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Strategic physician recruiting

Fri, 01 Jun 2012 04:00:00 GMT

Strategic physician recruiting

by Karen Minich-Pourshadi

With a nationwide physician shortage juxtaposed against the need for organizational growth to bolster the bottom line, hospitals and health systems are constantly, and feverishly, trying to fill physician vacancies. However, the "fervor to fill" can create a reactive recruiting cycle that may cloud the strategic nature of the hiring process and ultimately result in ill-fated personnel choices. With millions to be gained or lost with each decision, creating a comprehensive recruitment strategy can help you hire and keep Dr. Right and sidestep Dr. Right Now.

Forecasting need

Six years ago, J. Gregory Stovall, MD, senior vice president of medical affairs and organization development at Trinity Mother Frances Hospitals and Clinics in Tyler, Texas, brought to light an employment issue: The 400-plus-bed organization was losing far too many physicians. His organization had a physician turnover rate of 14%, more than double the industry average, according to the 6th annual Physician Retention Survey from the AMGA and Cejka Search.

The stats caused Trinity Mother Frances, which employs more than 250 of its nearly 500 physicians, to reevaluate how it approached the whole process. The organization estimated $50,000-$75,000 was spent per physician on recruitment. Then there was the additional $200,000-$300,000 spent to train, credential, market, and onboard a single physician. The total cost per new recruit came to roughly $250,000-$350,000.

Stovall's initial estimate of the financial loss due to turnover was conservative. After calculating the recruiting and onboarding costs, the organization looked at benchmark data and also calculated the downstream revenue lost when a physician left the organization. The result: An estimated $1 million per physician was lost with each doctor's departure, says Stovall.

The retention numbers made it clear that the organization needed to keep the physicians it hired and to be certain it was hiring candidates that fit the organization. To do that, it needed to get ahead of recruitment and slow turnover. Stovall says the hospital created an annual $100,000 retention budget to accomplish these goals. The money was used for outings, training programs, and other events to appeal to physicians and bring them into the fold.

Additionally, Trinity took a proactive approach to the hiring process. "We directed our department chiefs to make recruiting plans that looked out three to five years. That plan translates down into our annual recruiting plan for the organization," he says.

Getting ahead of the hospital's physician demand meant the organization could search for the best fit for the position and its culture. The approach has yielded results and saved millions-the organization's current turnover rate is just 5%, nine percentage points lower than when the effort started.

Being proactive regarding physician need is an integral part of the plan at Morristown (N.J.) Medical Center, part of Atlantic Health. David Shulkin, MD, president at the 692-staffed-bed hospital and vice president of Atlantic Health, says that his organization creates a medical staff strategic plan as part of the recruitment process. The organization's department heads are taking stock of their existing physician pool by age and by specialty, as well as the demand for and potential growth of each service line. They then calculate the estimated number of medical vacancies. Those are the positions that its six in-house recruiters strive to fill in advance of the need.

The data analysis is just one component of the process, Shulkin says. The organization does an annual review of its employment and compensation models to be sure they are in line with the national and regional norms. "I've run several different organizations, and the one thing you learn when you move around is that each local market is different. There are some markets where the employment model is dominant and well-established, and other areas where another one is," says Shulkin.

In Morristown, he says, the independent practice prevails. "[Hospital] employment isn't dominant, so we've worked hard to create a number of different alternatives to employment to help physicians feel comfortable and still be closely aligned with the system," he says. "Part of the skill involved in strategic recruiting is understanding the various modalities and choices available when addressing the needs of the physicians."

In some cases, however, quantifying the need for physicians may have to extend beyond the hospital's walls and into the larger community. For example, 47-bed Columbus (Neb.) Community Hospital (CCH) is helping group practices with their own recruiting. The joint effort has resulted in successfully bringing candidates to the rural area over the past two years. In total, the small rural facility has recruited 27 physicians and three midlevel providers to practice at the hospital or within the community-and all for less than $5,000 per recruit (the in-house recruiter's time plus physician sign-on bonuses for in-house recruits).

The effort is part of a larger strategy at CCH. Two years ago, the organization's president and CEO, Michael Hansen, determined with the board that it was vital to place more emphasis on physician recruiting, particularly to fill gaps in specialty areas of care. Hansen hired Amy Blaser as the vice president for physician relations and business development to handle the recruitment efforts.

"The practices feed the hospital, and that's how we get patients-they're not our competitors," notes Hansen. "We want our patients to get their care as close to home as possible. So we think it's important for the physicians to be able to refer here."

The co-recruitment effort between the practices and the hospitals is working, too. "We decided if we were going to focus on the overall physician community, we didn't just need to look at which doctors we needed to hire, but the doctors that could also be added to help the group practices. So we help them with a lot of the recruitment process, but they also put money into the game with sign-on bonuses for candidates," explains Hansen.

Intentional candidate profiling

Once a hospital has established the need for a physician, the next step is creating a profile of the doctor who should fill the opening, explains Roger McMahon, director of physician employment services at Mercy Medical Center in Des Moines, Iowa, and T. Clifford Deveny, MD, senior vice president of practice management of the Catholic Health Initiatives (CHI) system of Englewood, Colo. Mercy Medical, part of CHI, employs 330 physicians, and McMahon says the facility has 20-22 physician opportunities annually.

"You want to know the individual is going to have the right qualifications but that the personalities will also fit," says McMahon.

Shulkin agrees. "Depending upon the level of the position, we may approach [the creation of this profile] a little differently, but you want input," he says.

For a department chair search, for instance, the organization would establish a search committee and solicit formal input from members of the specialty as well as the broader medical community to get clinical and administrative characteristics for the position. "For someone below that level, we might reach out to other physicians in the department and the nursing staff for that information," Shulkin says. These profiles can be used during telephone screening interviews and can prevent the wrong candidate from being flown in for an interview or, worse, selected for a position.

Work the in-house network

The strategic recruitment of physicians goes beyond placing an ad or using an external recruiting agency. It is a targeted search to fill the vacancy, and the sources for this story agree that having an in-house recruiter is a key to finding the best candidate-though they may use an external agency occasionally.

Twelve years ago, Centra Health, a three-hospital, $700 million system in Lynchburg, Va., eliminated its in-house recruiting team due to budget reasons, but two years ago that changed, explains Chalmers Nunn, MD, senior vice president and chief medical officer at Centra Health and president of Centra Medical Group.

"If you look at the market and try to find a physician now, with the shortage, it's very difficult," he says. That is why the organization now uses three in-house recruiters to help locate doctors. Nunn says another reason the organization added an in-house team was the process. "It felt more like [agencies] were just résumé mills and the candidates being presented weren't vetted for how well they might fit the actual opening or hospital culture, plus the agencies were costly," he says. In 2009 the in-house team brought in 60 candidates and filled 22 slots. This past year the team addressed 33 requests, hosted 51 candidate site visits, and oversaw 22 placements. The total cost per candidate averaged $12,500 versus the agency cost of $25,000-$30,000 per candidate, plus another $12,000 for the marketing and any additional travel expenses for the candidates.

"We do it cheaper and better," Nunn says. "The only weakness with in-house recruiting is we can't cast a wide net like some of the big agencies."

The ability to do a nationwide search, however, is not necessarily a weakness when it comes to locating the best candidate. Shulkin, Blaser, and McMahon say reaching out to internal staff is often a better approach to the process. "We always start locally, and we always start with our own internal family of physicians and staff," says Shulkin. "We often find the best fit comes from the people who already know us."

Larger systems have a network of physicians to draw upon-something Mercy Medical Center is able to capitalize on through the CHI network. "Our size is an advantage that we can leverage to keep our recruiting search costs down," says Deveny. "And when we do have to use an external agency, we've put together a set of standards for our vendor contracts so we can't get taken advantage of on the pricing of the services."

The organization is also developing a profile with the qualities a CHI physician should possess, as well as a set of standard benefits and cultural norms that can be expected at all hospitals within the network. With 76 hospitals and other healthcare facilities in 19 states, the organization anticipates that by adding these attributes into the network it can retain more physicians within its family of hospitals.

"If a physician is ready to leave, then they can choose another of our hospitals and know there will be certain standards they can rely on," says McMahon.

Candidate searches can also be done over time by working with university medical students and residents. "If you have a local medical school or residency program, building relationships with those residents early on pays dividends," says Stovall.

Ultimately, the difference between recruiting and strategic recruiting is time, money, and fit. Recruiting is the search for any candidate to fill a position-it can produce candidates quickly, and it can be expensive. Strategic recruiting is a laser-focused hunt for the best physician to fill an opening. It can take more time to find the best candidate, but the doctor's employment longevity with the hospital means the time investment pays off.

"It's hard to put the price on finding the right physician for a job. We know when we pick a person that's not the right fit it's very expensive to the organization," says Shulkin. "We're getting smarter about recruiting ... we're looking for longer-term relationships with physicians."

Marketing know-how revs physician recruitment strategy

Fri, 01 Jun 2012 04:00:00 GMT

Marketing know-how revs physician recruitment strategy

by Marianne Aiello, with contributions by Karen Minich-Pourshadi

Ask any CEO intent on growing his or her organization's service lines what the top challenges are, and you're likely to hear that physician recruitment is on the short list. For service lines to grow, physician recruitment challenges must first be overcome. And service lines are booming. According to the HealthLeaders Media 2012 Industry Survey, roughly one in five leaders surveyed said they expect primary care, orthopedics, cardiology, and oncology service lines to grow by 6% or more.

Identifying and recruiting the best physicians is a growing concern nationwide. As baby boomer docs start to retire, not only must hospitals replace them, but they must also reinvent their recruitment tactics to reach the younger generation of physicians.

Southwestern Vermont Medical Center (SVMC) found itself with a substantial physician shortage in 2007 when the first round of baby boomer physicians retired, leaving a 25-position deficit-18% of its 140-physician staff. Ten of these positions had been open for longer than one year. What's more, SVMC was recruiting just one to two physicians each year.

These realizations led the 99-bed organization to reevaluate its recruitment process. Prior to the shortage, human resources was responsible for recruiting all physicians and staff. But as key positions remained empty, it became clear that SVMC needed a new approach. First, leadership appointed a medical staff office member to act as a physician liaison and recruiter. This decision was critical, as having a dedicated recruiter on staff is one of the most efficient ways to create a physician recruitment program and let applicants know that you take recruitment and retention seriously.

Identifying marketing's role in recruitment

As SVMC's physician recruiter began to learn the lay of the land in her new role, it became clear to her that the marketing department should be involved. Working together, marketing and the physician liaison created two key recruitment messages. "The first was that this is a fantastic practice environment and you don't have to give up anything in intellectual or technical quality to practice at a small rural hospital," explains Kevin Robinson, communications director. "[The second message was] we have highly trained physicians and trained staff and a collegial atmosphere. It's a fantastic place to live for a certain type of person-for a person who likes to know their colleagues and practice in a team environment."

Robinson and his team decided that the best vehicle to communicate this message was through a recruitment microsite featuring video testimonials, physician profiles, and benefit highlights.

"And in the videos we interviewed top physicians and asked what drew them here," Robinson says.

The recruitment strategy eventually expanded to include direct mail, online advertising, and social media campaigns. Tactics like these are key to targeting the younger generation of physicians, or even younger boomers.

Even if you don't have the budget for a full-time recruiter, you should have a page on your website listing physician openings, benefits, and application information. By using social media, banner ads, and pay-per-click advertising you're not only reaching potential candidates where they spend time online, but you're also sending a message that your organization is tech-savvy.

Attaining instantaneous results

The SVMC recruitment team didn't have to wait long to judge the success of their efforts. By December 1, 2007, just one and a half months after launching the campaign, more than 100 physician applications had been filed. Before the campaign launched, HR had only 20 active candidates. Robinson attributes the campaign's positive results to integrating marketing know-how and traditional recruitment tactics.

"There's some marketing know-how that can be used in physician recruitment to help define and target the audience and understand what kind of institution you work at and what might drive people to join your team," he says.

Patients set to unleash feedback on doctors

Fri, 01 Jun 2012 04:00:00 GMT

Patients set to unleash feedback on doctors

by Cheryl Clark

Recently, a friend on Facebook® posted a status update about a bad visit to the doctor's office:

She might as well have poked a tiger. Her update prompted several comments, all of which related similar humiliating experiences.

"I waited half an hour this morning while my doctor was schmoozed by some pharmaceutic[al] floozie. Very irritating," one person wrote.

They think they get to act that way because of "what we pay them," answered another.

The angry "we shouldn't have to take this anymore" thread got me thinking-and it reminded me that we are about to enter an era of formalized surveys that will finally give patients a chance to talk back to their doctors en masse, to say how they really feel about their office visit experiences.

Patient vehicles to rate experience

Given the above, doctors should brace for an earful about scheduling difficulties, hour-long waits, perceived disrespectful attitudes, and unreturned phone calls.

I know doctors think these aspects of the care process are, in the big scheme of things, minor annoyances that have nothing to do with their skills in diagnosis and treatment. But perceived mistreatment by physicians and their staffs may have a subtle but enormous impact on patient compliance, and ultimately on quality and outcomes. And that's why value-based purchasing "satisfaction" scorecards for primary care doctors as well as specialists are just around the corner. Soon these scorecards will be posted on some state health department websites, or on Physician Compare.

Patients across the country will get a formal chance to tell their doctors what they think about their patient experience, and some of this feedback is already taking place for physician care in hospital settings thanks to a patient survey modeled after HCAHPS (Medicare's Hospital Consumer Assessment of Healthcare Providers and Systems). It's called the Clinician and Group Consumer Assessment of Health Providers and Systems questionnaire, or CGCAHPS.

I don't think doctors are at all prepared for this. They'll no longer be able to brush away a bad review as just another outlier on Yelp. In time, there will be a real cost associated with bad reviews. "Many physicians have no idea what CGCAHPS is, and that value-based purchasing is coming soon for them," says Patricia Riskind, senior vice president of medical services for Press Ganey, which administers these surveys for its medical group clients, and soon for health departments in at least two states. "And it probably will be a little shocking, at least initially."

Versions of the survey are now being sent to patients of about 100,000 "early starter" physicians nationally-whose medical groups, including a certain group known as Kaiser Permanente, apparently are eager to know what patients think, Riskind says.

Under Medicaid waivers, such surveys will go out first in California, beginning April 1, to patients who receive care from doctors affiliated with 27 public hospitals. Minnesota is poised to follow starting September 1, with surveys for patients seen at clinics with at least 715 patients in a three-month period. California intends to post doctor scores by name on a public Web page. Minnesota will publicly post scores by clinic only.

The survey poses questions such as the following:

During your most recent visit, did this provider listen carefully to you?
In the past 12 months, when you phoned this provider's office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?
During your most recent visit, were clerks and receptionists at this provider's office as helpful as you thought they should be?

Certainly, the survey will be a wake-up call for many practitioners who didn't think they had to care about such issues as long as their diagnoses, prescriptions, and referrals were medically justified.

"There is a deep sickness in the way care is delivered in many practices, and the source of this sickness is that consumers are not just free to change merchants because of crappy service," says "e-Patient" Dave deBronkart, a patient advocate, who after surviving stage 4 cancer decided to work toward improving care from the patient's perspective.

"Supposedly, as the reform legislation rolls out, it will get easier, especially if it's easier to take records with you," deBronkart says. Some healthcare systems like the Cleveland Clinic are now offering same-day consults in any specialty, an expanding trend that will allow patients more opportunities to "vote with their feet."

Impact on quality of care and outcomes

The angry Facebook thread also made me wonder whether the satisfaction or frustration these patients will relate might somehow translate to better outcomes of care. Does a good patient experience, encompassing engagement with the physician, courtesy from the receptionist, and maybe even parking validation, mean the patient will get better faster and avoid hospitalization? And conversely, might a long wait or perceived disrespect be absorbed by the patient and perhaps-in some subtle, indirect way-translate to a poorer health outcome?

Gordon Moore, MD, seems to think so. Moore is a family practitioner and fellow with the Institute for Healthcare Improvement who specializes in care measurement, patient experience, and staff satisfaction, as well as their relationships to outcomes and cost.

"It's not overwhelming, as in lots and lots of evidence that's been repeated, but there's enough that I can say with confidence there's a good correlation between experience in the practice and outcomes," he says.

Research into the reasons why patients failed to follow up with appointments shows the negative impact of patients having poor experiences with their doctors. One contributing factor was physicians' failure to show respect to patients.

"When you parse out 'respect' with these individuals, it turned out that it masked things like, 'You kept me waiting around,' 'You didn't listen to me,' 'You treated me rudely,' " Moore says.

Likewise, he notes that there is a lot of scientific evidence that points to the inverse: Patients who have good experiences during their visits and perceive that their doctors treat them with respect are more likely to stick to their recommended treatment plans.

A colleague conveyed a comment made by a physician at the AMGA National Conference held in March in San Diego: "If your patients are noncompliant, then it's your fault [as the doctor]. You didn't convince them." And how can you convince your patients if they don't feel you respect them?

So to patients who think they deserve faster responses, shorter waits, and-yes-more respect from their doctors and practice staff, I say just wait a bit longer. You'll soon have your chance to tell them in a format that will force them to pay attention.

Improve patient billing experience to increase revenue

Fri, 01 Jun 2012 04:00:00 GMT

Improve patient billing experience to increase revenue

Patients today are overwhelmed by the complexity of medical bills. Physicians regret their patients' frustration, but they often don't realize how much it can impact a practice's revenue, says Joshua Greenberg, chair and president of Santa Monica (Calif.)-based HealthCPA, a company that helps both patients and physicians with healthcare billing management.

"Historically, physician practices have focused on where the lion's share of their revenue comes from-the payer. The patient side of it was just an afterthought," Greenberg says. "Now a number of physician groups are paying more attention to patient-friendly billing."

A poor patient billing experience can cost you money in several ways, Greenberg says. For example, patients may make numerous calls to the billing office but not get satisfactory answers to their questions. This creates overhead within the billing department and more paperwork for the provider-and worse, when patients are confused and left without answers, they leave bills unpaid, Greenberg says.

"Research shows us that about 40% of patients don't pay their bills simply because they're confused," he says. "They know they have health insurance, but this year it's a high-deductible health plan and they don't understand that the bill has been adjudicated and this $700 is what they really owe. So many patients just sit on the bill because they're confused and they assume they don't really owe that amount, that the insurance will cover it."

If Medicare or an insurer has denied a claim improperly, a poor interaction with the billing department may mean that the patient does not provide necessary information to get the claim paid, Greenberg says. With one in five claims mishandled and one in seven claims denied, a physician practice must devote substantial time to researching and resubmitting claims, he notes.

Getting patients involved in the reimbursement system is almost always a positive move, Greenberg says, because a letter from the patient usually has more impact than a letter from the physician. Patients are reluctant to do that, however, because they don't want to wade into the morass of the reimbursement system; instead, they assume that the insurer and the physician's office should sort it out themselves.

"That's how patients end up receiving collection notices and getting irate," Greenberg says. "They threw all the correspondence from the insurer in a shoe box and ignored it. To the extent that you can educate them on how the system works and their role in working with the insurer, both parties will end up better in the end."

Putting some of that work in the hands of a vendor who represents the customer can improve returns, he says. With individuals able to choose their own health plans much more than in the past, insurers are increasingly sensitive to keeping their customers happy, Greenberg says. And their customer is the patient, not you.

"In dealing with insurance companies for years, we see a very different experience when the billing process is driven by the doctor versus when it is driven by the patient, who is really the healthcare insurer's customer," Greenberg says. "When we partner up with the billing office of a physician group, they may have a claim that they have struggled with for months, but then we can get it resolved because we talk to the insurer as their client's representative. It's amazing how much difference that makes."

One of the most important ways to create a more patient-friendly billing experience is to be proactive with denied claims, Greenberg says. Remember that a denied claim doesn't just mean that you aren't getting reimbursed; it means that the patient is being denied too, and receiving that explanation of benefits in the mail can create tremendous anxiety and frustration.

"Proactive attention can be a big help to the patient," Greenberg says. "If you call that patient as soon as you know about the denial and explain any plans for appealing it or why you think this is the final adjudication, that can be a big help to them."

Service lines growing, but aligning physicians is tough

Fri, 01 Jun 2012 04:00:00 GMT

Service lines growing, but aligning physicians is tough

by Joe Cantlupe

As the HealthLeaders Media intelligence report Service Lines Grow Amid Strategic Challenges shows, most healthcare leaders anticipate that their service lines will grow over the next few years, with a big baby boomer-fueled push for oncology, orthopedic, and cardiology needs. And younger patients will generate the demand for wellness or neurological care, with new service lines to come.

Yet hospitals shouldn't automatically count on return on investment. There's great angst among hospital leaders, the survey shows, in plans to integrate physicians to deliver that bottom line.

Indeed, hospital systems are pushing vigorously to capture a burgeoning market with new service lines, from inpatient to outpatient. Over the next two years, 75% of hospitals say they plan on expanding their existing service lines, such as heart and oncology programs, and 50% say they will establish new service lines.

The MemorialCare Health System in Fountain Valley, Calif., is among the hospital systems exploring various pathways of service lines. As the hospital system explores population health and accountable care programs, they are "morphing into larger service lines" depending on the needs and demographics of the communities served, says Steve Geidt, CEO of Saddleback Memorial Medical Center in Laguna Hills, Calif.

At Saddleback, for instance, hospital leaders are exploring more geriatric and palliative care service lines to address a "very high concentration of very old seniors who are frail," Geidt says. "Our emphasis has been on disease management and end-of-life care."

At the Long Beach (Calif.) Memorial Medical Center, officials are looking into expanding pediatrics, wellness, neurosurgery, and neurology service lines, says Diana Hendel, PharmaD, CEO of Long Beach Memorial Medical Center, Children's Hospital Long Beach, and Community Hospital Long Beach.

Obstacles to hospitals' expansion of service lines include putting together physician teams to accomplish their goals, and the transition from fee-for-service to value-based care. The intelligence report shows that more than half-54%-of health leaders say it is difficult to attain physician alignment with organizational goals, and 8% say it is very difficult. Along those lines, 41% say it is difficult to develop physician compensation strategies.

As hospital systems work on aligning physicians in service lines, 74% say they are developing standard clinical and operational procedures. But only 35% say they involve physicians in fiscal oversight of organizations.

Geidt says he's not surprised by those findings. "It's hard," he says, referring to putting a physician team together for a service line. "It requires a lot of vision, a lot of capital, and a lot of energy." Not only are hospital systems working to improve that physician-hospital integration through EMRs, there's the human element. "There's a lot of independent physicians involved, and there's a lot of politics," he says.

Despite Geidt's cautionary comments, MemorialCare Health System's alignment with physicians may be considered relatively smooth compared to other systems because it has incorporated physicians into the process of hospital leadership and service line oversight for years.

At MemorialCare, a medical foundation and physician society were established to develop physician leadership programs, which have resulted in doctors "getting a true involvement in key decision-making areas," says Barry Arbuckle, PhD, president and CEO of the MemorialCare Health System and lead advisor for the HealthLeaders Media intelligence report.

Establishing data programs to help physicians within the system has been a key element in improving protocols, says Hendel, but so has the importance of working on physician relationships with each other and with hospital leadership.

"We've had a two-pronged effort here," Hendel says. "We have the data and strategic parts of aligning with physicians, but we've also been sensitive and aware of the cultural alignment aspects, with our physician society leading the way on a shared vision, a shared mission, a shared understanding, and involvement where we-as a health system-should be focused."

The return of the PHO?

Fri, 01 Jun 2012 04:00:00 GMT

The return of the PHO?

by Philip Betbeze

One common complaint about the transition from fee-for-service reimbursement to value-based schemes is that such groundbreaking changes cannot be done overnight and must be phased in. That's a problem for healthcare organizations that seek to be forward-thinking yet must continue to exist under current rules. A common refrain is that senior leaders feel as unsettled as a person with one foot on the boat and the other foot on the dock.

But there may be a way to bridge that transition through vehicles such as the physician hospital organization (PHO), which many hospitals and health systems formed under capitation more than a decade ago-and which many subsequently discarded as HMOs gave way to preferred provider organizations and as government payers continued to use fee-for-service reimbursement. However, the PHO, or at least something like it, is making a comeback as payers and the government make slow progress toward accountable care.

Commercial negotiation leverage

PHOs were developed in the 1980s as joint ventures between groups of independent physicians and hospitals or health systems as a way to pool risk and, in a key role that would signal their later downfall, offer more negotiating strength with payers. The PHOs were also expected to manage the continuum of care, and payers expressed a willingness to share some of the savings in utilization they were supposed to achieve.

But over time, many PHOs failed, largely because they were either unsuccessful in developing the technology and process infrastructure needed to manage utilization cost effectively, or they broke down among infighting between the hospital and groups of physicians. They also faced antitrust scrutiny.

"The way they were classically conceived came along when HMO risk contracts were in vogue," says Marty Manning, president of Advocate Physician Partners in Oak Brook, Ill., a Chicago suburb. Advocate operates one of the relatively few PHOs remaining from their inception in the 1980s and early '90s. "They would do credentialing, claims processing, some utilization management, contracting, and set fee schedules. Of course, the docs felt the hospital kept too much, and vice versa."

But most stumbled because they were constructed chiefly to gain negotiating might. Subsequently, the Federal Trade Commission (FTC) essentially outlawed any PHOs that weren't demonstrating better quality, efficiency, and lower overall cost.

"If they thought of themselves as an HMO risk vehicle, then the product life cycle ran its course because most areas don't have those risk contracts anymore," says Manning.

PHOs also fell out of favor as many physicians found ways to gain bigger pieces of the reimbursement pie by operating their own surgery centers, labs, and imaging centers. But many of those disincentives have withered as reimbursement for ancillary services operated by physician practices has been whittled away, as technology to help focus on care coordination has improved dramatically, and as the antitrust problems have been solved to the FTC's satisfaction. In fact, an FTC challenge to Advocate's PHO may have set the ground rules for a proliferation of future PHOs.

So why are many hospitals and health systems revisiting the structure as a way to better align the concepts of coordinated care with their independent physicians? Some never left, but many others are realizing that in a reimbursement system where hospitals' and doctors' financial fates are tied more closely together than ever, they have to work closely with their physicians, regardless of whether the physicians are employed by the system. The PHO can serve as a platform to unify the care protocols of both employed and independent physicians.

Recycling a relic?

It's helpful to get away from the vision of the PHO of the past. Manning says the new vision is a way for hospitals and physicians to begin to work together, including both employed doctors and those not ready to enter into full employment models.

"A PHO is a way to connect with the community-based physician practice model," Manning says. "Organizations dedicated to the employment model might see less value in a PHO than those who want a more pluralistic approach like we have chosen. The key is the value that can be created by truly integrating or engaging with physicians." This is why the integration factor is so important.

Iowa Health System (IHS), which includes 15 hospitals across Iowa and Illinois and more than 800 employed providers, seeks that pluralistic approach, says Alan Kaplan, MD, the system's vice president and chief medical officer, who has been building a PHO-like organization there for the past two years. The clinically integrated network (CIN), he says, is a nonprofit corporation based upon improving quality, enhancing patient experience, and increasing the overall value of healthcare. It's part of the longer-term strategy of engaging physicians as the system enters into risk- and performance-based contracting.

"When I came here, my boss, Bill Leaver, IHS president and CEO, told me that my main job is to build an ACO," he says.

In developing the ACO, Kaplan set about creating a CIN, which he says is taking place along with plans to integrate all of the owned physician practices at IHS under one structure. Physician alignment with IHS' employed groups began January 1, but Kaplan still needed a way to bring the area's independent physicians into the fold because forming an ACO, the ultimate goal, can't happen without them.

"It's great that we have employed physicians, but two-thirds of our medical staff is independent," he says. "They are our partners, and we cannot deliver care without them. So we have to engage them in our efforts to improve quality and create a better patient experience."

A critical part of that strategy is the CIN, Kaplan says, because it provides the platform for independent and employed physicians to work together to develop a care management infrastructure. One potential difficulty is that the CIN is not a joint venture-it's owned entirely by IHS.

To make the organization more physician-driven and welcoming of independents, the board of directors delegates significant authority to an operating committee composed of independent and employed physicians and physician group leaders. Only two IHS executives, Kaplan and Kevin Vermeer, the system's CFO, sit on that committee.

More than physicians

"Today's payment system doesn't support care management, but in the future, it will be demanded," says Kaplan. "We created our integrated care organization [ICO]-which is more akin to an independent practice association than a PHO-around a platform that focuses on quality improvement, not contracting."

The ICO that IHS is developing will administer value-based contracts throughout the health system's network, but will not operate as a contracting entity for fee-for-service.

"What success looks like is improved quality, enhanced patient experiences, and lower overall healthcare costs," Kaplan says. The ACO that IHS is developing will include physicians in key leadership positions because "the physicians are the heartbeat of the ACO."

But in building an ACO, the infrastructure to create value often spans beyond the direct physician sphere to include information technology-enabled clinical analytics, call centers, palliative care, home health, and skilled nursing.

Kaplan and others are busily putting these pieces together, which has involved hiring additional staff and reshuffling some internal talent.

"We didn't have trained people for care management," he says. "It's a lot of work to build the right care management teams and develop their skills so we can build a network."

A pathway to employment

As usual, a burning platform is needed to lead change, Kaplan says. In his market, it was healthcare reform leading to likely CMS shared savings and commercial ACO contracts. But he questions whether the CIN will be a permanent fixture in the healthcare landscape. In this climate, even the definition of what a hospital is seems up for debate.

"It's a comeback for the concepts of the original PHOs," he says. "These are bridging strategies, which allow us to work together. If external factors support CIN structures in the future, they may last."

But Kaplan acknowledges that environmental forces encouraging greater levels of coordination to improve quality and lower costs may end up forcing increasing numbers of healthcare organizations to adopt the integrated delivery system model.

"The ICO is a vehicle whereby our independent physician partners can remain independent, but if the market changes and we need tighter alignment, we will be in a better position to migrate there," Kaplan says. "I believe ultimately that's what's going to happen."

Even Manning, with his perspective as part of perhaps the oldest and most vetted PHO in the nation, says the PHO role is the transitioning structure that will increasingly serve as a nerve center for dialogue about improving clinical outcomes, efficiency, and patient experience.

"It has its own culture and a sense of citizenship, but what is the meaning of independence in an accountable care world?" he asks. "At the same time, most of the physicians who become employed are currently members of our PHO. Almost exclusively here, any physician who becomes employed starts in the PHO. But it doesn't matter if you're employed or private practice. The only thing that matters is performance."

Electronic submission of medical docs trial goes live

Fri, 01 Jun 2012 04:00:00 GMT

Electronic submission of medical docs trial goes live

by James Carroll

In March 2011, CMS announced its esMD (Electronic Submission of Medical Documentation) tool, which is an option for providers to electronically send medical documentation that is requested of them by Recovery Auditors and other government entities' contractors. Phase 1 of esMD kicked off on September 15, 2011. During this period, providers will still receive medical documentation requests via paper mail but will have the option to send their documentation to the requesting review contractor electronically.

Benefits of the esMD gateway

If you ask them, providers currently involved in their facility's recovery audit program won't hesitate to illustrate some of the correspondence issues that they are experiencing with their respective reviewing contractors. With the implementation of esMD, providers may enjoy a decrease in administrative burden and improved submission tracking when it comes to record requests, suggests Amanda Berglund, MS, MBA, COO of Pace Healthcare Consulting, LLC.

"Right now, providers are still saving medical records to CD-ROMs as PDF files and shipping these CD-ROMs to contractors. Even though you have a tracking number and somebody's signed for it, the recovery auditor or the [Medicare administrative contractor] may say they didn't get it. The facility may need to recreate and reship the files to ensure acceptance within the set deadlines," says Berglund. "But with esMD, there's an electronic trail and a report that indicates when the entity has received your medical records, whereas right now it's very proactive; you have to call UPS® or FedEx®, see who at the contractor signed for it, and check on the claim status tool to see if it's been received."

The ultimate goal of the program is aimed toward converting the process to be entirely online, says Elizabeth Lamkin, MHA, CEO of Pace Healthcare. In addition, the program is going to go a long way in protecting providers from a HIPAA standpoint. "It will reduce paperwork and costs, but also, with everyone being mandated to go to an EHR system, this is the logical next step. Also, with the Office of Civil Rights all over HIPAA, this definitely makes sense from a security standpoint," Lamkin says.

Berglund says, "The ultimate point I'd make with esMD is that this is now available and providers should be using it, as it's sure to be more effective, secure, and expedient than sending your records out in the mail."

For more information on esMD, visit www.cms.gov/esmd/01_overview.asp.

The Doctor's Office, June 2012

Fri, 01 Jun 2012 04:00:00 GMT

Strategic physician recruiting

by Karen Minich-Pourshadi

Forecasting need

Intentional candidate profiling

"You want to know the individual is going to have the right qualifications but that the personalities will also fit," says McMahon.

Shulkin agrees. "Depending upon the level of the position, we may approach [the creation of this profile] a little differently, but you want input," he says.

Work the in-house network

"We do it cheaper and better," Nunn says. "The only weakness with in-house recruiting is we can't cast a wide net like some of the big agencies."

"If a physician is ready to leave, then they can choose another of our hospitals and know there will be certain standards they can rely on," says McMahon.

Marketing know-how revs physician recruitment strategy

by Marianne Aiello, with contributions by Karen Minich-Pourshadi

Identifying marketing's role in recruitment

Robinson and his team decided that the best vehicle to communicate this message was through a recruitment microsite featuring video testimonials, physician profiles, and benefit highlights.

"And in the videos we interviewed top physicians and asked what drew them here," Robinson says.

Attaining instantaneous results

Patients set to unleash feedback on doctors

by Cheryl Clark

Recently, a friend on Facebook® posted a status update about a bad visit to the doctor's office:

She might as well have poked a tiger. Her update prompted several comments, all of which related similar humiliating experiences.

"I waited half an hour this morning while my doctor was schmoozed by some pharmaceutic[al] floozie. Very irritating," one person wrote.

They think they get to act that way because of "what we pay them," answered another.

Patient vehicles to rate experience

Given the above, doctors should brace for an earful about scheduling difficulties, hour-long waits, perceived disrespectful attitudes, and unreturned phone calls.

The survey poses questions such as the following:

During your most recent visit, did this provider listen carefully to you?
In the past 12 months, when you phoned this provider's office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?
During your most recent visit, were clerks and receptionists at this provider's office as helpful as you thought they should be?

Impact on quality of care and outcomes

"When you parse out 'respect' with these individuals, it turned out that it masked things like, 'You kept me waiting around,' 'You didn't listen to me,' 'You treated me rudely,' " Moore says.

Improve patient billing experience to increase revenue

Service lines growing, but aligning physicians is tough

by Joe Cantlupe

Yet hospitals shouldn't automatically count on return on investment. There's great angst among hospital leaders, the survey shows, in plans to integrate physicians to deliver that bottom line.

At Saddleback, for instance, hospital leaders are exploring more geriatric and pa

Homing in on the medical home

Tue, 01 May 2012 04:00:00 GMT

Homing in on the medical home

by Edward Prewitt

The concept of the patient-centered medical home (PCMH), introduced by the American Academy of Pediatrics way back in 1967, continues to gain steam. But what does it mean to be patient-centered?

Healthcare leaders discussed the motivation for PCMH and the path to creating one at HealthLeaders Media's Rounds event, The Business and Clinical Path to the Medical Home, hosted by St. Joseph Health System in Orange, CA.

Speakers at the event included C.R. Burke, president and CEO at St. Joseph Heritage Healthcare, the physician practice organization of St. Joseph Health System; Lee Penrose, president and CEO of St. Jude Medical Center, a 384-licensed-bed hospital in Fullerton, CA; G. Scott Smith, MD, medical director at St. Joseph Heritage Medical Group; Ewa Matuszewski, CEO of Medical Network One, a physicians' services organization based in Rochester, MI; and Jeff Gartland, senior vice president of connectivity and clinical integration services provider RelayHealth, which sponsored the Rounds event.

Penrose recalled the concerns he had after hiring a consultant to interview patients. "We asked them to come in and look with fresh eyes, talk with some of our patients, talk to community members about what they think about healthcare,” Penrose said. "The resounding answer we got back was: Healthcare is something you have to navigate your way through.

"We didn't always like a lot of what we heard,” Penrose admitted. "But we listened and made changes so that we could develop the essential elements of a patient-centered home-working closely with our communities, inspiring the team, and setting common goals for our patients' health.”

The interviews occurred early in the formation of a PCMH within St. Jude's parent organization, St. Joseph Health System, which has annual revenues of $4.5 billion.

Today, St. Joseph Heritage Medical Group, one of several physician practices under the St. Joseph umbrella, operates as a Level 1 PCMH, as recognized by the National Committee for Quality Assurance. Penrose and his colleagues emphasized that achieving this designation was a slow process, requiring substantial investment and groundwork, even for an already integrated health system. "This isn't a journey that started 18 months ago, or whenever it was that [PCMH] became a big topic. This started for us in 1994, and we built on it. The long-term perspective is very important,” said Smith.

The medical home approach is in keeping with St. Joseph's approach to healthcare, Penrose said. "We're all about promoting health … thinking about population health, the health of the communities we serve. It's very important to us that we do more than just acute care, but also reaching out into the community-and what a great way to do it,” he said. The organization's working definition is that "the patient-centered medical home describes how primary care practices should operate to ensure high-quality care and patient safety, as well as work within an integrated healthcare system.”

Information technology (IT) is important for PCMH. The integration necessary for a medical home requires IT connections. St. Jude invested $15 million in information systems, including an EMR system.

In 2009, the Healthcare Information Management Systems Society named St. Jude Medical Center among the top 1.6% of the nation's hospitals for its use of EMR to benefit patient care. EMR adoption did not come immediately, but has since become a key element of the medical home infrastructure.

Burke listed five elements of the medical home's IT infrastructure:

EMR/electronic health record
Patient health records
Shared case management
Utilization
Risk stratification and predictive modeling

All of these must work in concert within the PCMH. The medical home is not simply an IT project, however-a point emphasized by Gartland. PCMH "is deployed through technology and supported by technology, but it is a true business model transformation,” he said.

Another important step in building a successful medical home is getting the buy-in of physicians, Smith said. "The real big winner for doctors with PCMH is quality of care,” he said. Physicians "like to do two things: They like to take care of patients, and they like to provide quality care. If a healthcare system can provide the structure to do that and then give them the reward and feedback … you've got a medical home.”

According to Matuszewski, when the IT infrastructure is in place and doctors are on board, physician practices and healthcare systems preparing to launch a medical home should take five steps:

Appraise your practice's readiness for change: Does the culture frown on innovation or see a need for a new approach?
Evaluate the people who will be part of the medical home team: Are key players resistant, and if so, can they be won over?
Identify a medical home champion from within the practice.
Create a mission and vision to be adopted by the new medical home.
Create a specific project plan.

So what comes after the PCMH? St. Joseph executives envision a patient-centered medical neighborhood on the near horizon. A collection of PCMHs within a single healthcare system would dovetail nicely with accountable care organization (ACO) requirements.

The medical home is a critical step to achieving ACO status, Penrose said. The PCMH is designed to foster collaboration with physicians across the continuum of care and is the most efficient model for adopting clinical IT with both hospitals and physician offices.

And so, after 45 years, the PCMH model is finding a home at a time when coordinated and accountable care is becoming increasingly relevant.

Primary care docs weigh advantages of PCMH

Tue, 01 May 2012 04:00:00 GMT

Primary care docs weigh advantages of PCMH

by John Commins

WellPoint, Inc.'s plan to increase reimbursements for primary care physicians (PCP) who transition to patient-centered medical homes (PCMH) could signal a tipping point in the move toward the new care management model.

That's according to Glen R. Stream, MD, a family physician from Spokane, WA, and president of the 100,300-member American Academy of Family Physicians.

"It is a significant step in the right direction," Stream says. "WellPoint is a large insurer and their program has some features that are very much in line with what the academy has been promoting for some time: to align the payment model to support the medical home model of delivering primary care."

Indianapolis-based WellPoint, with 34 million members in affiliated plans, announced in January that it would "increase revenue opportunities? for some PCPs who participate in a patient-centered primary care medical home model.

The plan calls for care management fees for PCPs, who could see fee increases of about 10% with incentives that could improve payments by as much as 50%. The Wall Street Journal reported that WellPoint now spends between 6% and 8% of its $100 billion in annual claims on primary care, but that the payout could increase by an additional two percentage points under the new model.

"Primary care physicians who are committed to expanding access, to coordinating care for their patients and being accountable for the quality of care and the health outcomes of those patients, will get paid more than they do today, and we're committed to helping them achieve these quality and cost goals," Harlan Levine, MD, executive vice president of WellPoint's Comprehensive Health Solutions, said in a media release. "Primary care is the foundation of medicine, and it can and should be the foundation of our members' health."

Levine said that WellPoint's medical home models have seen an 18% decrease in acute inpatient admissions and a 15% decrease in total ED visits, while also improving compliance with evidence-based treatment and preventive care guidelines.

Stream says WellPoint's announcement that it will pay for care management "sends a message to primary care physicians that there is an advantage for them to transform practices because payments will align with that."

"We have had a bit of a chicken-and-egg problem with patient-centered medical homes," he says. "Physicians say," Pay us more, we will transform the practice.' The plans say," Transform practice and we'll pay you more.' Our responsibility in the academy is to see that there are enough of these plans moving to this payment model in an assured way so we can communicate and assist our members in transforming."

Any move to pay for care management would also make primary care a more attractive field for medical students, Stream says. "It sends an important message to medical students that we are trying to get people to choose primary care specialties," he says. "We don't want them to have that financial barrier of their educational debt and the serious discrepancy between subspecialty and primary care pay to be a disincentive to choose primary care."

Stream says a number of initiatives announced over the last several months by the federal government and private payers indicate that the PCMH model may soon expand beyond pilot project status.

He notes that at the end of September 2011 the Center for Medicare & Medicaid Innovation announced a primary care initiative that includes a similar care management fee for Medicare and Medicaid patients in a half-dozen test markets.

"The idea in those five to seven pilot markets is to get to at least 60% of their patients in the practice covered under that payment model, including the care management fee that supports the services that are part of the patient-centered medical home," Stream explains. "I'm not sure how they came up with that 60% number, but it seems like a reasonable tipping point to get the practice and enough of its payers aligned with that to make it meaningful."

But until more private payers across the nation are willing to embrace the PCMH concept within their networks, Stream says many PCPs will keep their distance.

"You have an issue if you are in a market where only 20% of your business is WellPoint," he says. "This is a great initiative, but is 20% enough if 80% of your patients are still covered by more traditional fee-for-service payment that is not paying adequately in primary care Is that going to be enough to make the transition?"

It's a step in the right direction, but it is not the be all and end all, Stream says. "The real issue [is] how many other payers are going to be willing to do this? Can we get to that critical mass that gets us over the hump for individual practices having enough patients under this payment model that allows them to transform and maintain their practices?"

Understand three-day DRG payment window to improve reimbursement

Tue, 01 May 2012 04:00:00 GMT

Understand three-day DRG payment window to improve reimbursement

CMS' rule for billing preadmission nondiagnostic services has long determined how physicians can bill for certain types of care, like presurgical lab tests, before a patient is admitted to a hospital, but now the requirements have been changed. The new rule broadens the requirement so that more outpatient procedures will have to be bundled with the inpatient billing.

The rule change could complicate billing procedures for physicians, increase denials, and result in a loss of revenue, explains Lawrence W. Vernaglia, JD, chair of the Health Care Industry Team with the law firm of Foley & Lardner in Milwaukee. It also will require more coordination between physician practices and hospitals with which they are affiliated.

"Historically, the three-day rule was interpreted to apply to all diagnostic services that occurred in those three calendar days before admission," Vernaglia says. "Nondiagnostic services were added later, but only if they were clearly and exactly related to the cause of admission. Now that's been broadened."

CMS changed the requirements on November 1, 2011, when it issued the final rule for the 2012 Physician Fee Schedule. One section of the final rule was a clarification of the application of the three-day diagnosis-related group (DRG) payment window for preadmission nondiagnostic services. The three-day window was long interpreted as applying to diagnostic services furnished in a hospital's provider-based departments or entities, such as physician clinics housed within the hospital, Vernaglia explains. All preadmission diagnostic services furnished within three days of an inpatient admission had to be bundled in the inpatient claim. Preadmission nondiagnostic services furnished within three days before the inpatient admission had to be bundled into the inpatient claim only if there was an "exact match" of the principal ICD-9-CM diagnosis code for the outpatient encounter and the inpatient admission.

That last part was changed in the new rule, says Vernaglia. Now preadmission nondiagnostic services must be bundled if they are "clinically related" to the reason for the patient's admission.

"An exact match meant all the way to the fifth digit of the ICD-9," Vernaglia explains. "Very few outpatient procedures needed to be bundled unless they were a preparatory procedure in advance of the inpatient treatment."

The rule change also signals CMS' commitment to enforcing the three-day rule. In the past, Vernaglia says, most freestanding practices and their associated hospitals were not too concerned with complying with the rule because it applied in so few instances and CMS did not seem interested in enforcing it. With provider-based outpatient care, hospitals often went the other direction and bundled everything-it was simpler than deciding on a case-by-case basis.

The hitch came when Recovery Auditors were hired by Medicare to sniff out overpayments. The Recovery Auditors reported that some hospitals were making too much money on bundling and suggested that better enforcement was the solution, Vernaglia says. "CMS thought they could save $2.5 billion by broadening it and enforcing it," he says.

The rule change could threaten physician revenue because if the physician's outpatient treatment is bundled, the physician's fee will be adjusted downward and billed as if the care were provided in a provider-based setting, Vernaglia explains. "That will be the case especially with proceduralists."

Vernaglia suggests that affected physicians address the issue soon. One solution would be for the employer to increase physician compensation rates, he says. "Presumably, CMS thinks the income is being shifted to the hospital that owns this medical practice, so that makes it fair for the hospital to compensate the physician for the change in revenue," Vernaglia says.

Adapted from Managed Care Contracting & Reimbursement Advisor, March 2012.

Three-day rule applies to broad range of providers

The three-day diagnosis-related group payment window recently changed by CMS is not limited to wholly owned/operated physician practices, but also applies to any other wholly owned/operated entity providing outpatient services, explains Lawrence W. Vernaglia, JD, chair of the Health Care Industry Team with the law firm of Foley & Lardner in Milwaukee.

CMS did indicate that rural health clinics and Federally Qualified Health Centers are not subject to the three-day window policy. This is because they are paid an all-inclusive rate. Critical access hospitals are, somewhat similarly, not covered by the three-day window rule, as they are cost-reimbursed.

The bundling rule applies to outpatient services in hospitals' wholly owned/operated entities, Vernaglia says. "We're talking about not just hospital outpatient departments, but also freestanding physician practices that are owned or controlled by the hospital," he explains. "This will apply to a lot of practices that operate as independent physician practices but in fact have some financial ties to the hospital."

However, the rule does not apply to a freestanding physician practice that is owned by a parent corporation that also owns the hospital, he explains. In the final rule, CMS indicated it thought most wholly owned/operated entities were already departments of the hospital.

However, Vernaglia says many such entities are not hospital departments, nor are their costs comingled with the hospital's costs. He says this creates two issues: 1) whether to transfer the facility component charges from the freestanding entity claim to the inpatient hospital claim; and 2) whether to transfer the "cost" of the bundled services to the applicable hospital department.

CMS says "hospitals should accumulate the costs incurred and the adjustments required for these services and report as costs with related organizations on the Medicare cost report."

"This means cost report preparers will need to make adjustments on Worksheet A-8 or A-8-1 to add the costs for the preadmission services provided in the freestanding entity to the appropriate department in the hospital's annual Medicare cost report, to achieve a proper matching of revenues and expenses," Vernaglia says.

Affected physician practices should coordinate with the hospital's revenue cycle and patient account contacts to ensure there is a method of communicating when services are performed that should be bundled. "This is a mighty hard change to implement," Vernaglia says. "One of the reasons these practices are independent is that they are not integrated into the hospital. If they were, they'd probably be deemed provider-based."

In many cases, the hospital will not even know that the patient was seen at the physician's practice in the prior three days, Vernaglia says. "I hope CMS is going to be patient as practices implement this new rule," he says. "They seem to be aware of the challenges here."

Don't let your iPad get in the way of good bedside manner

Tue, 01 May 2012 04:00:00 GMT

Don't let your iPad get in the way of good bedside manner

In the medical setting, electronic devices are supposed to help improve communication between physicians and various individuals and functions in the hospital. Despite how handy they are, mobile devices can negatively affect a physician's interactions with patients. Some patients may feel that physicians have become so distracted by their devices that they neglect the patient's need to feel listened to.

"Mobile devices aren't necessarily going to make anyone a better interpersonal communicator, but they can make you a worse one if you are not careful,” says Chad Udell, managing director of Float Mobile Learning, a consulting firm focused on mobile learning strategy and development, in Morton, IL.

Medical staff leaders should pass these three simple tips on to staff physicians to ensure that mobile devices don't take over the physician-patient relationship.

Tell the patient what you are doing

No one thinks twice when a physician walks down the hallway with a clipboard and pen, but mobile devices are still new to some patients. Whenever a physician pulls out a mobile device to access patient information or check medication indications, he or she should explain to the patient the purpose of the device.

"The doctor can jovially state, ‘We are transitioning to digital recordkeeping-I am not playing Angry Birds. This method is quicker than looking for your file in the records area or carrying binders and clipboards,' ” says Udell.

Adjust your settings

Physicians can adjust the settings on their mobile devices to alert them of incoming communications such that it doesn't interfere with the physician-patient interaction. Putting a phone on vibrate is less jarring to a conversation than a loud ringtone, and physicians can adjust the number of times a smartphone alerts them to an incoming e-mail.

"There are a lot of tools you can put in place to make sure your usage of the devices is fruitful and sequestered to the appropriate times,” says Udell.

Adjusting the settings on a mobile device can only get a user so far, though. Users must judge when it is appropriate to respond to a phone call or text or e-mail alert.

Bring the patient into the experience

Physicians should use their mobile devices openly, such that patients can see them accessing medical records or looking up drug interactions. If there are diagrams or visuals the physician can use to educate the patient, all the better, says Udell. By including patients in the experience, physicians can reduce patients' feelings of alienation. These small gestures can make all the difference to patients, even tech-savvy individuals who use mobile devices of their own.

Adapted from Medical Staff Briefing, March 2012.

Mobile devices causing dangerous distractions

Mobile devices, such as smartphones and tablet computers, are certainly handy, but a New York Times article, "As Doctors Use More Devices, Potential for Distraction Grows,” highlights the dangers posed by electronic devices in the healthcare setting. According to the article, 55% of perfusion technicians acknowledged that they had talked on cell phones while monitoring bypass machines during heart surgery. The article also calls to attention a surgeon who used a hands-free headset to make more than 10 phone calls to family and associates during surgery. He left a patient partially paralyzed and was sued for malpractice, but the case was settled before it got to court.

Physicians may be aware they are not supposed to be using their devices in certain circumstances, but many do it anyway because these devices have become so engrained in their everyday lives. It is important for medical staff leaders to educate physicians on appropriate use.

A Hospital Impact article, "Prevent fatal IT distractions with hospital support, enforcement,” encourages managers to speak to employees when they see them using their mobile devices inappropriately. If the medical staff does not have a policy regarding the use of mobile devices, it might be time to add language to the disruptive behavior policy.

5010 logjam means no pay for physicians

Tue, 01 May 2012 04:00:00 GMT

5010 logjam means no pay for physicians

by Joe Cantlupe

A strange thing is happening as physician practices transition toward HIPAA Version 5010 electronic transactions: Docs aren't getting paid.

Physicians are flooding their advocacy groups with complaints and questions about "cash flow problems.”

"We haven't seen anything like this before,” said Robert Tennant, MA, senior policy advisor at MGMA, referring to the onslaught of e-mails from distraught doctors.

Since the mandated transition to HIPAA Version 5010 began January 1, data disruptions, unforeseen rejections of claims, and improper mailings because of address issues have stopped docs from getting paid.

Beyond that, communication snafus with clearinghouses and secondary payers have been a problem. The bottom line: These issues and more are resulting in payments not making it to physician offices, according to MGMA.

While the number of physicians affected has not been specified, it is likely in the thousands. A flurry of meetings and e-mails between CMS and physician groups was under way in February, but authorities didn't expect any resolution to the issues for weeks.

Problems have been reported with both Medicare administrative contracts and commercial plans. Some physicians have resorted to taking out lines of credit simply to meet payroll and other expenses. No one seems to be able to pinpoint specific reasons for the cash flow problems.

AMA President Peter W. Carmel says that since the 5010 standard was implemented, physicians have been "experiencing very alarming problems that have resulted in significant interruptions in claims processing and cash flow.” As a result, more postponements should be made for any enforcement deadline of HIPAA Version 5010, he says.

Recently, CMS' Office of E-Health Standards and Services announced a 90-day period of "enforcement discretion” for compliance with the new 5010 HIPAA transaction standards. CMS extended the 5010 compliance deadline to March to allow more physician practices the opportunity to implement the new billing coding standard without incurring penalties.

When asked about the payment issues and the CMS 5010 enforcement deadline, Carmel says: "The AMA fully expects that another extension to the 5010 enforcement deadline will be needed to resolve the emerging issues. We are reviewing timeline recommendations for an extension, but it is clear that no enforcement action should be taken until the vast majority of physicians are being paid in a timely manner under the 5010 standard.

"These problems are particularly troubling since cash-strapped physicians are burdened with meeting several other government requirements, including quality reporting, e-prescribing, meaningful use, and of course, ICD-10,” Carmel adds.

Specifically, MGMA has called for an extension of the enforcement delay from March 1 to June 1. In a letter to HHS Secretary Kathleen Sebelius, MGMA has recommended to instruct Medicare Administrative Contractors (MAC) to "immediately” provide advance payments for physician practices that are struggling to meet Version 5010.

Moreover, HHS was asked to permit clearinghouses and health plans to accept and adjudicate Version 5010 claims that do not have all the required data content, and instruct the MACs to expeditiously adjudicate all outstanding claims.

Physician groups say that the government needs to take prompt action because physician practices may eventually face delayed revenue and operational difficulties, reduced ability to treat patients, or even the prospect of closing practices. MGMA officials have not specified any particular impacts from the situation.

The situation highlights the delicate balance of uncertainties between government mandates and private physician groups. It spotlights the issue of the fragile, and possibly tentative steps needed to enforce new deadlines. Physician groups also raise concerns about the move toward ICD-10, considering that the magnitude of that mandate is even greater than Version 5010's reach.

Many physicians report not having been paid by Medicare or TRICARE since November 2011 as a result of the Version 5010 issues, according to the letter sent by MGMA President and CEO Susan Turney, MD, MS, FACP, FACMPE, to Sebelius.

As for CMS, it has little to say publicly on the issue. "HHS has a correspondence response process and CMS will be contributing to development of HHS' response,” says Joe Kuchler, a spokesman for CMS, referring to a letter from MGMA. "In the meantime, MGMA's letter is considered open correspondence and we can't comment on specific issues.”

While practices have contacted their MACs to receive clarification on the reason for rejected claims, they are provided with little or no information beyond a vague explanation that problems must "lie with your clearinghouse,” according to Turney's letter.

Oddly enough, some practices are taking drastic action to try to circumvent the cash flow problems with electronic records.

They are reverting to paper claims, Tennant says. "If they have to drop back to paper, we don't recommend it, but if that's the only way to get paid, they may have to take that step,” he says. Tennant says MGMA is recommending that physicians take their cases, if necessary, directly to CMS. "The more complaints CMS hears, the more chance they will take action,” he says.

Medicare physician payment rule factors in GPCI

Tue, 01 May 2012 04:00:00 GMT

Medicare physician payment rule factors in GPCI

by HCPro staff

The final 2012 Medicare physician payment rule from CMS includes an adjusted fee schedule for the Geographic Practice Cost Index (GPCI) that some industry leaders say is a great deal more fair to many physicians.

As a result of intense lobbying by the California Medical Association (CMA), CMS adjusted the fee schedule so that a larger percentage (3%) of the payments are adjusted for geographic differences in practice costs. This adjustment prevented large cuts in 2012 and will help California physicians in future years.

CMA provides the following summary of other major changes in the fee schedule:

E-prescribing. CMS finalized its proposal for the 2012 and 2013 incentive, and 2013 and 2014 penalty programs. Despite continued CMA and AMA opposition, physicians will need to report 10 times during the first six months of 2012 and again in 2013 to avoid application of e-prescribing penalties in subsequent years.
Physicians may use claims-, registry-, or electronic health record (EHR)-based reporting methods. Improvements to the program, which the CMA and AMA supported, include allowing the use of a certified EHR to e-prescribe and making it easier to avoid the penalties by (1) not requiring physicians to link the e-prescribing codes to qualifying visits, and (2) allowing physicians to apply for additional hardship exemptions online.
Physician Quality Reporting System (PQRS). In response to CMA/AMA advocacy, CMS finalized its proposal to provide interim feedback reports for physicians reporting individual measures and measure groups through claims-based reporting for 2012 and beyond. These reports will be a simplified version of the annual feedback reports that CMS currently provides and will be based on claims for the first three months of each program year.
The interim feedback reports will be provided to physicians during the summer of each program year. Despite strong opposition from the physician community, CMS finalized its proposal to use 2013 as the reporting period for the 2015 PQRS penalty. If CMS determines that a physician or group practice has not satisfactorily reported quality data for the 2013 reporting period, its 2015 payments will be reduced 1.5%. The rule also redefined "group practice” under the Group Practice Reporting Option as a group of 25 or more eligible professionals.
Value modifier. While acknowledging the strong opposition of CMA, AMA, and others in organized medicine, CMS finalized its proposal to base payment adjustments in 2015 on yet-to-be-determined cost and quality measures to be finalized in November 2012. Quality measures for the modifiers will most likely be based on PQRS and EHR measure sets.

Cost measures to be used in the modifier will be based on average total per capita cost for the physician's patients and per capita cost for four conditions (chronic obstructive pulmonary disease, heart failure, coronary artery disease, and diabetes). CMA will continue to oppose the value modifier payment methodology and urge Congress to withdraw it.

The Patient Protection and Affordable Care Act established the value modifier, which in 2014 will pay physicians more than the Medicare fee schedule if they successfully report on quality measures and spend less than the national average per patient. It will also pay physicians less if they spend more than the national average and do not successfully report on quality measures.

Multiple procedure cuts. In response to comments from AMA, the AMA/Specialty Society RVS Update Committee (RUC), and many specialties, CMS scaled back its proposal to apply a 50% reduction to the professional component (PC) of certain imaging services. Instead, the rule applies a 25% reduction to the payment for the PC of second and subsequent CT, MRI, and ultrasound services furnished by the same physician on the same patient in the same session on the same day.
Lab test signatures no longer required. CMS has retracted the requirement for physicians to sign paper lab requisitions for clinical diagnostic laboratory tests-a policy AMA strongly opposed.
Annual wellness visit (AWV) changes. CMS is increasing the payment for the AWV codes to recognize additional resources associated with adding a health risk assessment to the service's requirements, but is continuing its policy of not covering a physical exam as part of these services.
RUC. In a significant accomplishment, the RUC persuaded CMS that the resources involved in hospital observation care visits and hospital inpatient visits are equivalent. CMS also accepted the vast majority of the RUC's recommendations. However, the RUC had recommended that CMS begin paying for telephone calls, anticoagulant management, team conferences, and patient education in 2012. CMS did not announce any plans to consider payment for these services, but emphasized that the agency will continue to work with stakeholders to ensure that care coordination and primary care services are appropriately recognized.

The payment impact by specialty is available online. The fee schedule and additional information is available on CMS' website at www.cms.gov/physicianfeesched.

Convincing rival docs to become partners

Tue, 01 May 2012 04:00:00 GMT

Convincing rival docs to become partners

by Joe Cantlupe

To organize teams of erstwhile rivals, health system leaders must manage egos, negotiate ambitions, and acknowledge that they may be bringing on board some professionals who can't stand one another.

Merging groups in healthcare are often forced to work together after being competitors for years. Can physicians who compete and dislike one another put their differences aside and join a hospital organization with the shared goals of maintaining quality and reducing costs? Can they overcome the competitive mind-set? Can they achieve championship-quality healthcare?

It is a difficult process that health systems are beginning to grapple with, especially as more physicians become aligned with hospitals, says Lawrence S. Levin, PhD, a leadership and team consultant. Levin, founder and president of the Levin Group in Atlanta, and author of Top Teaming: A Roadmap for Leadership Teams Navigating the Now, the New, and the Next, often works with former competing specialty groups to develop the team mind-set he says is needed for a successful practice or relationships with hospitals.

"Sometimes it gets ugly, and it can get ugly pretty easily," Levin says.

At St. Joseph's Regional Medical Center in Paterson, NJ, things apparently had gotten ugly for a while with physicians and their department chairman, who had apparently announced that he would "separate their skulls from their bodies" if they disobeyed him. The doctors' medical group left the hospital and then sued. In January, a jury decided that the chairman and the hospital should pay the doctors $1.7 million.

"When it gets ugly with physician groups and hospital administration, it gets uglier than in a lot of other businesses and it becomes much more personal for some reason," Levin says, speaking generally and not about the Bergen County case. "You have to reset the clock. Why are you there? What do you agree on? It may sound soft and fuzzy, but it's not. You understand what everyone's interests are and you proceed forward, then face the dialogue.?

Levin discussed the following three moves that leaders must make in creating a functioning team out of once-competing physician groups and hospitals:

1. Forget the vision thing. Levin says that while many groups get together and talk about a vision, few actually realize it. Too often, they rely on a statement without substance.

Levin worked with merging medical groups to make their vision practical. "We pulled together the leadership from these groups, and we really began the dialogue by talking about why the people in the room were there, what they stood for," he says. "We elevated the conversation about what their frame of reference was, what they were about. Why did they go into medicine in the first place? What was the most important thing for them?"

It was about creating a potential vision of what these groups would do instead of a vision statement, Levins says. "Vision statements are rarely practical. They are aspirational, and when put under pressure, they dissolve pretty quickly. "If you don't understand what people want and what their expectations are, what their self-interests are, aspirations don't stand the test of battle very well."

2. Act like a hostage negotiator. Oddly enough, Levin finds that some standard hostage negotiation techniques are helpful in dealing with healthcare rivals planning on becoming partners. From the outset, when a negotiator speaks to a hostage-taker and wants him to change his position, "the one thing they do is get to a common ground," Levin says. "They have to agree on something to begin with. In hostage negotiations, they may agree it's nighttime, or that everybody is nervous."

Once there is a point of agreement, "when you run into difficult issues, then you circle back to what you agreed on," Levin says. The same technique can be used in negotiations with healthcare leaders.

3. Don't pretend you all like one another. Levin worked with a group of hospital and physician leaders who had tried to make a deal, but at the 11th hour, after attorneys, accountants, and various business models, they broke off the negotiation. Some admitted that the deal breaker was that they just didn't like one another.

Newly formed teams often mistakenly think it's okay if they just set aside their disagreements and not put them out front. That's what happened with this group, Levin says. Eventually, the differences rise to the surface. "What they tried was peace over trust," he says. "Peace over trust rarely works. You acknowledge the issues and make agreements around those issues, and over time you build trust.

"We acknowledged there were issues that were not going to fully resolve. They had some people who didn't like each other, but they had a working agreement and kept to that agreement," he says.

Why should the group members go to so much effort to bridge their differences? Levin's book on "top teaming" discusses the teamwork concept and opportunities, as well as obstacles. "Top teams carry with them tremendous collective intelligence, operating experience, and the ability to exert significant influence over their company's mind-set, focus, and performance," he says.

Stage 2 meaningful use proposed rules released

Tue, 01 May 2012 04:00:00 GMT

Stage 2 meaningful use proposed rules released

by Margaret Dick Tocknell, with additional reporting by Cheryl Clark

The long-anticipated proposed rules for Stage 2 meaningful use were released in February by HHS.

In a press conference at the annual conference for the Healthcare Information and Management Systems Society, Farzad Mostashari, head of the Office of the National Coordinator for Health IT, characterized the proposed rules as "reducing the regulatory burden? for providers. He noted that the proposed rules are consistent with recommendations by the Health IT Policy and Health IT Standards committees. Mostashari highlighted these aspects of the proposed rule:

Regardless of when they start, everyone would have two years in Stage 1, two years in Stage 2, and two years in Stage 3
A 90-day reporting period would be retained for the first year
By default, vendors would enable encryption on end user devices
The rule also allows medical groups to report quality measures as a group instead of on an individual basis ?

When asked to put meaningful use in perspective with regard to healthcare reform efforts, Mostashari noted that providers now care about how they do on quality and patient satisfaction measures, and how well they coordinate care.

"There are such a number of payment changes happening. It's almost as if Medicare unplugged a dam and there's just an explosion of new initiatives. It's really, really good because it provides, finally, a business case for the coordination of care that we need and, frankly, which health IT enables.?

The 455-page document released by HHS also includes these points:

Stage 1 of meaningful would be extended to fiscal year 2014
There would be two new menu objectives: electronic reporting to registries and viewing images through electronic health records (EHR)
Hospitals and physicians would have to use computerized physician order entry for more than 60% of medication, laboratory, and radiology orders
Providers would be required to enable patients to view, download, and transmit their medical records online
Specialists could qualify for meaningful use by using EHRs that are certified for their specialties

Comments will be accepted for 60 days after the proposed rules are published in the Federal Register.

The Doctor's Office, May 2012

Tue, 01 May 2012 04:00:00 GMT

Homing in on the medical home

by Edward Prewitt

The concept of the patient-centered medical home (PCMH), introduced by the American Academy of Pediatrics way back in 1967, continues to gain steam. But what does it mean to be patient-centered?

Penrose recalled the concerns he had after hiring a consultant to interview patients. "We asked them to come in and look with fresh eyes, talk with some of our patients, talk to community members about what they think about healthcare,? Penrose said. "The resounding answer we got back was: Healthcare is something you have to navigate your way through.

"We didn't always like a lot of what we heard,? Penrose admitted. "But we listened and made changes so that we could develop the essential elements of a patient-centered home-working closely with our communities, inspiring the team, and setting common goals for our patients' health.?

The interviews occurred early in the formation of a PCMH within St. Jude's parent organization, St. Joseph Health System, which has annual revenues of $4.5 billion.

The medical home approach is in keeping with St. Joseph's approach to healthcare, Penrose said. "We're all about promoting health ? thinking about population health, the health of the communities we serve. It's very important to us that we do more than just acute care, but also reaching out into the community-and what a great way to do it,? he said. The organization's working definition is that "the patient-centered medical home describes how primary care practices should operate to ensure high-quality care and patient safety, as well as work within an integrated healthcare system.?

Information technology (IT) is important for PCMH. The integration necessary for a medical home requires IT connections. St. Jude invested $15 million in information systems, including an EMR system.

Burke listed five elements of the medical home's IT infrastructure:

EMR/electronic health record
Patient health records
Shared case management
Utilization
Risk stratification and predictive modeling

Another important step in building a successful medical home is getting the buy-in of physicians, Smith said. "The real big winner for doctors with PCMH is quality of care,? he said. Physicians "like to do two things: They like to take care of patients, and they like to provide quality care. If a healthcare system can provide the structure to do that and then give them the reward and feedback ? you've got a medical home.?

According to Matuszewski, when the IT infrastructure is in place and doctors are on board, physician practices and healthcare systems preparing to launch a medical home should take five steps:

Appraise your practice's readiness for change: Does the culture frown on innovation or see a need for a new approach?
Evaluate the people who will be part of the medical home team: Are key players resistant, and if so, can they be won over?
Identify a medical home champion from within the practice.
Create a mission and vision to be adopted by the new medical home.
Create a specific project plan.

And so, after 45 years, the PCMH model is finding a home at a time when coordinated and accountable care is becoming increasingly relevant.

Primary care docs weigh advantages of PCMH

by John Commins

That's according to Glen R. Stream, MD, a family physician from Spokane, WA, and president of the 100,300-member American Academy of Family Physicians.

Stream says a number of initiatives announced over the last several months by the federal government and private payers indicate that the PCMH model may soon expand beyond pilot project status.

But until more private payers across the nation are willing to embrace the PCMH concept within their networks, Stream says many PCPs will keep their distance.

Understand three-day DRG payment window to improve reimbursement

That last part was changed in the new rule, says Vernaglia. Now preadmission nondiagnostic services must be bundled if they are "clinically related" to the reason for the patient's admission.

Adapted from Managed Care Contracting & Reimbursement Advisor, March 2012.

Three-day rule applies to broad range of providers

CMS says "hospitals should accumulate the costs incurred and the adjustments required for these services and report as costs with related organizations on the Medicare cost report."

Don't let your iPad get in the way of good bedside manner

"Mobile devices aren't necessarily going to make anyone a better interpersonal communicator, but they can make you a worse one if you are not careful,? says Chad Udell, managing director of Float Mobile Learning, a consulting firm focused on mobile learning strategy and development, in Morton, IL.

Medical staff leaders should pass these three simple tips on to staff physicians to ensure that mobile devices don't take over the physician-patient relationship.

Tell the patient what you are doing

"The doctor can jovially state, ?We are transitioning to digital recordkeeping-I am not playing Angry Birds. This method is quicker than looking for your file in the records area or carrying binders and clipboards,' ? says Udell.

Adjust your settings

"There are a lot of tools you can put in place to make sure your usage of the devices is fruitful and sequestered to the appropriate times,? says Udell.

Adjusting the settings on a mobile device can only get a user so far, though. Users must judge when it is appropriate to respond to a phone call or text or e-mail alert.

Bring the patient into the experience

Adapted from Medical Staff Briefing, March 2012.

Mobile devices causing dangerous distractions

Mobile devices, such as smartphones and tablet computers, are certainly handy, but a New York Times article, "As Doctors Use More Devices, Potential for Distraction Grows,? highlights the dangers posed by electronic devices in the healthcare setting. According to the article, 55% of perfusion technicians acknowledged that they had talked on cell phones while monitoring bypass machines during heart surgery. The article also calls to attention a surgeon who used a hands-free headset to make more than 10 phone calls to family and associates during surgery. He left a patient partially paralyzed and was sued for malpractice, but the case was settled before it got to court.

A Hospital Impact article, "Prevent fatal IT distractions with hospital support, enforcement,? encourages managers to speak to employees when they see them using their mobile devices inappropriately. If the medical staff does not have a policy regarding the use of mobile devices, it might be time to add language to the disruptive behavior policy.

5010 logjam means no pay for physicians

by Joe Cantlupe

A strange thing is happening as physician practices transition toward HIPAA Version 5010 electronic transactions: Docs aren't getting paid.

Physicians are flooding their advocacy groups with complaints and questions about "cash flow problems.?

"We haven't seen anything like this before,? said Robert Tennant, MA, senior policy advisor at MGMA, referring to the onslaught of e-mails from distraught doctors.

AMA President Peter W. Carmel says that since the 5010 standard was implemented, physicians have been "experiencing very alarming problems that have resulted in significant interruptions in claims processing and cash flow.? As a result, more postponements should be made for any enforcement deadline of HIPAA Version 5010, he says.

Recently, CMS' Office of E-Health Standards and Services announced a 90-day period of "enforcement discretion? for compliance with the new 5010 HIPAA transaction standards. CMS extended the 5010 compliance deadline to March to allow more physician practices the opportunity to implement the new billing coding standard without incurring penalties.

Specifically, MGMA has called for an extension of the enforcement delay from March 1 to June 1. In a letter to HHS Secretary Kathleen Sebelius, MGMA has recommended to instruct Medicare Administrative Contractors (MAC) to "immediately? provide advance payments for physician practices that are struggling to meet Version 5010.

As for CMS, it has little to say publicly on the issue. "HHS has a correspondence response process and CMS will be contributing to development of HHS' response,? says Joe Kuchler, a spokesman for CMS, referring to a letter from MGMA. "In the meantime, MGMA's letter is considered open correspondence and we can't comment on specific issues.?

Oddly enough, some practices are taking drastic action to try to circumvent the cash flow problems with electronic records.

They are reverting to paper claims, Tennant says. "If they have to drop back to paper, we don't recommend it, but if that's the only way to get paid, they may have to take that step,? he says. Tennant says MGMA is recommending that physicians take their cases, if necessary, directly to CMS. "The more complaints CMS hears, the more chance they will take action,? he says.

Medicare physician payment rule factors in GPCI

by HCPro staff

Multispecialty practice shares four pieces of advice to qualify for meaningful use

by Carrie Vaughan

For the most part, the first group of providers to qualify for Stage 1 of the meaningful use regulations in 2011-and deposit incentive checks in the bank-were early adopters of electronic health records (EHR), such as Old Hook Medical Associates, LLC (OHMA) in Emerson, NJ, a multispecialty practice that implemented its EHR in 2007.

OHMA has one location and 20 providers, including full- and part-time positions and nurse practitioners. It began using the Sage Intergy EHR product (now Vitera Intergy) in 2007. "That was essentially our first real EHR," says Edward Gold, MD, president of OHMA, as well as an oncologist and hematologist. "We had been using a medical manager product and were using some of the EMR capabilities that it had, which were limited. But we really weren't fully electronic until 2007."

OHMA began its 90-day meaningful use attestation period on January 1, 2011; it submitted its data on April 19, 2011, qualified for everything it submitted, and received a $180,000 incentive payment in May 2011. The practice submitted data for 10 physicians. OHMA has some part-time physicians who didn't qualify because they only work a couple of days per week and OHMA isn't their primary practice, Gold explains.

For practices still pursuing Stage 1 meaningful use criteria, Gold offers the following four pieces of advice:

1. Don't accept pushback. Gold says OHMA made a corporate decision to switch from paper to EHRs and didn't accept opposition from its physicians. As such, the physicians didn't get to choose whether to use the technology, Gold says, adding that OHMA still had paper charts at the time. "We said, ‘Okay, if you want the chart, it will be in the medical records room but it won't be delivered to your desk anymore," he explains. "We made it inconvenient to use the paper chart, and pretty quickly the physicians found it easy to use the electronic medical record."

2. Adopt the system-whichever you choose-wholeheartedly. OHMA used every capability its EHR system offered, including the health maintenance portion, says Gold. "We went into it with both feet," he says. "The software is designed to be used as a whole unit. While you can pick and choose what you want to use with some of these programs, if you want to get the most out of it, you have to use the full functionality of the product-and that goes for any EHR product."

Gold says the one suggestion he gives to physicians in his community-many of whom know OHMA received its incentive payment-is not to adopt an EHR in bits and pieces. "If you try to piecemeal your way around because you like one thing and not another, or because you've done it this way for 30 years, ultimately you will have problems," he says. "If you adapt it wholeheartedly, you'll qualify."

3. If you plan on pursuing a patient-centered medical home (PCMH) designation, combine your efforts. About one and a half years before meaningful use, OHMA made the decision to become a PCMH. OHMA was seeking a level three PCMH qualification, and through that process it fulfilled many of the criteria for meaningful use-such as coordinating care, setting up a patient portal, and using e-prescriptions, says Gold.

In addition, the practice was already using the health management aspect of its EHR-which provides recommendations, such as tests or screenings, for patients based on age or disease-as part of its effort to achieve the PCMH designation. OHMA was using practice analytics to identify diabetic patients with high blood sugar levels, for example, and it had processes in place for a nurse to follow up with those patients. Because OHMA had these processes and the capability to collect data, "it became fairly easy to meet the level one meaningful use criteria," Gold says.

"The thing that we had the most difficulty with was giving patients the summary description of their visit," he notes. OHMA didn't previously offer patients a synopsis of their visit, so it had to change its work flow to meet that element of meaningful use. Generating the summary description is an extra step in the process, and you need multiple levels of backup to make sure that it gets done, says Gold. "Establishing it to be done on a consistent basis was the hardest part."

To ensure that patients received the summary description, physicians were trained to generate the summary, nurses were trained to follow up with physicians, and receptionists were trained to check that the summary was done and offer it to the patients. "Now we give it to patients as they leave the reception desk," Gold says. Ironically, he estimates that 95% of patients don't even want the summary, and "the 5% who do want it are happy to go on to the patient portal and get it."

OHMA launched its patient portal roughly one year ago and already has about 2,000 people signed up. Gold notes that the meaningful use regulations were unclear about whether offering patients an electronic visit summary via the patient portal is sufficient, or whether practices must offer a hard-copy summary as well. "We do both at this point because we want to cover our bases," he says.

4. Double the training time. Like any software product, whether it's an EHR or Microsoft® Excel®, the more familiar you are with the ins and outs of the software, the easier it is to get things done, says Gold. The problem is that physicians are very busy and don't have a lot of patience, he says. "[Physicians] don't want to spend the time necessary to learn the product properly so that they can get the results that they want. They are used to telling an office manager to do this and it gets done," Gold says. However, the meaningful use criteria require physician participation. "If the physicians are not going to have the time, patience, or wherewithal to participate in [meaningful use], don't expect to be able to qualify for it," he says.

When it implemented its EHR, OHMA asked for additional training above and beyond what came with the product, says Gold. The practice had trainers on-site when the EHR went live. It also had a train-the-trainer program, where a number of people in the practice were trained first and became very familiar with the product so they could answer questions after the vendor's trainers left.

Physician practices need to spend time on implementation. Without a robust training plan, you can't succeed, says Gold. The challenge today is that "it is such a busy field right now with people buying products that the [vendor] companies are stressed to get [providers] implemented and get the training done," he says. "Some [vendors] will say, ‘We'll have you trained in a day and half-up and running-and you'll be good.' That is not true. My advice is no matter what product it is-Sage, Allscripts, NextGen, GE, or whatever-is whatever they tell you you need in training, double it."

William F. Jessee talks physician-hospital alignment

Sun, 01 Apr 2012 04:00:00 GMT

William F. Jessee talks physician-hospital alignment

by Joe Cantlupe

After being president and CEO of MGMA for 12 years, William F. Jessee, MD, FACMPE, stepped down in October 2011, which has given him the chance to spend more time examining the landscape of physician and hospital integration.

From his vantage point, that landscape is pretty rocky.

Few hospitals and physicians are yet up to the challenge of properly aligning themselves, even though the pace of hospitals acquiring physician practices is accelerating across the nation, Jessee tells HealthLeaders Media.

Since leaving MGMA, Jessee has been senior vice president and senior advisor for Integrated Health Strategies of Minneapolis, a consulting firm for physicians and hospitals with alignment and performance issues.

Discussions with hospital clients are showing that too many "don't have organizational goals or strategies for their physician practices. Hospitals simply bring in [physician] practices because they are out there," Jessee says. After a contract is signed, he adds, "now they are trying to figure out, ‘What do I do next?' "

It's not only hospitals stumbling in alignment strategies, says Jessee, noting that many physicians expect large payments, but they should lower their expectations of hospital employment and not be "greedy" when it comes to anticipated incomes.

"I think what the doc must do is to step back from the prospect of short-term economic gain and ask themselves, ‘How can I do a deal with the hospital that is a win-win for both of us?' " he says. "If they are both happy with the deal, they are more likely to have a lasting relationship than if a [doctor] felt after a deal was made, ‘Boy, did I really sucker the hospital administration.' "

Jessee discussed some of his best-of-alignment ideas in an interview with HealthLeaders:

1. Hospital CEOs should ask, "Why do you want this physician?" It is not uncommon for hospital systems to bring physicians on board for employment merely because they believe competing systems are courting them. Too often, hospitals haven't done the necessary homework to do a good job, says Jessee. In seeking physicians, he says, hospital CEOs often are standing alone and not soliciting input from their management or physician leadership, not doing enough analysis of fiscal returns, or not raising other potential deal-breaker issues.

Hospitals need to have a strategic objective first and foremost in acquiring physician practices. "If you can't answer that question, all the other stuff becomes kind of irrelevant," Jessee says. CEOs may be excited about acquiring a physician practice, but there may be no buy-in from hospital boards or physician leaders.

To hospital leaders, "the first questions I ask are, ‘Why did you acquire this practice? What was your objective?' " Jessee says. Often, he hears that "the reason a hospital or health system enters into a practice acquisition is because the physician wants to sell or because if we don't buy it, our competitor will.

"Those are hardly what I would call good strategic reasons," he says.

2. Hospitals should establish strategic objectives in hiring physicians. Jessee says the board, management team, and physician leaders must clearly support and gain buy-in for strategic objectives. That is an "essential prerequisite to a successful transition," he says.

Jessee tells the story of one hospital CEO who brought in a cardiology practice that failed to deliver business the hospital sought, yet gave the physicians guaranteed incomes.

The CEO hired an outside cardiologist to drive patient referrals. When that failed, the CEO sought to hire one of the local cardiology practices. None were interested. So he went to another town 25 miles away and hired four cardiologists who hadn't used the hospital.

"I started thinking to myself, how many ways can you screw something up?" Jessee says.

The scenario underscored the need to have board and physician buy-in for plans. "How does your board and physician leadership feel about this?" Jessee asks. In the case he discussed, "the board was really angry because [the hospital] was losing so much money over this and they weren't brought in to discuss it. And the physician leadership believed the hospital was bringing in outsiders to compete with them. They've been longtime supporters [of the CEO] and now they are out to get the CEO."

3. Hospitals must examine the overall fiscal picture. When hiring physicians, hospital executives should examine an array of fiscal possibilities. Those include benchmarks, payer-mix incentives, and total revenues collected. In addition, they should review efficiency of the physician practices. Finally, specialist referral patterns and potential litigation issues as well as physician performance should be evaluated, Jessee says. And executives must eyeball the fine print: Does a doctor have a potential conflict such as ownership in a pharmaceutical company?

"Before purchasing a practice, be sure you understand how cost-effective its physicians are," Jessee wrote in a report for Integrated Health Strategies. "If their cost per case (usually driven significantly by physician choice of drugs, supplies, devices, etc.) is higher than the hospitals' revenue for those cases, additional volume will only make the problem worse."

4. Physicians must evaluate their goals. Jessee says that physicians must forsake short-term gains and be flexible in relationships with hospitals. As physicians, "you are obligated to change your mode of decision-making. It is no longer management who will decide what is best. As a doctor, if you want those [management] guys to be on your side and for an integrated system to work, you've got to be part of the decision-making process."

Over the years, "docs have historically done a very good job of playing one hospital against the other," says Jessee, noting that a trustworthy relationship is essential.

Indeed, for both doctors and hospitals, it is crucial that they do their homework before entering an integrated model to avoid regrets-and consequently having to call a consultant to ask, "Now what do I do to get out of this mess?"

Underlying it all is the need for foundational trust.

"Building a trust relationship and learning the behaviors of one another are what either firms up a relationship or it can destroy trust. It's a lot easier to destroy trust than to build it," Jessee says. "It's a matter of getting physicians to realize that if they see their future as having a closer relationship with a hospital-and more and more docs are seeing that-they have to all be trustworthy partners."

Incident-to billing in OIG's sights this year

Sun, 01 Apr 2012 04:00:00 GMT

Incident-to billing in OIG's sights this year

HHS has put physician practices on notice that it will be taking a close look at billing under Medicare's "incident-to" billing rules this year, so now is a good time to review how you use this option.

Incident-to is one of the top concerns for 2012 announced recently by the Office of Inspector General (OIG) in its annual Work Plan. Under the sometimes complicated rule, a physician can bill for an employee's work as if the physician had performed it, as long as it is "incident to" the physician's services. This option often is used for low-level office visits, drug injections, and blood draws, which can then be billed incident-to and paid at 100% of Medicare's physician fee schedule.

It's a legitimate billing option as long as you follow the requirements outlined by HHS, notes Charla Prillaman, CPCO, CPC, CPC-I, CCC, CEMC, CPMA, CHCO, southeast regional director for AAPC Physician Services, a company in Salt Lake City that provides education and professional certification to medical coders. Incident-to billing becomes a concern when the practice depends on mid-level providers (also known as physician extenders)-clinical medical professionals who provide patient care under the supervision of a physician. Mid-levels can include nurse practitioners, physician assistants, and certified registered nurse anesthetists.

"This is a very high-risk area because the rules are so confusing," Prillaman says. "Physician practices that employ mid-level providers really need to take the time to thoroughly understand incident-to billing. What the mid-levels may do by scope of process is often different from what the billing rules require."

The OIG explained in its Work Plan why it is concerned about incident-to. In 21% of the services that nonphysicians performed for incident-to billing, the nonphysicians were not qualified to render them; the OIG says they lacked needed licenses or certifications, verifiable credentials, or appropriate training. It cited extreme examples in which medical assistants performed complex skin surgeries such as micrographic surgical removal of tumors. In ophthalmology practices, unqualified nonphysicians performed eye exams, diagnostic imaging, eye photography, and ophthalmoscopy.

Incident-to billing "may be vulnerable to overutilization and expose Medicare beneficiaries to care that does not meet professional standards of quality," the OIG cautioned.

Incident-to is applicable only in an office setting as hospital services typically do not qualify for it, explains Craig B. Garner, JD, an attorney in Santa Monica, CA, who handles Medicare billing and other healthcare issues. In the office setting, the service billed as incident-to must be an "integral part" in treating or determining the diagnosis, he explains.

The service must also be common to an office setting, and the item for which the physician bills must be an actual expense to the physician. A sample medication, for example, would not qualify. The physician must establish a plan of care for the patient, and then subsequent visits by a mid-level provider can be billed incident-to.

The nonphysician providing the service must be an employee or contract employee of the physician or group, and most importantly, the physician must also be present in the office suite and immediately available to provide assistance, Garner explains. (There are certain exceptions for physician home visits in rural settings.)

"A lot of times the physician isn't present, and that's where this can go wrong," Garner says. "It's really about accountability, especially now that the OIG is rooting out fraud and overuse any way they can. The OIG has made it very clear that they're taking this seriously, so physicians have to be careful about what they let occur in their practices and how it is billed."

Difficulties arise when a mid-level has the authority and licensure to provide a type of care that does not fit the incident-to billing requirements-such as treatment that was not included in the physician's plan of care-but then that care is billed as incident-to, Prillaman explains.

It is common for incident-to billing to be misused, sometimes requiring practices to return funds received in error, says Prillaman. The errors usually are the result of poor oversight, but excessive errors could rise to the level of fraud, she says.

"Practices often want to bill incident-to for increased compensation, and the billing department routinely takes information for both the doctor and the mid-level. There isn't a lot of effort put into determining when incident-to is allowable," Prillaman says. "You should find a way to know that what you're doing is the right thing. That requires an actual system for making sure that the treatment meets the incident-to requirements and not taking a casual attitude towards this."

Incident-to services subject to specific rules, physician must be nearby

The rules for billing incident-to services can be found in Chapter 15 of the Medicare Benefit Policy Manual. To access the chapter online, go to http://tinyurl.com/6lz3avf.

The chapter explains that for therapy services to be appropriately billed incident to a physician's service, the therapy is subject to the same requirements as therapy services furnished by a physical therapist, occupational therapist, or speech-language pathologist in any other outpatient setting-with one exception. When therapy services are performed incident to a physician's service, the qualified personnel who perform the service do not need to have a license to practice therapy, unless it is required by state law. The qualified personnel must meet all the other requirements except licensure.

In effect, these rules require that the person who furnishes the service to the patient must, at least, be a graduate of a program of training for one of the therapy services as described above. Regardless of any state licensing that allows other health professionals to provide therapy services, Medicare is authorized to pay only for services provided by those trained specifically in physical therapy, occupational therapy, or speech-language pathology.

That means that the services of athletic trainers, massage therapists, recreation therapists, kinesiotherapists, low-vision specialists, or any other profession may not be billed as therapy services.

Where policies have different requirements, the more stringent requirement shall be met. For example, when therapy services are billed as incident to physician services, the requirement for direct supervision by the physician and other incident-to requirements must be met, even when the service is provided by a licensed therapist who may perform the services unsupervised in other settings.