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Rick Rutherford, CMPE Director – Practice Management American Urological Association,Inc. 9/18/20091WV-MGMA Meeting 2009.

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Presentation on theme: "Rick Rutherford, CMPE Director – Practice Management American Urological Association,Inc. 9/18/20091WV-MGMA Meeting 2009."— Presentation transcript:

1 Rick Rutherford, CMPE Director – Practice Management American Urological Association,Inc. 9/18/20091WV-MGMA Meeting 2009

2 Patients seen in accordance with doctors time parameters Fees set through negotiation and relative amounts of work and costs Quality measured by patient satisfaction and lack of lawsuits Government oversight primarily via retrospective reviews Payers controlled costs by downward pressure on payments Consumer choice focused on payers, steered by employers Claims data analysis for follow-up 9/18/20092WV-MGMA Meeting 2009

3 Patients seen in accordance with their needs Fees set based on data publicly available to patients Quality set by consensus and medical evidence – measured by reporting against benchmarks Payments determined by meeting quality standards Government oversight driven by drilling into clinical or claims data Payers control costs by fixed budgeted outlays Consumer choice focused on cheapest source of quality care 9/18/20093WV-MGMA Meeting 2009

4 Major payers are testing various quality measurement processes Medicare PVRP followed by PQRI Aetna Aexcel United Health Premium Providers Consumers are assuming more responsibility for treatment options Browsing the Internet for information on conditions Developing Personal Health Records using computer assistance Participating in health savings accounts Payers are publishing provider fees online Baby boomers demand more service, faster with better results 9/18/20094WV-MGMA Meeting 2009

5 What do you think? Employer costs are rising Medicare is going broke quickly Too many Americans remain uninsured Utilization is rising rapidly Outcomes undefined New technology becomes available We live in an era of mistrust 9/18/20095WV-MGMA Meeting 2009

6 Successful managers will change their view from looking inside to looking outside the practice walls Efficient business operations will be considered a minimum acceptable standard for employment Effectiveness will be measured by scanning the horizon for opportunities to demonstrate: Superior performance in delivering clinical care Optimal cost to benefit ratios from a patient/payer viewpoint Rapid delivery of care at the optimal site of service Marketing skills as important as operational skills 9/18/20096WV-MGMA Meeting 2009

7 Trend Number 1 9/18/2009WV-MGMA Meeting 20097

8 Institute of Medicine - The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. 9/18/2009WV-MGMA Meeting 20098 Reality bites Currently Q=most likely outcome available at lowest cost Medical evidence is just now making its way into quality measures in a serious way Can measures be refined as new evidence is published?

9 Congress, President & CMS very interested in paying for quality/evidence-based medicine CMS has been a contract payer in the past -wishes to become a value-based purchaser MedPac recommends research into comparative effectiveness – comparison of treatments based on outcomes AND costs 9/18/2009WV-MGMA Meeting 20099

10 Physician Voluntary Reporting Program (PVRP) – 2006 36 measures to choose from – only 16 reportable by CMS Reported via claims data Comprised of re-written hospital measures and consensus based patient-care measures from NQF and AQA Participation was very low 9/18/2009WV-MGMA Meeting 200910

11 Physicians Quality Reporting Initiative (PQRI) 2007 74 quality reporting measures Claims based reporting –about 100,000 individuals reported 1.5% incentive bonus to successful participants – 51,000 payments to be made for 2007 Success = minimum of 3 measures (with exceptions) - reported on 80% of eligible patients/cases Reporting started July 2007 – bonus paid July 2008 Performance reports must be downloaded from CMS website 9/18/2009WV-MGMA Meeting 200911

12 2008 – 119 measures – dual entry dates 1/1/2008 and 7/1/2008 Claims based reporting plus experimentation with registries and EMR reporting 1.5% incentives 2009 – 153 measures in seven measures groups Three reporting options plus testing of EMR extraction Claims based using CPT Category II codes Registry using Medicare approved contractors (dual entry dates) Measures groups – all measures in group for a batch of consecutive patients EMR reporting available for certain systems in 2010 Program made permanent by MIPPA w/ 2% bonuses through 2010 9/18/2009WV-MGMA Meeting 200912

13 United HealthCare Premium (2 Star) rating system Quality & Cost Efficiency * = quality physician; ** = quality + efficiency of care physician (efficiency translates to lowest charges) Patients driven to * * Docs Purported to save employers 2-5% Ingenix Software used by other payers 9/18/2009WV-MGMA Meeting 200913

14 Network doctors reviewed for : case volume clinical performance hospital readmission rates complications or adverse health events other specialty-specific measures (if they exist) Only those with lowest 4% of index scores are reviewed and may be excluded Overall cost efficiency compared to adjusted average in their regions determines star designation. 9/18/2009WV-MGMA Meeting 200914

15 Various agencies and coalitions fighting for lead in measurement development Performance criteria and structural necessities Cost per patient to third parties Patient satisfaction – CAHPS & S-CAHPS being considered – Consumer Assessment of Health Providers and Systems Outcomes – does compliance with measures actually improve patient health? 9/18/2009WV-MGMA Meeting 200915

16 Revenue affected more by effective care delivery & less by effective billing practices How to achieve performance without seeing the patients How to take proactive steps toward quality 9/18/2009WV-MGMA Meeting 200916

17 Electronic medical records – the ability to efficiently get at the data Quality reporting training camp – start practicing now Development of internal quality code processes Formulate a quality team to institute changes Learn from hospital activities Constantly measure patient expectations and satisfaction Closely track clinical guidelines 9/18/2009WV-MGMA Meeting 200917

18 Trend Number 2 9/18/2009WV-MGMA Meeting 200918

19 According to National Center for Policy Analysis: Health Savings Accounts (HSA) now available to 250 million non- elderly Americans Patients using them – 1.5 million in 2002 – expected to grow to 18 million by 2012 Patients who have HSAs forego health care for less serious conditions twice as often as those covered by traditional policies 70 percent of HSA purchasers are > 40 years of age How many in this audience are covered by an HSA or Health Reimbursement Arrangement (HRA)? 9/18/2009WV-MGMA Meeting 200919

20 EMPLOYERS Converts variable cost item into semi-fixed cost item Enhances attractiveness of employer to young, healthy employees Reduces the administrative and contract hassles with managed care companies EMPLOYEES Allows more flexibility in provider choice Provides opportunity for increased retirement funds Incentivizes natural trend toward self-diagnosis and treatment 9/18/2009WV-MGMA Meeting 200920

21 Patients Moments of Decision – before visit Internet research – Find a Doctor Web sites, YELP, Angies List, even Zagat Ease of obtaining appointments – open access schedules on Web Clear explanations of financial arrangements Patients Moments of Decision – during and after visit Doctors willingness to listen Level of patient involvement in treatments Accommodative nature of staff 9/18/2009WV-MGMA Meeting 200921

22 Do the research to know what employers are offering in your area Train appointment, front desk and billing staff on selling your practice Improve your practice Web site Consider VIP appointment slots for cash payers React quickly to patient satisfaction ratings Create your own patient blog about your practice tied to Web site 9/18/2009WV-MGMA Meeting 200922

23 Trend Number 3 9/18/2009WV-MGMA Meeting 200923

24 The patient decides what they need based on a doctors recommendation. The patient decides if they can afford it and how they will pay the price. The patient undertakes comparison shopping to see if there is a better deal. The patient makes a decision. The patient receives the service. 9/18/2009WV-MGMA Meeting 200924

25 John W. Rowe, M.D., retired Aetna Chairman defines it as the opaque inner workings of the health care system are made much more transparent Aetna members in Connecticut and 10 other states, plus the District of Columbia, now have online access to physician-specific cost, clinical quality and efficiency information. 51.shtml?id=2240034n 51.shtml?id=2240034n 9/18/2009WV-MGMA Meeting 200925

26 Data release rules should be multi-tiered General public Limited data set for analytic purposes Comprehensive data set for policy work General public needs information that can be used to shop for healthcare services Aggregate data: cost of entire episode of care Cautionary notes should be included in release: small sample size, severity of population differences, aggregate data explanation Website is easiest dissemination tool 9/18/2009WV-MGMA Meeting 200926

27 Section 1. Purpose. It is the purpose of this order to ensure that health care programs administered or sponsored by the Federal Government promote quality and efficient delivery of health care through the use of health information technology, transparency regarding health care quality and price, and better incentives for program beneficiaries, enrollees, and providers. It is the further purpose of this order to make relevant information available to these beneficiaries, enrollees, and providers in a readily useable manner and in collaboration with similar initiatives in the private sector and non-Federal public sector. Consistent with the purpose of improving the quality and efficiency of health care, the actions and steps taken by Federal Government agencies should not incur additional costs for the Federal Government. 9/18/2009WV-MGMA Meeting 200927

28 Price Transparency: Insurers and third-party administrators will be asked to disclose their prices on the most frequent medical procedures, so that consumers can have a clear picture of the overall cost, not just of the procedure, but in relation to a specific doctor or hospital. 9/18/2009WV-MGMA Meeting 200928

29 eqc eqc http://www.mihospitalinf http://www.mihospitalinf https://www.mymedicalc https://www.mymedicalc 9/18/2009WV-MGMA Meeting 200929

30 Identify your practice strengths and market them aggressively Quality reporting participation Cutting edge services Insurance plan participation Rapid appointment access Develop your own transparency plan Work with hospital to publish average episode of care costs Publish your patient satisfaction scores (if favorable) Publish favorable comments from patients or referral sources Publish E&M bell curve compared to averages 9/18/2009WV-MGMA Meeting 200930

31 Anticipate and publicly justify Robotic surgeries incur more equipment costs but better outcomes Office charges are higher because we spend more time with our patients Hallmark approach – when you care enough to choose the very best 9/18/2009WV-MGMA Meeting 200931

32 Trend Number 4 9/18/2009WV-MGMA Meeting 200932

33 9/18/2009WV-MGMA Meeting 200933

34 Physician-Population Ratios (providing direct patient care) 1980 – 1/614 population 1990 – 1/500 population 2000 – 1/427 population 2005 – 1/413 population Population > age 65 expected to increase by 36% between 2010-2020 AGE<3535-4445-5455-64 198027%25%19%15% 199022%30%20%14% 200017%26%25%15% 9/18/2009WV-MGMA Meeting 200934

35 Residents and fellows 2000 – 95,725 2005 – 95,391 Council on Graduate Medical Education (COGME) recently predicted a 10% shortfall of physicians by 2020 9/18/2009WV-MGMA Meeting 200935

36 Will Baby Boomers demand more services? Will cost controls further reduce the physician supply? Will technology adoption improve the efficiency of the process? What will be the overall effect of wounded warriors? Will the U.S. finally face the problem of uninsured? Could the U.S. face a widespread pandemic? What will be the effect of recession? 9/18/2009WV-MGMA Meeting 200936

37 What management strategies can increase the efficiency of patient care delivery? Streamline the record keeping process through adoption of electronic record keeping Expand capacity at low cost through use of non-physician providers Investigate the potential for group patient visits Evaluate the practices payer mix and boost profit margins per patient seen Demand more patient/family involvement in the health care process Explore more efficient delivery of procedures 9/18/2009WV-MGMA Meeting 200937

38 Surgical practices - Consider providing more office visit time for aging physicians – E&M reimbursement is on the rise Primary care - Negotiate for reimbursement for e-visits Prepare for shared reimbursement – DRGs for doctors Economically advantaged areas - Consider the advantages of boutique practices – fewer patients for equal compensation Specialists – investigate the potential for telemedicine Reduce the number of Medicare patients 9/18/2009WV-MGMA Meeting 200938

39 Trend Number 5 9/18/2009WV-MGMA Meeting 200939

40 Sustainable Growth Rate formula – the annual roller coaster ride Aetna caps out-of- network payments at 125% of Medicare rates (AMNews - Jan. 14, 2008) California introduces law that requires physician seeing patient in an in- network hospital to accept in-network rates CMS launches Acute Care Episode (ACE) demonstration project Accreditation for imaging services required by commercial and state payers State laws prohibit certain ancillary services in physician offices CMS proposes physicians meet IDTF standards 9/18/2009WV-MGMA Meeting 200940

41 Increase skills at business modeling based on controlling the volume of patients and services delivered by the practice Who and where are the profitable patients? What ancillary services are most profitable and least likely to be regulated? Enhance your ability to compile meaningful data from various sources Cost per encounter data Claims data Quality reporting data Disease management data 9/18/2009WV-MGMA Meeting 200941

42 Managed care contract review and negotiations Quality measurement and reporting Target marketing to the most profitable patient cohorts Hospitality service to keep those cohorts happy Cost accounting to better control unit costs 9/18/2009WV-MGMA Meeting 200942

43 Three major factors in political health care reform: Access Provider participation Cost control Third rail – the cost of quality improvement Massachusetts Health Care Reform Act improved access but costs ^ to 33% above U.S. average What will it take to achieve universal provider participation? Mandatory participation? – No Financial incentives? – No Providers as fiduciaries? - Maybe 9/18/2009WV-MGMA Meeting 200943

44 9/18/2009WV-MGMA Meeting 200944

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