of the Performance Year, as well as selecting their preferred reporting method for each category. This enables providers to choose the best methods for accurate and complete data collection.

For the Quality category, data must be collected during the entire Performance Year across six different quality measures. If a MIPS participant submits more than six measures, only the six measures with the highest scores will be counted. The option to submit additional Quality measures for scoring can help a provider boost their overall MIPS score, as Quality counts for 45 percent of the final score.

For the Promoting Interoperability category, data must be submitted for four or five Base Score measures depending on the participant’s certified electronic health record technology (CEHRT) edition. CEHRT edition also determines whether a participant chooses their Promoting Interoperability measures from the Promoting Interoperability Objectives and Measures set or the Promoting Interoperability Transition Objectives and Measures set. As with the Quality category, providers can choose to submit more than the required number of measures, with a cap at nine measures, and only the highest scoring measures will be counted. The Promoting Interoperability category accounts for 25 percent of the final MIPS score.

For the Improvement Activities category, which counts as 15 percent of the final score, participants must complete a combination of activities that total 40 points. This can be completed with two high-weighted activities, four medium-weighted activities or a combination of one high-weighted activity and two medium-weighted activities. Providers must plan to complete each activity over 90 continuous days during the Performance Year.

4. Review the Cost Measures and Track Your Performance

For the Cost category, all MIPS participants are scored using the same 10 performance measures, as long as they meet or exceed the specified minimum case volume for that measure. CMS collects Cost performance data directly from Medicare claims data, so physicians and practices do not need to submit data for this category. However, physicians and practices should still review the 2019 Cost performance measures so they can better gauge their performance and consider ways to provide more affordable and cost-efficient care.

Ensure MIPS Data is Complete

5. Ensure Your Data Is Complete

Each MIPS category has different requirements for the completeness of the data submitted. If a participant does not submit enough data to meet this level of completeness, they will not be able to receive the maximum points for that performance category. Data completeness requirements also vary based on how a provider chooses to collect their data. MIPS participants should review the data completeness requirements for their collection type to ensure they submit enough data to receive a high score in that category.

6. Submit Your MIPS Data Before the Submission Deadline

The final step to MIPS compliance is to ensure your Quality, Promoting Interoperability and Improvement Activities data is submitted before the submission deadline. While submission deadlines may vary based on your collection method or submission type, most MIPS performance data is due before March 31st of the year following the Performance Year. For 2019, performance data must be submitted prior to March 31st of 2020. Providers should verify the submission deadline for their chosen submission type and make sure to meet that deadline so they can earn the highest MIPS score possible.

Healthcare Information Management and MIPS

Healthcare Information Management (HIM) and MIPS

To achieve high performance scores and earn an incentive payment for the 2019 MIPS, clinicians and group practices must accurately collect medical data across a variety of measures and activities, while also improving their quality of care and reducing their healthcare costs. This means there is no room for error, and healthcare providers must seek streamlined and efficient information management systems.

Working with an HIM partner can help providers accurately collect and report their data while eliminating coding errors and staying on top of changing industry requirements. At Healthcare Resolution Services, we offer a variety of healthcare information management services, so your practice can enjoy improved productivity and accuracy. Healthcare Resolution Services can ensure your practice stays compliant with CMS regulations, while you focus on providing high-quality care to your patients. Contact Healthcare Resolution Services today to learn more.

HCRS Teams Win Places on Government-Wide IT Contracting Vehicles


A Government-Wide Acquisition Contract (GWAC) offers all Federal agencies a streamlined and cost-effective way to purchase Information Technology (IT) services. The two CIO-SP3 GWACs (Chief Information Officer-Solutions and Partners 3) — one for unrestricted procurement (any size business) and one small business version to help agencies reach socioeconomic goals — are 10-year contracts administered on an all-agency basis by NITAAC, the National Institutes of Health (NIH) Information Technology Acquisition and Assessment Center. CIO-SP3 allows expedited acquisition of health and biomedical related IT services to meet Federal defense and civilian agencies’ scientific, health, administrative, operational managerial, and information management requirements. CIO-SP3 also contains general IT services, because medical systems are increasingly integrated within a broad IT architecture, requiring a systems approach to their implementation.

Many health information management and program integrity services can be obtained through the CIO-SP3 vehicle. HCRS is a subcontractor to one unrestricted and two small business contractors.

Xerox is our unrestricted (large business) prime contractor for CIOSP-3. Xerox is a growing presence in the Federal IT space, with contracts with some 25 agencies.
Paragon is a small business offering logistics, integrated governance, advanced technology and data management services to health, science, other civilian and defense agencies.
SCSJV is a Service-Disabled Veteran-Owned Small Business Joint Venture, a group of innovative, stable and fiscally responsible, agile and price-sensitive companies, primarily small (85%) and committed to staying together throughout the life of CIO-SP3.

CALL US to find out how to leverage CIO-SP3 to meet your health information management and other IT needs!

HCRS Principal Addresses Small Businesses on Successful Federal Sub-Contracting

“Focus on your company’s uniqueness and understand that the secret ingredient is YOU, and you will succeed as a Federal subcontractor,” HCRS Principal Brenda Doles, RN, MBA told an audience of about 100 Philadelphia area small business owners recently. The event was one of a series of community outreach events sponsored by the U.S. Department of Health and Human Services Office of Small and Disadvantaged Business Utilization (OSDBU) to encourage more small business participation in Federal contracting. At the Philadelphia event, the emphasis was on how to find, win and carry out subcontracting opportunities, from both the prime’s and the subcontractor’s perspectives. HCRS and one of its prime contractors, RTI International, presented each side of the story.

Ms. Doles pointed out that subcontracting has several advantages to small businesses as an introduction to the Federal marketplace. For example, she noted, subcontracting can shortcut the typical government sales cycle of 18 months. Regulations for market entry as a subcontractor are less stringent than those for primes. Mentor/Protégé arrangements (both formal and informal) can facilitate teaming and help new small businesses gain “past performance” that will help them win more business. Her advice to small businesses on how to win contracts? “Identify your target client. Know your client and do your homework. Plan. Be prepared. Seize the moment. Be flexible and expect the unexpected. Most important, have a passion for what you do.”

HCRS Helps Policymakers Understand and Predict Healthcare Use

During the past year HCRS has developing an ongoing relationship with RTI International, an independent not-for-profit research institute that does important work for the Agency for Healthcare Research and Quality (AHRQ) and other Federal healthcare agencies. We have supported RTI in two research studies activities.

  • Medical Expenditure Panel Survey (MEPS) coding. MEPS is a large scale survey of families and individuals, their medical providers, and employers across the United States that is the Federal government’s go-to source of information on the cost and use of health care and health insurance coverage. RTI’s role is to analyze raw data from the surveys to create the information that policymakers need. HCRS helps in the analysis by turning written descriptions of care from doctors and hospitals into medical codes, making it possible for biostatisticians to aggregate and manipulate the data.  The data are then shared with government and other health policy researchers such as the Kaiser Family Foundation. The Kaiser Family Foundation finding illustrated at right, like many such findings in non-government organization policy research, is based on MEPS data.
  •  Medicare Advantage Predictive Model DRG mapping. Federal officials use a mathematical model to predict future use of health care services in Medicare managed care plans (“Medicare Advantage”).  The prediction becomes part of the payment the managed care plan receives for taking care of each member. The current model was built using ICD-9 codes. We were asked to make the model accommodate ICD-10 coding by “backward mapping” ICD-10 coded data to ICD-9.

HCRS Assists in Reporting Healthcare Associated Infections (HAIs) Accurately.

HCRS is working with Advanta Medical Solutions, LLC to validate the accuracy of hospitals’ reporting of Healthcare Associated Infections (HAIs) to the state. HAIs are infections acquired in the course of receiving health care. They are now the fourth leading cause of death in the United States. The Centers for Disease Control and Prevention estimates there are 1.7 million HAIs in this country each year, resulting in about 100,000 deaths, and costing millions of dollars in lost productivity. For public health and safety reasons, it is critically important that government officials have accurate records of where these infections are occurring. Therefore, HCRS auditors, along with auditors from Advanta, audit a sample of medical records at hospitals around the state to ensure that HAIs are captured and accurately reported. The results of the audits are passed along to the Maryland Health Care Commission.

HCRS Helps Determine How Well “Patient-Centered Medical Homes” Work

In a PCMH, primary care physicians guide patients and orchestrate all their care.
HCRS is working with IMPAQ International, LLC, a policy research firm, in conducting an evaluation of the Maryland Patient Centered Medical Home Pilot Program. Patient Centered Medical Homes (PCMHs) are practice arrangements in which the primary care physician or practice delivers, integrates or coordinates all the care that patients require, including specialist and hospital care. PCMHs have been promoted as a potential solution to many of the problems facing the American health care system (e.g., fast-rising costs, medical errors/declining quality of care, and lack of coordination of care). Nearly all States have implemented a Medicaid and/or private insurance demonstration involving PCMH, including Maryland, whose 3-year pilot began in 2011 with 53 primary care practices and about 200,000 patients. All the major insurance carriers and the Maryland Medicaid program are participating.  The study is being conducted under the auspices of the Maryland Health Care Commission.

Our job is to help IMPAQ answer the following questions about the PCMH Pilot Program: (1) Did access to and the quality of care improve? (2) Did patient, provider, and staff satisfaction increase? (3) Have disparities in health been reduced? (4) Has the utilization of costly services decreased? (5) Are payer costs of care lower? Answering these questions will involve gathering care outcomes and cost data along with information about patient, provider and staff perceptions during 2012 and again in 2014.