The Winner’s Circle in Healthcare: How to Avoid Political Paralysis

By Hank Duffy, President & CEO

The political circus around healthcare has dawned, and it’s hard not to get wrapped up in the chaos, confusion and contradictory advice. While the knee-jerk reaction is to become paralyzed and to take a wait-and-see approach, this is wrong.

Instead, it is the right time to focus on what will make care-delivery organizations more effective in managing clinical quality and cost and improving the patient experience.

There are two “no brainer” areas where near-term focus will only enhance competitiveness:

  • Improving how the care delivery network operates
  • Strengthening the primary care component

Improving how the network operates involves more change management than most physicians enjoy, but it is essential to managing clinical quality and bringing down cost. The network should be the “Care Manager.” The quiz to assess how well your network is operating includes:

  • Do we have reliable transitions of care, particularly from inpatient to outpatient?
  • Do we regularly and reliable coordinate care among PCPs and specialists?
  • Are the referral systems “user friendly” and supporting two-way communication?
  • Are we providing data on the effectiveness of care coordination (i.e. readmits, access times, clinical outliers, etc.)?

When it comes to strengthening the primary care component, the obvious question is if there are enough PCPs in the right locations. But an equally important question to be addressed when it comes to keeping, attracting and incenting PCPs is: Are we creating an environment that is a joy to practice in?

Going back to the research done by the Annals of Family Medicine, Inc.’s publication In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices1, there are at least five tests of a practice that is “joyful”:

  1. Proactive planned care with pre-visit planning and pre-visit laboratory tests
  2. Sharing clinical care among a team with expanded rooming protocols, standing orders and panel management
  3. Sharing clerical tasks with collaborative documentation (scribing), non-physician order entry and streamlined prescription management
  4. Improving communication by verbal messaging and in-box management
  5. Improving team functioning through co-location, team meetings and work-flow mapping

Getting care delivery networks fully operational with a world-class primary care provider experience is where the healthcare winners will stay focused in this tumulus time.

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1 2013 Annals of Family Medicine, Inc.;In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices; Christine A. Sinsky, MD, Rachel Willard-Grace, MPH, Andrew M. Schutzbank, MD, Thomas A. Sinsky, MD, David Margolius, MD and Thomas Bodenheimer, MD2
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The Golden Ticket to Healthcare’s Future – Physicians

By: Hank Duffy, President JHD Healthcare Partners

November 8, 2016, had a surprising presidential election outcome that many people, including myself, didn’t see coming. For us in healthcare, it’s very likely there is a wave of changes coming our way.

Yogi Berra said, “Making predictions, particularly about the future, can be very difficult.” So we don’t know what will come in the next few years under the Trump administration, but my sense is the endangered aspects of Obamacare are:

  • The “Individual Mandate”
  • The role of the Exchanges
  • The approach to Medicaid
  • Possibly, the role of CMMI

However, one aspect about our industry I am convinced will not change is The Prime Directive to reduce the cost of healthcare. Whether we have Value-Based Reimbursement, Bundled Payments, Fee-For-Service or Capitation, the pressure to bring down the cost of care is going to continue. This means reducing the Total Medical Expense Ratio – the cost of the clinical care process – not freezing salaries, cutting nurses or Medical Assistants, or closing floors.

There is a golden ticket to succeed at reducing the clinical cost of care – it’s the physicians.

Today, enough focus isn’t on positioning the physicians as the leaders in driving quality up and clinical cost down. They need to be:

  • Better equipped
  • Better supported
  • Incented to focus on larger patient populations
  • Recognized as the “healers” of successfully reforming healthcare

In the midst of the potential chaos, how do we, as an industry, get the golden ticket?

  • Integrating Technology: The technology is here, but we are not putting enough effort into “optimizing” its use for the physicians and their care teams. As was the case with the introduction of the EHRs, we made the day-to-day work of the physician more difficult. Having the technology is great, making it work to the needs of the specific physicians is essential.
  • Fix Clinical Support Staffing: As an industry, we are not adequately preparing for the coming physician shortage, and we can do more to better leverage the clinical support staff mix. At some point in the future, a Primary Care Panel will be 6,000 – 7,000 lives, which is unmanageable with the current staffing model.
  • Make Clinical Data Usable: A lot of progress has been made in the availability and use of clinical metrics, particularly through CMS programs and the successful ACOs. As physicians take on changing care patterns/pathways and creating true integrated care management, the data needs to be:
    • More credible
    • Easier for them to use
    • Embraced by them
  • Strengthen Financial Incentives: If the physicians are the engine in driving down clinical cost, they need to have the same incentives as the industry. Physician arrangements should be crafted to reward:
    • Productivity
    • Clinical quality
    • Clinical cost
    • Patient satisfaction
    • Citizenship in the clinical enterprise.
  • Facilities: Our ambulatory facilities need to be more user-friendly and designed to support integrated care. It’s a long-term investment, but we will not reduce the cost of care without moving away from antiquated small physician offices.

Physician satisfaction has been decreasing for the past 15 years or more, and we need to start here to succeed with any healthcare change. So while we wait to see what “Trumpcare” brings, it is in everyone’s interest to find a way to:

  • Make the physician work environment easier
  • Align incentives faster
  • Embed the clinical quality and cost data into the care process
  • Accelerate the movement toward clinical integration as a means to bring down clinical cost

Medicare announces a new program to pay primary care practices for managing their own patients

On April 11, 2016 CMS announced Comprehensive Primary Care Plus (CPC+), a significant advancement of an earlier program known as CPC that was launched in 2012.

The new initiative is open to primary care practices that do not participate in other types of comprehensive care programs such as ACOs, including MSSPs.

A unique feature of CPC+ is that CMS wants to include other types of health insurance plans, in addition to Medicare, to participate so that the majority of a practice’s patients are covered.  This will reduce the complexity for participating practices and will create enough of a critical mass to make participation viable.

The CPC+ design is intended to provide partial up-front funding, added to FFS payments, and backward looking quality performance rewards to practices who actively manage the health of a panel of patients.  Many details have yet to be explained, but the Medicare component will contain two Tracks.  Track 1 is intended for practices who want to develop comprehensive care capabilities.  It is less demanding than Track 2, but also comes with lower $PMPM and performance rewards.  The prospective $PMPM will be risk stratified under both Tracks, with the methodology still to-be-determined.  As an example, under Track 1, a primary care practice with an average risk score will receive:

  • Full FFS reimbursement, billed as usual
  • Plus, a $15 PMPM, paid in advance
  • Plus, up to $2.50 PMPM based on quality performance

For a practice with 300 Medicare beneficiaries, the $PMPM payments could amount to $63,000 per year on top of any FFS dollars received.

Track 2 is designed for PCPs who are already advanced in their PHM efforts.  Compensation under Track 2 follows a similar structure, but the amounts have been increased to reflect the additional effort and resources needed.

Commercial and other health plans will need to develop their own parallel programs and coordinate with CMS so that practices can achieve economy of scale by including most, if not all, of their patients.

The next step for the CPC+ program is for CMS to receive applications for participation from insurance in order to define the participating regions.  The regions will be announced in June.  At that time practices who are in a participating region can submit their applications.   Participating practices will be announced in October.

Find out more at http://bit.ly/1sAdIfm.

 

 

 

Physician Revenue Cycle: A Key to Successful Integration

By Kelvin Drawdy, Director, JHD Healthcare Partners

As hospitals and health systems take steps to develop sustainable relationships with physicians, they are increasing physician practice acquisition and physician employment.  Effectively integrating the revenue cycle should be a top priority because it not only affects the financial performance of the health system, but may also affect the physicians’ compensation, and their satisfaction.

The Healthcare Financial Management Association defines revenue cycle as: “All administrative and clinical functions that contribute to the capture, management, and collection of patient revenue.” In other words, from the point of first patient contact to final payment and settlement of the claim. Each of the following functions must be performed for the revenue cycle to be effective – and must be prioritized as part of the integration of new physicians and practices.

  • Pre-Visit/Pre-Service Processes
  • Front-End Process at Time of Service
  • Encounter – Patient Services
  • Billing
  • Third Party Claims
  • Payment Processing
  • Patient Collections

There are challenges to successfully integrating the revenue cycle functions of the newly acquired practice into the health system and gaining the trust of the physician that the revenue cycle is working.   Efficiencies can be achieved working in a large health system, but if not executed well there is a risk of losing the physician’s trust and lowering the patient’s satisfaction.

If the physician revenue cycle isn’t meeting expectations, this could be an indicator the health system has issues integrating the physician revenue cycle or that it is not effectively prioritized or managed as part of the overall system.  Timely recognition and resolution of these issues will keep physicians and patients happy, and improve the health system’s financial results.

Let’s discuss how your health system is managing the challenges of your physician revenue cycle.

Kelvin Drawdy is a director with JHD Healthcare Partners.  For a complimentary assessment, please visit JHDHealthcarePartners.com.

Yes, PHM Can Get You Paid

Stethoscope and cash sm

Skip Leavitt, PA, MBA, FACMPE

The case for effective population health management couldn’t be clearer. But still there is great reticence on the side of providers and health systems, many of whom believe that adding PHM activities will threaten fee-for-service revenue. They want to be able to increase quality and lower costs for their patients, but there are some commonly held concerns that don’t have to be true:

  • Myth 1. If they are successful with their PHM, then their fee-for-service revenue will drop, and it will drop faster than value-based revenue increases.
  • Myth 2. The tech cost will be very high and they think they have to pay for the technology up-front.

Here is what organizations that have been successful at a transition to PHM have figured out: There are activities documenting a track record of increasing quality that are also reimbursable under the current fee-for-service system.

Let’s take, for example, Chronic Care Management (CCM), which Medicare has just put in place.

If a provider has a Medicare patient who meets CCM criteria, they can get paid $42 per month per person for care coordination, which can be done by non-physician staff, such as an office nurse.  For a typical internist, who has 500 Medicare patients, that’s $21,000/month for doing care coordination. And that’s just one example.

By appropriately documenting the care coordination done for those patients, providers can build their record.  Also, it’s been shown practices doing chronic care management experience a higher rate of Medicare patients coming in for annual medical evaluation — which increases the compliance with the wellness evaluation.

Many practices would like to do care coordination, but are overwhelmed by the day-to-day issues of running the practice. Becoming part of a clinically integrated network can provide the needed expertise and resources at minimal cost.

Another example to show how PHM can get you paid is closing care gaps. We know most patients don’t get the preventive care they need; typically, less than half of the patients get the recommended preventive care measures. Simply identifying those patients, bringing them into the office, and arranging for preventive care increases FFS volumes and also increases the documented improved quality of care.

PHM can be game-changing for your practice, if you’re willing to make a few changes. Don’t let the misconceptions about transitioning to value-based care hold your practice back.  Not only can you set your practice up for success in this new healthcare landscape — but also increase your revenue during the change-over.

Skip Leavitt, PA, MBA, FACMPE, has more than 25 years of healthcare management experience, including clinical and executive positions in both the provider and payor sectors. On the leadership team of JHD Healthcare Partners, Mr. Leavitt puts that expertise to work helping physicians, hospitals and health systems succeed.

Cowboys and Pit Crews: Change is Here

by John H. (Hank) Duffy, founder, JHD Healthcare Partners

shutterstock_240686083.jpg pit crewA few years ago, New Yorker magazine published a commencement address from Atul Gawande, a surgeon, writer, and public health researcher, who spoke to students at Harvard Medical School. Dr. Gawande made the very insightful remark that today’s medicine doesn’t need “cowboys,” the lone rangers who do everything themselves. Rather, in today’s medical environment, you want the patient to be surrounded by a “pit crew” — several medical professionals collaborating on how best to care for one person. Never before has the industry experienced such a dramatic shift in ideology, and culture change it requires.

The public’s experience is that while we have amazing technology and highly trained clinicians, there is little consistency with doctors and technology coming together to provide an actual system of care, from start to finish. We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.

The solution to rallying the front lines around this new methodology is aligning incentives — creating frameworks for success where the physicians are incented to team, to look at clinical quality, to manage clinical costs, and to be patient-focused.

With the healthcare landscape shifting from a pay-for-service model to one based on accountable care and qualitative patient outcomes, the way physicians are incentivized and compensated needs to change in step with what the market is dictating. Physician compensation is a major issue in this transition. At one extreme, physicians are suspicious about changes in their income. At the other extreme are legal regulatory issues related to compensation.

The reality is that no matter how you configure it, any successful physician compensation plan needs to be built around 5 pillars:

  1. It (still) needs to be volume- or productivity-related. Within this are two components that must be artfully balanced: panel-sized — how many patients the physician is responsible for; and how many encounters (wRVUs) — how busy is the physician?
  2. It needs to require demonstrated clinical quality. This can be broken down into two parts. First, are the patients being given the right protocols (pap smears, vaccines for children, and best-practice processes for illnesses)? Secondly, are they staying out of the hospital and living longer?
  3. It should include clinical cost management. There is a saying that the most expensive item in healthcare today is a pen: the pen that writes multiple MRI screens, multiple pharmaceutical scripts, multiple X-rays, and more. It’s the physician’s ability to quell his or her use of the pen (or mouse) that will be the greatest impact on clinical cost. More often than not, it’s because the physicians are practicing what we call “defensive medicine”: prescribe the Z-pak, do the CT scan just to be “safe” – rather than focus on rational clinical need.
  4. It must focus on the patient experience. Enhancing the patient experience starts with opening up the schedules to get the patients cared for on a timely and convenient basis. The patient experience is knowing your patient when they come in the door, knowing what’s going on with them. It’s the antithesis of having all the patients re-do their paperwork every time they come in the door, rather than greeting them and asking if anything has changed.
  5. It has to include citizenship. It’s more than showing up at work. Citizenship is teaming with your colleagues, being a part of the group, helping to find solutions and sharing in both successes and opportunities for improvement. Being a part of the health system not only of your patients, but also your provider organization, is important in this new healthcare landscape.

There are several things that have to happen to get us from being cowboys to being well-oiled pit crews, starting with a significantly different communication process. This is not about management trying to hustle down the cost of the physician cohort; it’s about moving from fee-for-service to fee-for-value. Here’s what your communication plan needs:

  1. Education on all sides. All sides need to understand the other. You have to have an involved physician cohort in the development of your organization’s methodology; you can’t take two or three accountants and have them go in a room and develop the methodology. It’s a process that is going to take time, and you can’t do it in 3 weeks. We just completed one successfully and it took 10 months.
  2. Explain the positives. Show physicians the upside to this alignment,….how it will be good for the patients. Explain what there is to be gained and how the entire organization is going to be aligned. Otherwise, assumptions will be made that they are the ones bearing the brunt of this change. Show them the upside, which lies in tangibly demonstrating clinical quality.
  3. Data. It’s easier to say than to deliver on, but you have to give physicians data on their panel size/demographics, clinical outcomes, to the extent you can get clinical costs, and more. Also, get them comparative data, which should be blinded initially to ensure the data is correct, and then once you have enough built up to be meaningful, make it transparent to all providers. It’s the way to get us all in the same boat, and the way for us to start to feel like we’re reliant on each other, and focus more on the patient.

The reality is that change is inevitable. CMS has said it wants 70 percent of its payments under a value-based stream of contracts by 2018. Whether this happens for your organization in late 2017 or late 2018 doesn’t matter; it’s inevitable. There are going to be winners and losers, and the winners are going to be the ones who learn how to do this sooner.

Teaming — like a good pit crew.

For more information on how JHD Healthcare Partners can help your organization through this transition, please contact us at www.jhdhp.com/contact.html. For a copy of the “Cowboys and Pit Crew” commencement address, please visit newyorker.com/news/news-desk/cowboys-and-pit-crews.

 

Report Says Physician Engagement is Greatest Challenge for Healthcare Executives

by Skip Leavitt and Kimberly Buser, JHD Healthcare Partners

HealthLeaders recently published an insightful report on physician alignment, centering on strategies that require both risk and clinical integration. The article notes that physician engagement is the greatest need, and also the greatest challenge, for health system executives: it’s highest on the list of objectives, at 66 percent, and is most frequently cited as being the most difficult.
Some other key findings from the report include:
• The survey showed 66 percent of respondents engage physicians in quality initiatives. And, 24 percent say engagement is the most difficult part of aligning physicians. Physicians know that the goal is delivering higher-quality, lower-cost healthcare, but they are often resistant to change. A proactive change management plan is needed to help the physicians achieve their goals.
• Clinical integration is often cited as a mechanism for health systems to gain physician alignment. For employed physicians, 55 percent of health systems use clinical integration, and for independents, 52 percent, according to the HealthLeaders report. This movement can be an important way to align with physicians on common ground, but it cannot succeed in isolation.
• Executives are expecting a 48 percent growth in clinically integrated medical staff over the next three years – the same staff that are expected to provide a high level of coordination of care, but only if they are properly engaged.
The successful organizations we work with realize that to really engage physicians in the alignment effort, the entire health system needs a philosophical shift to a culture of inclusion. They also have a detailed action plan to guide the change process on all levels. We recommend that clients provide a flexible range of alignment options including employment, participation in clinically integrated networks, or through a “fabric” of supporting physician practice services.
Creating a plan for successful alignment often includes these practices:
• Implement a robust physician engagement and communication program that is bi-directional, inclusive and transparent
• Provide a robust clinical and non-clinical education program
• Establish physician support capabilities as good, or better than, what is available in the market elsewhere for them.
Lots of people talk about physician alignment. But let’s discuss how it can be one of your organization’s main strategies for success. Give JHD Healthcare Partners a call today at 972-220-0474.
To download your free copy of the HealthLeaders article, click here.

“More Care is Better Care” is Dangerous Mythology

by James Couch, MD, JD

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At least since the beginning of third party payment of health services, the myth has grown that “more care is better care.” The default position has always been that it is better to be safe than sorry when it came to ordering tests, procedures or consultations. The “more care is better care” mythology has also been driven by “defensive medicine” where providers of care seek to protect themselves by obtaining as many tests as possible, even those of marginal value In the name of providing better care, many physicians did not consider enough the extra time, hassle, medical risk (from invasive procedures and false positive test results), uncertainty and anxiety that those extra interventions may have caused patients and their families.

No matter how good the sensitivity, specificity and positive predictive value of diagnostic tests and procedures, there is always an irreducible possibility of false positives. These faulty findings may send patients and their families off into yet additional blind alleys of hassle, time wasted, anxiety and distractions away from their activities of daily living and quality of life. Plus, with the rapid growth of high deductibles and other cost shifting health plan features, patients and their families will have to absorb a steadily increasing proportion of those costs.

As the drumbeat to convert from a volume to a value-based system has grown louder, the medical establishment has begun to move the profession in anticipation of this inevitable transformation.   The American Board of Internal Medicine (ABIM) Foundation has served as the convener for the “Choosing Wisely” campaign. This campaign has also been supported strongly by the leading medical journal JAMA Internal Medicine and its Editor-in-Chief, Rita Redberg, M.D., M.S., professor of medicine and director of Women’s Cardiovascular Medicine for the University of California San Francisco School of Medicine.

A total of 60 medical and surgical specialty and sub-specialty societies have each identified the five most commonly overused and abused tests and procedures in each of their specialties and pledged to find ways to reduce the use of them.

More on the “Choosing Wisely” campaign can be found at its website: http://www.choosingwisely.org.

In his new book, Achieving the Quadruple Aim in a Technology-Driven Transformed Health System: Better Care, Improved Health, Lower Costs and Decreased Medical Liability, James Couch, MD, JD, explores the questions in America’s medical liability system and how they relate to the current effort to transform the health care system.

Why Only Three? Should We Have a “Quadruple Aim”?

healthcare focus aimThe “Triple Aim” concept, first articulated by Don Berwick, MD, has become the guiding principle for the nation and for many individual providers as they seek to address the chaos in the American healthcare system.  As Dr. Berwick notes, he believes that improving the health care system in the U.S. is dependent upon the simultaneous pursuit of three goals:

  •  improving the care experience,
  • improving the health of populations and
  • reducing per-capita costs associated with health care.

But is there a fourth component to this?

In his new book, Achieving the Quadruple Aim in a Technology-Driven Transformed Health System: Better Care, Improved Health, Lower Costs and Decreased Medical Liability, James Couch, MD, JD, explores the questions in America’s medical liability system and how they relate to the current effort to transform the health care system.

Unless we also address the medical liability system, Dr. Couch argues, our ability to realize the Triple Aim is in jeopardy.

Is that the final piece of this healthcare puzzle?  Stay tuned as we feature a series of posts around the Quadruple Aim and Dr. Couch’s insights.

Does PHM Stand for Patients?

Drew Nietert, CPHIMS, PCMH CEC, CHPSE, JHD Group

If you know your “ABCs” of healthcare, you’ve undoubtedly heard the term “PHM.”  You may know that it stands for population health management.  But you may also be like many out there, struggling to understand what this term, and this notion, really means.

population healthcareThe confusion is understandable. Terms such as population health management (PHM) and accountable care organization (ACO) are often interchanged.  In practice, PHM is not accountable care, but without PHM, accountable care is unlikely to be successful.  The term is also widely defined: PHM has come to be defined mostly by vendors selling PHM solutions, and has adopted a variety of meanings depending on the various systems’ capabilities.

The definition of “population health,” as noted by Kindig and Stoddart in an article they co-authored in 2003, is “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”  Population health management is how that gets done or, in other words, the methodology and tools for managing the health outcomes of a defined group of people and ensuring the effective distribution of those outcomes across the group.  Key steps in PHM methodologies include, but are not limited to:

  • sharing data
  • aligning and partnering with all aspects of the care continuum
  • changing the mindset and work at the point of care
  • incorporating other modalities of care
  • understanding which patients are costing the system the most
  • proactively reaching out to patients with specific health indicator
  • creating solutions for patient engagement
  • and others

The tools are the data analytics, the EHRs, the engagement DME and patient portals.  PHM must affect the entire continuum of care and be tied into it — otherwise, even small gaps in patient health management will cause great cavernous pit holes of quality and cost.

As you can see, the method is complex and requires a lot of change. In addition excellent and integrated tool sets are needed to drive almost all of the changes.  So how does a healthcare entity create a strategy for success that employs and fully utilizes the best of PHM?

First, a group should define its goals around ACOs and PHM.  For example, does the group want to become an ACO, become part of an ACO, or simply try its hand at managing a portion of its patient population? Second, based on those goals, a group will need to determine what tools it needs to manage its population.  Needless to say, there are dozens available — and choosing the right solution can be time-intensive and mind-boggling.

The JHD Group has developed a comprehensive RFP that helps identify more than 400 software features, as well as how the software and implementation is designed to work with patient engagement, point of care changes, cross continuum workflows, etc.  If you are just starting on this journey or are stuck in the middle of it, call the JHD Group and we will help guide you through a strategy, selection and implementation as needed.  Simply put, we know the ABCs to PHM success, and we’re happy to spell that for you.

Give JHD Group a call today or send me an email to learn more about this new RFP tool.