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Information Management
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Business New Haven
6/1/1998
By: Lori Green
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BNH interviewed Robert Leary, CEO of HSS, a software company specializing in coding, reimbursement and profiling of heath care services.
What are some of the key features that your software offers customers?
Our products benefit clients by improving the quality of their data fo decision-making, improving accuracy in managing complex health care reimbursement, tracking and predicting utilization of services by specific enrolled populations, and managing risk in the contracting process.
Who is your current client base?
We serve more than 900 health-care providers, payers and managed care organizations across the U.S, with 70 percent of revenues derived from sales to hospitals and integrated delivery systems. The remaining 30 percent comes directly from heath plans and health care payers.
Does HSS play a role in developing health-care policy as it relates to database and coding diagnostics?
We have people participating on national committees where some of the fundamental decisions for the industry are being made. For instance, virtually all the payment systems employed today are based on coded medical-record data. One of our people is a director of the Society for Clinical Coding, which sets guidelines for how coding needs to take place.
How does HSS contribute to helping providers offer more cost-effective and higher quality care to patients?
We're helping develop much more sound databases or data sources upon which to develop these payment systems. These software tools are aimed at putting the incentives in the right place for delivering health care. For example, right now with the current Medicare DRG system you take all the patients that go into Yale-New Haven Hospital, about 40,000 patients per year, and you categorize them into 500 patient types, or DRGs. Each DRG then has a fixed price associated with it. Because of the variability of the services that get delivered to those patients, the DRG system is what's called an “averaging system.” So payers are working on the basis of an average. The more precise and well-defined you can make the DRG system, the better the average payment is for each DRG.
What drives improvements to the current system?
Most activities on the commercial side of the market really get spawned by federal initiatives, and then the commercial groups adapt them to their own needs. For instance, over the past few years, everyone has wanted to implement out-patient classification systems, but no one has really grabbed the bull by the horns because Medicare was dragging its feet. But by the first of the year, Medicare will have a new system in place and we expect that the commercial market will be close on their heels. At that point, Ambulatory Payment Classifications (APCs) will be used. which are similar but more complex than DRGs.
Why are so many Connecticut physicians having a difficult time with reimbursements?
Hospitals are a major purchasing force, and they are major clients of insurers. Individual physicians' voices are still very small in comparison Another factor y is the quality of data that is being transmitted to meet the insurers' requirements. The rigor for submitting a claim has intensified. Individual doctors' offices have maybe one administrative assistant. Most individual physicians' offices are highly under-automated.
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