Post on 26-Mar-2015
Rick Rutherford, CMPEDirector – Practice Management
American Urological Association,Inc.
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Patients seen in accordance with doctor’s time parameters
Fees set through negotiation and relative amounts of work and costs
Quality measured by patient satisfaction and lack of lawsuits
Government oversight primarily via retrospective reviews
Payers controlled costs by downward pressure on payments
Consumer choice focused on payers, steered by employers
Claims data analysis for follow-up
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Patients seen in accordance with their needs
Fees set based on data publicly available to patients
Quality set by consensus and medical evidence – measured by reporting against benchmarks
Payments determined by meeting quality standards
Government oversight driven by drilling into clinical or claims data
Payers control costs by fixed budgeted outlays
Consumer choice focused on cheapest source of “quality” care
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Major payers are testing various quality measurement processes
Medicare PVRP followed by PQRI Aetna Aexcel United Health Premium Providers
Consumers are assuming more responsibility for treatment options
Browsing the Internet for information on conditions Developing Personal Health Records using computer assistance Participating in health savings accounts
Payers are publishing provider fees online
Baby boomers demand more service, faster with better results
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What do you think?
Employer costs are rising
Medicare is going broke quickly
Too many Americans remain uninsured
Utilization is rising rapidly
Outcomes undefined New technology
becomes available We live in an era of
mistrust
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Successful managers will change their view from looking inside to looking outside the practice walls
Efficient business operations will be considered a minimum acceptable standard for employment
Effectiveness will be measured by scanning the horizon for opportunities to demonstrate:
Superior performance in delivering clinical care Optimal cost to benefit ratios from a patient/payer viewpoint Rapid delivery of care at the optimal site of service
Marketing skills as important as operational skills
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Trend Number 1
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Institute of Medicine - The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
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Reality bites
Currently Q=most likely outcome available at lowest cost
Medical evidence is just now making its way into quality measures in a serious way
Can measures be refined as new evidence is published?
Congress, President & CMS very interested in paying for “quality”/evidence-based medicine
CMS has been a contract payer in the past -wishes to become “a value-based purchaser”
MedPac recommends research into “comparative effectiveness” – comparison of treatments based on outcomes AND costs
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Physician Voluntary Reporting Program (PVRP) – 2006
36 measures to choose from – only 16 reportable by CMS
Reported via claims data
Comprised of re-written hospital measures and consensus based patient-care measures from NQF and AQA
Participation was very low
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Physicians Quality Reporting Initiative (PQRI) 2007
74 quality reporting measures
Claims based reporting –about 100,000 individuals reported
1.5% incentive bonus to successful participants – 51,000 payments to be made for 2007
Success = minimum of 3 measures (with exceptions) - reported on 80% of eligible patients/cases
Reporting started July 2007 – bonus paid July 2008
Performance reports must be downloaded from CMS website
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2008 – 119 measures – dual entry dates 1/1/2008 and 7/1/2008
Claims based reporting plus experimentation with registries and EMR reporting
1.5% incentives
2009 – 153 measures in seven measures groups
Three reporting options plus testing of EMR extraction
Claims based using CPT Category II codes Registry using Medicare approved contractors (dual entry dates) Measures groups – all measures in group for a batch of consecutive patients EMR reporting available for certain systems in 2010
Program made permanent by MIPPA w/ 2% bonuses through 20109/18/2009 WV-MGMA Meeting 2009 12
United HealthCare Premium (2 Star) rating system Quality & Cost Efficiency*= quality physician; **= quality + efficiency of care physician (efficiency translates to lowest charges)
Patients driven to * * Doc’s Purported to save employers 2-5%Ingenix Software used by other payers
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Network doctors reviewed for : case volume clinical performance hospital readmission
rates complications or
adverse health events other specialty-specific
measures (if they exist)
Only those with lowest 4% of index scores are reviewed and may be excluded
Overall cost efficiency compared to adjusted average in their regions determines star designation.
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Various agencies and coalitions fighting for lead in measurement development
Performance criteria and structural necessities
Cost per patient to third parties
Patient satisfaction – CAHPS & S-CAHPS being considered – Consumer Assessment of Health Providers and Systems
Outcomes – does compliance with measures actually improve patient health?
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Revenue affected more by effective care delivery & less by effective billing practices
How to achieve performance without seeing the patients
How to take proactive steps toward quality
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Electronic medical records – the ability to efficiently get at the data
Quality reporting training camp – start practicing now
Development of internal quality code processes
Formulate a quality team to institute changes
Learn from hospital activities
Constantly measure patient expectations and satisfaction
Closely track clinical guidelines
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Trend Number 2
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According to National Center for Policy Analysis: Health Savings Accounts (HSA) now available to 250 million
non-elderly Americans Patients using them – 1.5 million in 2002 – expected to grow to
18 million by 2012 Patients who have HSAs forego health care for less serious
conditions twice as often as those covered by traditional policies
70 percent of HSA purchasers are > 40 years of age
How many in this audience are covered by an HSA or Health Reimbursement Arrangement (HRA)?
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EMPLOYERS Converts variable cost item into “semi-fixed” cost item Enhances attractiveness of employer to young, healthy
employees Reduces the administrative and contract hassles with
managed care companies
EMPLOYEES Allows more flexibility in provider choice Provides opportunity for increased retirement funds Incentivizes natural trend toward self-diagnosis and treatment
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Patients’ Moments of Decision – before visit Internet research – “Find
a Doctor” Web sites, YELP, Angie’s List, even Zagat
Ease of obtaining appointments – open access schedules on Web
Clear explanations of financial arrangements
Patients’ Moments of Decision – during and after visit Doctor’s willingness
to listen Level of patient
involvement in treatments
Accommodative nature of staff
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Do the research to know what employers are offering in your area
Train appointment, front desk and billing staff on selling your practice
Improve your practice Web site
Consider VIP appointment slots for cash payers
React quickly to patient satisfaction ratings
Create your own patient blog about your practice tied to Web site
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Trend Number 3
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The patient decides what they need based on a doctor’s recommendation.
The patient decides if they can afford it and how they will pay the price.
The patient undertakes comparison shopping to see if there is a better deal.
The patient makes a decision.
The patient receives the service.
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John W. Rowe, M.D., retired Aetna Chairman defines it as “the opaque inner workings of the health care system are made much more transparent”
“Aetna members in Connecticut and 10 other states, plus the District of Columbia, now have online access to physician-specific cost, clinical quality and efficiency information. “http://www.cbsnews.com/sections/i_video/main500251.shtml?id=2240034n9/18/2009 WV-MGMA Meeting 2009 25
Data release rules should be multi-tiered General public Limited data set for analytic purposes Comprehensive data set for policy work
General public needs information that can be used to “shop” for healthcare services Aggregate data: cost of entire episode of care Cautionary notes should be included in release: small sample
size, severity of population differences, aggregate data explanation
Website is easiest dissemination tool
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Section 1. Purpose. It is the purpose of this order to ensure that health care programs administered or sponsored by the Federal Government promote quality and efficient delivery of health care through the use of health information technology, transparency regarding health care quality and price, and better incentives for program beneficiaries, enrollees, and providers. It is the further purpose of this order to make relevant information available to these beneficiaries, enrollees, and providers in a readily useable manner and in collaboration with similar initiatives in the private sector and non-Federal public sector. Consistent with the purpose of improving the quality and efficiency of health care, the actions and steps taken by Federal Government agencies should not incur additional costs for the Federal Government.
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Price Transparency: Insurers and third-party administrators will be asked to disclose their prices on the most frequent medical procedures, so that consumers can have a clear picture of the overall cost, not just of the procedure, but in relation to a specific doctor or hospital.
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www.healthgrades.com
www.mass.gov/healthcareqc
http://www.nhhealthcost.org/
http://www.mihospitalinform.org/
https://www.mymedicalcosts.com/
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Identify your practice strengths and market them aggressively Quality reporting participation Cutting edge services Insurance plan participation Rapid appointment access
Develop your own transparency plan Work with hospital to publish average episode of care costs Publish your patient satisfaction scores (if favorable) Publish favorable comments from patients or referral sources Publish E&M bell curve compared to averages
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Anticipate and publicly justify Robotic surgeries incur
more equipment costs but better outcomes
Office charges are higher because we spend more time with our patients
“Hallmark” approach – when you care enough to choose the very best
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Trend Number 4
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Physician-Population Ratios (providing direct patient care) 1980 – 1/614 population 1990 – 1/500 population 2000 – 1/427 population 2005 – 1/413 population
Population > age 65 expected to increase by 36% between 2010-2020
AGE <35 35-44
45-54
55-64
1980 27% 25% 19% 15%
1990 22% 30% 20% 14%
2000 17% 26% 25% 15%
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Residents and fellows 2000 – 95,725 2005 – 95,391
Council on Graduate Medical Education (COGME) recently predicted a 10% shortfall of physicians by 2020
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Will Baby Boomers demand more services?
Will cost controls further reduce the physician supply?
Will technology adoption improve the efficiency of the process?
What will be the overall effect of wounded warriors?
Will the U.S. finally face the problem of uninsured?
Could the U.S. face a widespread pandemic?
What will be the effect of recession?
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What management strategies can increase the efficiency of patient care delivery? Streamline the record keeping process through adoption of
electronic record keeping Expand capacity at low cost through use of non-physician
providers Investigate the potential for group patient visits Evaluate the practice’s payer mix and boost profit margins
per patient seen Demand more patient/family involvement in the health
care process Explore more efficient delivery of procedures
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Surgical practices - Consider providing more office visit time for aging physicians – E&M reimbursement is on the rise
Primary care - Negotiate for reimbursement for e-visits
Prepare for shared reimbursement – DRGs for doctors
Economically advantaged areas - Consider the advantages of boutique practices – fewer patients for equal compensation
Specialists – investigate the potential for telemedicine
Reduce the number of Medicare patients
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Trend Number 5
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Sustainable Growth Rate formula – the annual roller coaster ride
Aetna caps out-of-network payments at 125% of Medicare rates (AMNews - Jan. 14, 2008)
California introduces law that requires physician seeing patient in an in-network hospital to accept in-network rates
CMS launches Acute Care Episode (ACE) demonstration project
Accreditation for imaging services required by commercial and state payers
State laws prohibit certain ancillary services in physician offices
CMS proposes physicians meet IDTF standards
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Increase skills at business modeling based on controlling the volume of patients and services delivered by the practice Who and where are the profitable patients? What ancillary services are most profitable and least likely to be
regulated?E
nhance your ability to compile meaningful data from various sources Cost per encounter data Claims data Quality reporting data Disease management data
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Managed care contract review and negotiations
Quality measurement and reporting
Target marketing to the most profitable patient cohorts
Hospitality service to keep those cohorts happy
Cost accounting to better control unit costs
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Three major factors in political health care reform: Access Provider participation Cost control
Third rail – the cost of quality improvement
Massachusetts Health Care Reform Act improved access but costs ^ to 33% above U.S. average
What will it take to achieve universal provider participation? Mandatory participation? – No Financial incentives? – No Providers as fiduciaries? - Maybe
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