Dr. Teresa Koenig and Dr. Eric Nielsen from our firm shared their insights on clinical integration at Becker’s Hospital Review’s annual meeting. Check out a recap of their session!

http://www.beckershospitalreview.com/hospital-physician-relationships/7-key-concepts-for-successful-clinical-integration.html

Becker’s Hospital Review has published Steve Gelineau and Virginia Tyler‘s article on critical steps hospitals need to take post merger.  This article first appeared in the Q2 2012 issue of The Camden Quarterly and is one of several articles we have written recently on mergers and acquisitions in the healthcare industry.  Read the article now, or visit our Resource Center for more articles on the topic!

The tide has changed, and owning and/or having strategic alliances with post-acute care resources has become vital for acute care providers in managing the health of a population and in meeting the Triple AimTM: reducing costs, enhancing quality, and achieving superior patient experience. In addition to extending an organization’s care management process, supporting bundled payment and clinical integration (“CI”), and reducing its exposure to readmission rate penalties, an effective post-acute strategy is now fundamental to an organization’s financial success.

Post-acute care constitutes a breadth of resources including in- and outpatient rehabilitation, behavioral health, long-term acute care (“LTAC”), skilled nursing (“SNF”), assisted living, and home health. The absence of a strategy specific to these resources, or a poorly crafted one, can be disastrous. Here are ten parameters that provide a framework for an acute care organization to determine its post-acute strategy. First, consider five strategy “drivers” to identify strategic alternatives. Items one through five provides a structure for doing so. Next, prioritize those alternative approaches and focus resource allocation. Items six through ten support that process. Together, the ten parameters represent a planning process (Figure 1).

California Healthcare Foundation has published a paper written by Laura Jacobs, MPH and Cleo Burtley, MBA that explores the impact of the economy and health reform on physician-hospital integration activity in California. In addition to research findings, the paper presents perspectives from leaders at hospitals, physician groups, health plans, and provider industry associations. Also described are several ACA initiatives that are likely to define, in large part, future integration efforts in California:

Health Care Innovation Challenge. Awards up to $1 billion in grants to fund innovative service delivery and payment model

Comprehensive Primary Care Initiative. Offers bonus payments to primary care doctors for improved patient care coordination

FQHC Advanced Primary Care Practice Demonstration. Tests the effectiveness of FQHC providers working in teams to improve care coordination for Medicare patients

Bundled Payments for Care Improvement. Enables provider organizations to receive Medicare payments for specified clinical services in a single payment

Accountable Care Organization. Enables legal entities composed of provider organizations in which primary care physicians use care management processes for Medicare patients

The paper concludes with case studies on the current and future integration plans of six California provider organizations: Adventist Health, Arrowhead Regional Medical Center, John Muir Health, Presbyterian Intercommunity Hospital, Scripps Health, and the University of California, San Francisco, Medical Center. It also includes discussion of some of the policy implications raised by integration activity.

Read more: http://www.chcf.org/publications/2012/04/physician-hospital-integration-2012#ixzz1rm7SbwhX

Due to our growth, the following opportunities are available in our Los Angeles, Chicago, and Rochester offices: Interested applicants may e-mail resumes to Miriam Hansen at mhansen@thecamdengroup.com.

Jay Warden, Senior Vice President, The Camden Group, shares his thoughts on how the Supreme Court’s decision on the constitutionality of the individual mandate will impact healthcare reform and delivery in Becker’s Hospital Review.

Hospitals in this current environment are finding themselves in a difficult position as the ability to obtain rate increases from commercial payers has become increasingly difficult. The pressure to reduce “cost shifting” is strong, and ultimately, hospitals will have to learn how to survive on Medicare rates – even as these are also decreasing. While the immediate reaction has been to cut costs departmentally, realistically, those opportunities are limited and will not enable a hospital to ultimately survive on reduced reimbursement rates. The real cost management opportunities are in redesigning how care is delivered. Redesigning how healthcare is delivered requires clinical integration throughout the hospital. Here are the ten ways to survive on Medicare, starting with three “big picture” culture changers and some specific action-oriented tactics for cost management. All ten require participation of clinical leaders in the hospital:

1. Big Picture: Eliminate waste or work that is not valuable to the patient. Many hospitals have tackled waste and unnecessary work steps through the Lean Thinking method, with success particularly in organizations where physicians have a role in governance and management. The Lean Method aims to continuously improve outcomes and quality by redesigning the processes based on the needs of the consumer, the patient. Lean Thinking efforts in the past may have been incomplete without full clinical participation by clinicians closest to the work, but these efforts should be revisited as an organization advances towards clinical integration. Physicians and nurses are critical in identifying opportunities for reducing waste, duplication, and over-utilization. There has been a resurgence of interest in Lean Thinking in hospitals over the past several years because the method is simple and works by reinforcing the need to be 1) patient-centered and 2) inclusive in decision-making

2.  Big Picture: Reduce process variability errors through mapping and improving both productivity and safety. Process variability is a significant driver of resource waste and error. When each transaction becomes slightly different, or staff must double or triple check, then time is wasted, patient satisfaction decreases, and safety is compromised. “Painting the picture” through process mapping identifies points and sources of variability. Mapping using the Lean method of creating a value stream allows a work team to effectively separate the value-added activities from those that are unnecessary and redundant and cause variability in standards of practice. Since this method is oriented to the patient’s perspective, the end product drives change that increases safety and satisfaction while eliminating waste.

3.  Big Picture: Operational improvement tracking must be multi-dimensional and measure what is important. The Balanced Scorecard is an example of a management strategy that is focused on four dimensions: finance, internal processes, customers, and innovation and learning. The theory is that “what gets measured gets managed.” Hospitals that use the Balanced Scorecard are able to identify gaps between current values and benchmark targets and implement process improvements immediately. Targets and standards may be borrowed from the International Organization for Standardization (“ISO 9000″), The Joint Commission, Magnet Recognition Program, or other organizations that encourage high levels of performance. Balanced Scorecards are especially useful in hospitals because they provide the framework to 1) identify problems immediately 2) begin improvements immediately, and 3) provide transparency. They are most effective using five to six measures per department that encompass clinical quality, financial, and customer service.

With those three “big picture” changers in mind, here are six specific ways for hospitals to manage cost that are especially effective in clinically integrated organizations:

4.  Manage labor costs. In healthcare organizations today, labor costs account for at least 60 percent of total expenses. Monitoring productivity and streamlining processes in the near-term will improve service and control workforce costs. Additionally, long-term planning is essential to maintain gains and position the organization to continue the economical use of human resources. One very effective tool is to create a workforce strategic plan, similar to a facility master plan, business plan, or marketing plan. Planning for workforce requirements two to three years in the future positions the organization to hire individuals with the skills and background to meet continuing challenges, plan recruitment strategies, and transition current employees through training and education to fill new roles. The planning should also take into consideration the changes in care processes and new staffing patterns identified through Lean and other operational improvement initiatives.

5.   Focus on improving perioperative service efficiency from the start. Perioperative services are responsible for up to half the revenue in many organizations, so maximizing operations throughput and efficiency yields big dividends. Most perioperative services work on the “in suite” areas for improvement, such as room turnover and room and block time utilization. While these are important and merit focused attention and energy, it is equally important to maximize efficiency in the front end, pre-surgical patient preparation. It is impossible for perioperative services to run efficiently if, on the day of surgery, the patient arrives without signed consent, valid history and physical, and completed clinical tests and data. Using Lean methods to focus on pre-surgical patient preparation enables organizations to improve throughput by starting on time and staying on time throughout the day, which allows for better room utilization and high satisfaction marks from patients, surgeons, and staff.

6.  Prioritize quality – this will pay off as CMS implements Value Based Purchasing. The design of Value Based Purchasing moves CMS from a passive payer to a driver of healthcare in both pricing and quality. Under this, program reimbursement will be based on the outcome of 25 well established clinical quality core measures related to acute myocardial infarction, heart failure, pneumonia, and hospital acquired infections. Also, consumers’ assessment (Healthcare Providers and Systems ["HCAHPS"] scores) reflecting provider care, communication, pain management, and teaching add a much needed dimension component of the formula. In addition to directly influencing reimbursement, these scores will be publically available to consumers and competitors alike.

7.  Use electronic media to manage readmissions and preserve Medicare reimbursement. New to the reimbursement picture is the aggressive management of heart failure, heart attack, and pneumonia patients to prevent readmission. Data collected from 2012 will be applied to 2013 rates and can result in a one percent decrease of all Medicare reimbursement in 2013. This program is expected to expand diagnosis groups in subsequent years to include diabetes and other chronic conditions while adding an increase in penalties up to three percent. This change effectively mandates that care resources must be directed to “out of hospital” venues that will coach, counsel, and apply early intervention strategies to keep people as well as possible. Focusing resources on innovative strategies to give patients and providers easy accessibility will be the key, and electronic media will be a central strategy. Using mobile phones to communicate and monitor patient status through texting,Twittering, FaceTime, and email will become the norm. In addition, developing apps to record and transmit health information will allow the earliest of intervention. For example, consider a heart failure patient who uses an app to record daily weights, make dietary decisions based on sodium content, and receives a reminder to take their medication. These low cost interventions could preserve Medicare reimbursement dollars and keep patients healthy.

8.  Grow service lines around procedures with higher-margin Medicare reimbursements. Although Medicare payment for some traditionally profitable services such as cardiology is on the decline, cardiology is still a high-margin, highly reimbursed service line. Services such as cardiology are also early to embrace clinical integration where evidence-based care protocols can streamline care providing valuable quality, efficiency, and financial data to continually improve services.

9.  Improve documentation to maximize reimbursement under the ICD10 code transition. The transition to the ICD10 codes originally planned for 2013 will most likely occur in early 2014. The change will be profound with an estimated five codes for every one code now used in the current ICD9 system. The clear strategy to capture reimbursement under this new system is to create extensive templates and tools that translate into a detailed and comprehensive patient document. If done correctly, patient documents such as history and physicals, progress notes, and discharge summaries will provide the data required to meet the highest DRG criteria and appropriately risk adjust for optimal reimbursement. Today many organizations do not user-friendly templates or electric programs to support physician documentation. Using a Lean value stream mapping approach, organizations should identify barriers to charting in a timely and complete manner. Through clinical integration, physicians and hospitals share the same health record platform and can improve documentation that maximizes reimbursement.

10.  Maximize grants and government payments available to hospitals serving the safety net between now and 2014. Management teams in the public hospitals are well aware of the money available to help them prepare to care for “newly eligible” individuals under healthcare reform, but there may also be funds available for non-public hospitals that meet certain criteria or form partnerships in some states. Two examples of this are the Section 1115 Waivers in California and Texas. Both waivers provide funds for public hospitals committed to redesigning their delivery systems to accommodate their existing indigent and uninsured patients. If desired outcomes are achieved between now and 2014, some of the additional costs required to implement initiatives can be funded under certain circumstances. If a hospital is serving the safety net population and/or if its Medicaid population is estimated to increase in 2014 because of the potential downsizing of public services, this would be the time to explore alternatives with public hospital neighbors and determine what can be done together to maximize these available funds that are designed to provide the “Bridge to Reform.”

For more information on cost management in preparation for healthcare reform, please contact Rebecca Bales at 310.320.3990 or rbales@thecamdengroup.com or Bonnie Barndt-Maglio at 312.775.1700 or bbarndtmaglio@thecamdengroup.com.

Patricia Hines, RN, Ph.D., Vice President, The Camden Group, shares her insights on the changing role of nurses in March’s issue of Hospitals & Health Networks.  Read the full article here.

Medical training historically required autonomy and focused on the needs of “one captain” of the ship – that is, the patient. However, new healthcare models require not only changes to the autonomous physician driven care model but also for a transformed physician leader/role, one who can lead other physicians and clinicians toward new clinical and financial benchmarks while driving and engaging all members of the healthcare team toward future success.

With all these changes comes the new look of the physician leader who has the necessary skillset to help transform healthcare delivery of the organization and the industry overall. For those wanting to identify and develop the next generation of physician leaders, and for the physicians who want to develop their own skillset, here are ten necessary skills and characteristics to keep in mind:

1. Collaboration and cooperation. These are both mandatory traits. Finding compromises, welcoming new ideas, and often meeting in the middle are necessary attributes in leadership roles. Building new teams across the care continuum requires an open mind and a willingness to accept different ideas and change.
2. Strong listening skills The collaboration and teamwork requires good listening skills. Good listeners hear the true message conveyed − not just the words. The ability to listen to conflict and disagreement while working towards cooperation must be developed.
3. Communication skills. Both verbal and written communication skills are critical. Clarity, precision of message, and the ability to be consistent and be heard are necessary to deliver a message of change. Storytelling is not only for children’s bedtime any more. The ability to present and tell a story with listeners engaged and understanding the message is critical.
4. Self-confidence and mental resilience. Both are necessary for a change agent. Not all may welcome the changes in healthcare, and the agent of change at times needs to have a tough skin. Remember, in transformation periods one can often tell the leaders by the arrows in their backs!
5. Humility. Humility and the ability to accept the missteps and mistakes that will occur at times are essential. While this seems in conflict with characteristic #4, it is the balance of self-confidence and humbleness that will serve physician leaders very well.
6. Lack of arrogance. A lack of arrogance in giving direction and guidance is necessary. Transforming healthcare requires teambuilding as well as giving direction. However, the direction needs to invoke a collaborative and participatory environment − not one of “I say; you do.”
7. Appreciation for others. An appreciation for others’ thoughts, ideas, and inputs is vital. Teams will only materialize when the members believe their voices are heard, and their thoughts and ideas are considered.
8. Mentoring. Mentoring team members must be in the skill set, and if it is not, then it must be developed. The skills to allow professional development of other physicians, clinical staff, and administrators may take time and effort but promotes self-sustaining teams and success.
9. Life balance. A life balance needs to exist that includes work, family, colleagues, work environment, and physical and mental fitness. Whether this includes some clinical practice is dependent on the situation. More physician leaders now prefer to retain some clinical duties rather than previously, and many health systems support this as well.
10. Vision. The vision to see beyond the short-term and stay the course toward the future is needed. True physician leaders have the vision to look to the future and navigate the system, physicians, and teams through the challenges of healthcare transformation to the next level and beyond.

For more information on how to develop physician leaders, please contact Teresa Koenig at tkoenig@thecamdengroup.com or 330.715.2906

The transition from fee-for-service (“FFS”) to fee-for-value (“FFV”) is a challenging journey for many healthcare organizations, but the stakes are high, and the ability of an organization to navigate the road to success in a FFV world is critical. Though most hospitals and health systems face similar strategic, operational, and financial challenges, the priorities, timing, and approach to preparing an organization for FFV will vary from market to market. This five-part series of webinars, co-presented by The Camden Group, a national healthcare business advisory firm, focuses on “stops” along The Camden Group’s “Roadmap to Fee-for-Value.”  Save the dates, and register for these webinars today!