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Adapting to the current healthcare environment for most medical groups may feel like a house of cards, each card representing a different initiative precariously stacked, one on top of the other, with the slightest slip causing the pieces to crumble. However, simulation modeling is one tool that can assist practices in modifying practice patterns with minimal disruption to operations, resulting in better outcomes.
Too many wrong steps on the road to population health management could erase margins. Finance leaders need a data-driven “value model” to plan the scale and pace of investments into
population health and move confidently into value-based contracting.
As we approach 2017, physician practices are being challenged on all fronts. Payers are changing the way that physicians are paid, patient expectations are at an all-time high, hospitals are seeking new ways to align, and competition is mounting from new types of providers. To some physician groups, this unprecedented level of change will threaten their financial viability. To others, it will represent an opportunity to transform their group for future success. Here we take a look at the top 2017 trends for physician practices that will have the biggest impact.
While the recent federal elections portend changes to the insurance marketplace and other aspects of the Affordable Care Act, the transformation of care delivery is well underway and unlikely to fundamentally change course from a delivery system perspective.
Here are some trends to watch out for in 2017.
As has been the case for many years, hospital organizations continue to look to perioperative services to be one of the most important financial engines for the institution – consistently looking for ways to maximize the utilization and efficiency of the department.
As reimbursement declines, new payment models are being explored, and hospitals continue to consolidate, organizations are expanding on and moving beyond past methods to drive improvement. Here are key priorities in the perioperative world that healthcare leaders should keep in mind.
The transition to value-based payment systems has medical practices aligning with accountable care organizations (ACOs) and clinically integrated networks (CINs), which requires a new level of support to medical practices. A true population health support organization (PHSO) can be a perfect fit in a dynamic medical practice setting.
October 1, 2016 | HFMA's Physician Business Advisor
Note: This is Part 3 in a series on how physicians can prepare for MACRA, the new Medicare payment law. Read Part 1 for an overview of how the Merit-based Incentive Payment System works and Part 2 on applying change management to practices ahead of the new law.
The key to success in MIPS rests on a practice’s ability to gather, quantify, and report on elements of patient care that exhibit improvement in outcomes and cost reduction. IT infrastructure, scalability, and continued development and process improvement are all necessary components of a MIPS strategy. Here we explore how a practice can achieve its goals, regardless of size or specialty, in the four defined areas of MIPS.
September 1, 2016 | HFMA's Physician Business Advisor
Note: This is the second part in a series on how physicians can prepare for the new Medicare payment law. Read Part 1 for a breakdown of how the Merit-based Incentive Payment System works and how to succeed once it takes effect.
In April, the Centers for Medicare & Medicaid Services (CMS) issued the proposed rule for the Medicare Access and CHIP Reauthorization Act (MACRA), which consolidates Medicare's current quality reporting programs into one. MACRA features the new Merit-based Incentive Payment System (MIPS), which combines parts of the Physician Quality Reporting System, the Value-based Payment Modifier, and the Meaningful Use incentive program for electronic health records (EHRs), and adds a fourth category: clinical practice improvement activities.
By Jeff Gourdji, Prophet and Laura Jacobs, GE Healthcare Camden Group
To understand the state of patient experience, Prophet and GE Healthcare Camden Group conducted intensive research among healthcare executives and created a maturity model based on our findings. We learned that most organizations fall into four broad stages of performance, and there are steps to take to transition from one stage to the next. An honest appraisal of where an organization is now is the only way to get better.
August 1, 2016 | HFMA's Physician Business Advisor
The Medicare Access and CHIP Reauthorization Act (MACRA), in the form of a proposed rule from the Centers for Medicare & Medicaid Services (CMS), aims to encourage medical groups to pursue advanced payment models and accountable care. MACRA replaces several Medicare reporting systems and creates two potential paths for medical groups: the Merit-based Incentive Payment System (MIPS) and advanced payment models (APMs).
Health care currently is in a state of flux as providers strive to navigate a payment and incentive shift with the focus moving from volume to high-quality care delivery. Relative costs are rising while quality measures—including beneficiary satisfaction and clinical outcomes—are becoming more crucial to payers and embedded in payment calculations.
By William Ringwood, MBA and Tawnya Bosko, DHA, MS, MHA, MSHL
When assuming financial risk for healthcare delivery, a provider has many options to choose from and a broad range of internal and market based factors to consider to be able to choose the right option for its specific circumstances.
Primary care practices will be continually challenged to drive clinical transformation and care coordination across the continuum as more and more systems evolve to care for patient populations. This transition will have a major impact on practices and require significant cultural and operational shifts away from the status quo.
Change in reimbursement isn’t waiting for tomorrow. It’s happening right now. Rather than paying for each procedure and office visit, government and private health plans are moving toward a payment model based on the health of an organization’s patient population. During this transition, an organization’s success depends on its ability to manage a variety of payment models.
By Tawnya Bosko, DHA, MS, MHA, MSHL and Megan Calhoun, MS, MSW
Historically, many organizations managing care in a risk-bearing structure such as independent practice associations, medical groups, or related enabling entities such as management services organizations have primarily concentrated on utilization management, referral authorization, and claims processing, with attention to cost containment and ensuring all compliance standards are met. These functions have served as an "operational core," focused on getting the job done and meeting necessary requirements.
February 1, 2016 | Journal of Healthcare Management
By Tawnya Bosko, DHA, MS, MHA, MSHL, Vice President, Population Health Practice, GE Healthcare Camden
Group, Los Angeles, California; Mark Dubow, independent healthcare consultant; and Teresa Koenig, MD, senior medical officer, Medical Mutual of Ohio, Cleveland
The Centers for Medicare & Medicaid Services (CMS) implemented hospital quality incentive and penalty programs as part of the Affordable Care Act, and they are the starting points for transitioning to value-based payment. Not only do the programs affect hospitals’ bottom line, but they also could affect their market position because of the transparency of results. Thus, creating an effective strategy to succeed under these programs is important.
In this paper we address some important questions about the CMS incentive and penalty programs. Please email firstname.lastname@example.org for a complimentary pdf copy.
One month into 2016, it’s clear that this will be a year of massive change for the managed care industry. Here are seven predictions for some of the key issues that will emerge, intensify, or be resolved by the end of this year.
Provider coordination is of paramount importance for healthcare organizations preparing for the industry’s shift in focus from volume to value. The most ambitious coordination model that has been developed to date is the clinically integrated network (CIN) —a contractual collaboration among hospitals, physicians, and other providers to manage patients across the entire continuum of care. A CIN uses population health management tools, including care management techniques, to build value through improving patient outcomes and controlling costs. This innovative model offers providers access to value-based payment contracts and an opportunity to improve quality and reduce costs.
By Tina Wardrop MHA MSSW and Susan Corneliuson MHS FACHE
In most markets, single healthcare systems have formed independent clinically integrated networks ("CINs") in an effort to more formally align independent and employed physicians in the region. In certain markets, we are starting to see the development of Super CINs or Population Health Alliances. Consider these 8 components before forming a CIN.
Ready or not, Medicare's mandated 90-day bundle will require immediate action. Astute hospital and health system leaders will quickly lock in network partners and make critical buy-versus-build decisions when it comes to developing post-acute care capability. Medicare's Comprehensive Care for Joint Replacement program signals an evolution in payment that demands a strong strategic response from hospitals and health systems.
By Andy McNerney MBA and Danielle L. Sreenivasan MHA
If you are a commercial managed care plan leader or an executive for a self-insured employer, you may have initially thought that the Centers for Medicare & Medicaid Services Comprehensive Care for Joint Replacement Model ("CCJR") would have little impact on your plan or employees. With further consideration, you may have even celebrated that CCJR would benefit your members as a result of a “halo effect” as hospitals deliver higher quality, more cost-effective care under this model. With new incentives to deliver value (i.e., payments tied to quality and patient satisfaction) across an episode and an anticipated go-live date of January 1, 2016, hospitals are incentivized to quickly evaluate their current relationships and care delivery programs, and invest in the resources needed for program success. However, as hospitals prepare for the mandated management of episodes of care under CCJR (with other diagnoses likely to follow), they will focus on improving competencies that have traditionally been the responsibility of managed care plans—and by taking on these roles, will threaten the value proposition of most managed care plans today.
As part of healthcare reform, these programs are designed to transition hospitals to more value-based reimbursement by incentivizing or penalizing providers based on their performance on certain quality metrics. The broad questions of whether the programs are designed correctly and whether Medicare has chosen the most appropriate metrics underscore the complexity of reimbursing providers based on quality, but overall these three programs provide a fundamental change in how Medicare reimburses hospitals for services and in how hospitals manage and monitor quality performance.
Consolidation of medical practices into hospital systems and/or larger groups continues to rise. Separately, between 2012 and 2013, solo practitioners decreased from 21 percent to 15 percent of practicing physicians, while hospital-employed physicians increased from 20 percent to 26 percent, and physicians working as non-ownership employees increased from 12 percent to 15 percent. The effect of consolidation and the increasing losses per provider will likely have a dramatic impact on the acquiring hospital or medical group’s financial performance unless practices are managed and monitored appropriately.
Healthcare providers must conduct effective due diligence and analyses to ensure that the efficiencies and business justifications for mergers/acquisitions support the transaction, and that the benefit to the market in terms of quality and cost of care are apparent and fully achievable. Integrating anti-trust compliance into the due diligence phases of merger and acquisition considerations is imperative.
Many healthcare organizations, in the name of integration, have acquired a collection of overlapping units that fail to achieve the intended goal of system development. To avoid being a system in name only, healthcare organization leaders should undergo some intensive self-evaluation, and then take concrete steps to ensure that their organizations are, in fact, integrated.
Healthcare delivery in general, and physician reimbursement specifically, are undergoing unprecedented transformation. While most physician practices still operate largely in a fee-for-service (FFS) world, government and commercial payers alike have signified
their intent to reimburse physicians and other providers based on value.
How do you lead a medical group when reimbursement is based on patient volume, yet quality of care and cost management are (or may be soon) driving additional reimbursement streams? Many practice leaders are unsure which performance metrics to track as they try to manage the transition. The solution is to create a strategic performance measurement program that blends old and new metrics.
Maintain your focus on traditional key performance indicators (KPIs) while selectively adopting new KPIs that help you manage the emerging payment environment.
March 10, 2015 | Hospitals & Health Networks Daily
Our experience with providers nationwide has indicated that successful health care partnerships rely on one indispensable tool — a business plan of operational efficiency. A detailed BPOE helps partnering organizations achieve the large-scale cost reductions necessary for value-based care and declining reimbursement.
Healthcare reform has placed a new emphasis on data transparency as a mechanism to improve value. Consumers today have unparalleled access to information for comparing healthcare providers—far surpassing the limited availability of such information in the past.
Healthcare reform has placed a new emphasis on data transparency as a mechanism to improve value. Consumers today have unparalleled access to information for comparing healthcare providers—far surpassing the limited availability of such information in the past. Moreover, consumers and the public are able to access a growing abundance of hospital data, which are being made available through a variety of sources and mechanisms.
Your performance in 2015 on quality and cost will impact your Medicare payments in 2017. In 2017, potential penalties under the Physician Quality Reporting System (“PQRS”), the Value Based Payment Modifier (“VBPM”), and Meaningful Use (“MU”) could result in a cumulative 8 percent decrease in 2017 Medicare payments if your medical group underperforms.
By Lawrence Wagman, MD, FACS, Raymond Casciari, MD, John Maurice, MD, Peggy Crabtree, MBA, RN, and Ruslan Horblyuk, Ph.D., MBA
Targeted therapies with molecular testing requirements are a prime example of processes that contain natural gatekeepers in their operation flow. Process improvement techniques, such as Lean methodology, can help identify the underlying inefficiencies that are delaying or deterring patients from receiving treatment they require.
changing economic, political, competitive, regulatory,demographic, technology, consumer, and other factors. This will impact hospitals, health systems, physicians, and other stakeholders financially, clinically, and operationally.
In 2015, trustees will see last year’s cost and quality pressures continue. At the same time, they should develop closer relationships with all the providers along the continuum of care. These 10 trends are where boards should direct their attention in 2015.
January 8, 2015 | Hospitals & Health Networks Daily
Health system leaders should view any steps they take to prepare for their state’s Medicaid reform initiatives as integral to their organization’s evolution toward value-based care and population health. Hospitals and health systems should follow a four-step process to evaluate their state’s Medicaid initiatives and to develop new care models to better manage the Medicaid patient populations they serve.
October 22, 2014 | Hospitals & Health Networks Daily
It used to be that M&A in health care stood for mergers and acquisitions. But many innovative affiliation models exist that do not require fully giving up independence to create organized health care systems capable of delivering value-based care. Thus, M&A in health care has morphed to mean mergers and affiliations, which encompass the full spectrum, from loose clinical or administrative agreements to full asset combinations through traditional mergers or acquisitions.
September 19, 2014 | Mass Media (HFMA Massachusetts-Rhode Island Chapter's Newsletter)
With evolving payment models and the shift from volume to value-based care across the continuum, organizations throughout the country are designing and building clinically integrated networks of regional providers and hospitals with goals to improve access, quality, and outcomes.
September 19, 2014 | Mass Media (HFMA Massachusetts-Rhode Island Chapter's Newsletter)
Hospitals and health systems affiliate with partners to improve access to capital, achieve critical mass and economies of scale, increase access points, and expand their presence across geographic regions. Over the next two to three years, these incentives will lead hospitals and health systems of all types to seek alliances that will ensure their success
By Susan Corneliuson, MHS, FACHE and Brian Hackman, MBA, MSIS
Designing a physician compensation plan that reflects the transition to value-based payment should be a fluid and forward-looking process, wherein the plan ultimately adopted is continually reevaluated and updated.
Hospital Case Managers ("HCMs") have the opportunity to evolve their practice to support the clinically integrated organizations in the goal of population management through their interventions in the acute care setting. HCM training and development for successful population management should include core functions such as care transitions, clinical guidelines, community based services, health coaching and caregiver lifestyle management, as well as disease specific strategies. Here are ten considerations in evolving hospital case management for population health management.
In a value-based purchasing environment, basic survival necessitates that most healthcare providers establish or join a regional, clinically integrated delivery network (CIDN). This case study highlights Dignity Health’s approach. The article originally appeared in the May/June 2014 issue of Spectrum, a publication of SHSMD.
Recruitment planning must take into account the clinical and strategic impacts of current developments in population health management, care model redesign, regional market dynamics, use of technology, and the changing role of the physician in the patient care continuum. Here are five considerations to evaluate in determining future physician recruitment needs.
May 12, 2014 | HFMA's Strategic Financial Planning
As hospitals and health systems assume risk for patient populations under value-based payment structures, a rigorous planning approach that incorporates a broad perspective and non-hospital variables is essential.
In recent years, an increasing number of hospitals are looking to freestanding emergency departments as the solution to gain new market share, increase and enhance brand awareness and provide quality care to surrounding communities. Building a FED can bridge the gap between an acute-care hospital and a traditional outpatient clinic. Here are ten factors to consider when building a FED.
March 19, 2014 | HFMA's First Illinois Chapter Newsletter
Cost reduction is nothing new to healthcare; however, the circumstances around which cost reduction must be achieved have changed. The effort to provide quality, cost effective care across the continuum while achieving optimal patient outcomes has become more challenging than ever. Although the road has become more complicated, the ease with which it can be traversed can be simplified by considering these key elements noted below.
The year 2014 figures to be an important transitional year in health care as key provisions of the Affordable Care Act (ACA) take hold, including health insurance exchanges and expansion of the Medicaid program. The following are the top 10 most critical issues likely to impact CFOs in the coming year.
By Susan Corneliuson, MHS, FACHE, Senior Manager, The Camden Group and Johnson Gill, DPT, MPT, MPH, Associate Hospital Administrator at Arrowhead Regional Medical Center
This is a case study on Arrowhead Regional Medical Center's efforts to redesign care delivery in three off-campus primary care community health centers associated with the teaching hospital. The goal of the project was to move to a patient-centered medical home model. Here we share critical success factors to experience.
This all points to an interesting year: mid-term elections, insurance exchanges (love them or hate them), provider consolidation, cost management and a slowly growing economy. Here are the top 10 trends for 2014, and the areas that management and trustees should keep an eye on.
Throughout the year, top priorities for health systems, hospitals, and physicians will center on successfully navigating payment reform to increase revenues, managing (reducing) per unit costs, achieving Medicare breakeven, economically aligning with physicians, and continuing to redesign clinical care systems and
processes. Following is our best advice for setting policy priorities and monitoring progress in the boardroom, C-suites, and leadership councils for 2014.
The uncertainty and financial pressures of today’s healthcare environment have caused many hospital boards to consider affiliating with other healthcare organizations in various ways, from loose clinical affiliations to full mergers or acquisitions. Affiliating can provide many valuable benefits, and trustees are increasingly choosing to follow the path of consolidation.
The rapid evolution of the healthcare industry is about to thrust upon hospital and health system board members a new set of vocabulary, performance oversight responsibilities, and resource allocation decisions specific to post-acute care. For a copy of this article, please contact us at email@example.com.
With the move to value-based reimbursement, medical group leaders nationwide are searching for the “right” formula for physician compensation: one that aligns behavior with reimbursement methodologies, is fair to all physicians, and is financially viable for the
medical group. Your group must continuously update and revise its compensation plan to ensure that it continues to meet the group’s needs and responds to market changes.
By Sylvia Hastanan, BSN, and Megan Calhoun, MS, MSW
Seamless care coordination and care management are pivotal components of clinically integrated delivery systems, ensuring that high quality care is provided effectively and efficiently across the care continuum. After a common vision is established, physician leaders are identified, and a budget is allocated — what is next?
The following is a prioritized list of 10 service line operational and growth strategies which must be applied following a transaction. Each is a tried and true step that reflects the practical realities of integrating physicians, clinical and administrative teams as well as the cultures of different entities. Collectively, they represent an integration blueprint.
To ensure a successful transition for merging or acquired physician practices and to provide a clear roadmap, an onboarding work plan is critical. The detailed work plan steps should be followed with variations based on the existing infrastructure of the medical practice being onboarded.
Given the sweeping changes in health care, forward-thinking hospitals, systems and medical centers are carefully evaluating board
member succession and recruitment. The challenging environment in which these organizations operate requires strong, knowledgeable boards whose members have deep insights into the field and a fundamental understanding of business, management practices and how to compete in a highly competitive market.
The impact of Covered California will not be fully realized until well into 2014, but here are some initial implications that can be drawn based on what we do know about the exchange, the recent announcement of the participating health plans and rates for individuals, California’s population, and the current healthcare environment.
Never before has there been a greater call to action for physician organizations experienced in managing care under capitation: managing populations of patients, measuring quality, and coordinating diverse providers are characteristics that many healthcare organizations now aspire to achieve. Yet it is also a time in which the model is threatened by the market’s desperate need to reduce health insurance premiums.
Care delivery continues to evolve at a rapid pace in both primary and specialty care, with many changes occurring in both outpatient and inpatient settings. Practices wishing to stay ahead of the pack should consider these ten practice re-design approaches.
With declining reimbursements, a weak national economy, and increasing deductibles, employers and payers will shift more payment responsibility to patients and significantly increase the importance of patient collections in medical practices.
The Internal Revenue Service issued a notice of proposed rulemaking on April 3, 2013 that provides more clarity and specificity on the rules that will govern Community Health Needs Assessment reports. We have outlined the major provisions covered in this latest notice.
With the recent CMS announcement of the condensed timeframe for the 2014 Medicare Shared Savings Program (“MSSP”) application cycle, many provider executives have been evaluating if the time is right for their organization to apply. Here are some considerations for why the Medicare Shared Savings Program could be the right move for your organization now.
The new year of 2013 has just begun and our vision is already squarely on 2014. Will 12 months be sufficient time
to prepare our organizations, communities, states, and the nation for the changes required by ACA, the American Taxpayer Relief Act of 2012, and other regulatory and economic trends? Following are our best recommendations to guide your strategic thinking and
priorities for 2013 and beyond.
The Veterans Health Administration (“VHA”) and Military Health System (“MHS”) are great examples of integrated healthcare delivery organizations that serve veteran and military populations in the U.S and around the world. There are lessons to be learned from these governmental agencies as health systems in the private sector seek innovative ways to serve their patients in an integrated environment and to minimize redundancies in clinical and administrative processes.
This year's priorities will be cost-reduction, building a physician base, implementing new care models and, most importantly, preparing for 2014. As board members, senior management and physician leaders develop their strategies and budgets for 2013 and beyond, allocating limited resources grows more difficult. Here are the top 10 trends for this year and what trustees should keep an eye on as they look to 2014.
Over the last several weeks, the Center for Medicare & Medicaid Innovation (CMMI) has announced numerous design changes to the BPCII, some of which may enable ease of BPCII execution (standardized episodes, discounts, and readmit exclusions) and some of which will shift considerable risk to applicants, possibly making this an untenable situation for some.
After a hospital consolidation, leadership will typically consider how to integrate existing medical staffs but may
not give immediate thought to the recruitment of new providers. The following are some special considerations to take into account when developing the first physician manpower needs assessment after a consolidation, including: timing, service area definition, medical staff data completeness, non-patient care activities, and legacy approaches to recruitment packages.
The director of case management is one of health care's leadership positions most frequently in demand. The lack of qualified and effective case management leaders will continue to be an issue for organizations for years to come, influenced by increasing pressures on health care reimbursement and the aging case management workforce. Organizations have an opportunity to create a program to develop future case management leaders from their internal talent.
Listed below are the top 10 ways in which the changes in the market, including healthcare reform, are affecting
physicians. Some may be more effective in individual situations than others, but they cannot be ignored for
those who, at the very least, wish to "ride out the storm" successfully. For while some are hunkering down to
"survive," others are seizing the opportunity to lead. Here are the trends to watch for in your market.
November 11, 2012 | Hospital & Health Networks Daily
Providers, health systems, health plans, disease management companies and the like are trying to assist patients through the complex maze of care delivery. As a result, we have an excess of care coordinators - care managers, case managers, disease managers, health educators and others of varying titles, but who fill the same role and responsibilities.
Operating a thriving medical practice is becoming more challenging with the decline in reimbursement, increased burden of paperwork and regulations, and the rapid changes in the healthcare landscape. As value-based payment models emerge,
medical groups need to be appropriately positioned to move from a productivity-based environment to a value-based environment. Here are operational strategies and options for tapping into various sources of capital and for streamlining processes to ensure financial viability.
Health systems, in particular, will either need to embrace population health management models as health plans introduce shared savings or bundled payment revenue arrangements, or prepare for deep cuts in fee-for-service revenue. Now more than ever the linkage between financial and market strategies is key in determining how to maintain/grow the health system's commercial business.
Although pharmaceuticals drive costs within hospitals and must be incorporated into clinical protocols and embedded within information technology systems, the key considerations outlined below must be evaluated to determine how drugs may ultimately help hospitals improve quality as well as their bottom line.
With more healthcare organizations consolidating every year, it is critically important that newly formed systems develop a comprehensive strategic plan that sets the new organization's path towards success.
August 30, 2012 | Hospital & Health Networks Daily
Leaders at clinically integrated provider networks - those that may include both hospital and physician providers - understand that they need to adopt some risk- and value-based arrangements with insurers, but often are at a loss on how to proceed. Following the tried-and-true playbook for payer negotiations simply doesn't work.
Due to industry and economic pressures, many acute care hospitals are deciding to form an affiliation or merge with another entity rather than continuing to operate as a stand-alone entity. Although each transaction is unique, hospitals generally experience five phases in the process: assessment, partnership planning, transaction development, transaction execution/due diligence, and integration.
For organizations that have decided to implement an health information exchange, there are roles and
responsibilities for many staff groups both in and out of the IT department. Here are four high-priority
recommendations to avoid common pitfalls during this major endeavor.
With the expectations embedded in healthcare reform, the patient experience is an essential component to the short- and long-term success or failure of a healthcare organization. An important component of the Medicare Shared Savings Program for ACOs is a financial reward for providers who put their patients first. As a result, providers are paying increased attention to how they can retain patients by making every patient interaction as engaging, positive, and meaningful as possible.
For many organizations, telemedicine offers the ability to improve access to medical services while potentially lowering the costs associated with the delivery of care. This objective aligns well with the national mandate to deliver efficient and effective care in a consistent and reproducible way. Here are five essential factors to consider when implementing a telemedicine system.
In arguably one of the most highly anticipated rulings, the Supreme Court upheld yesterday, in a five to four vote, the health reform law (Affordable Care Act) with the exception of one key provision: that the federal government can take away existing funding from states that refuse to fully comply with the law's Medicaid expansion requirements. Here we look at the impact of this ruling.
With the imminent healthcare reform ruling from the Supreme Court to be issued any day now, The Camden Group's experts weigh in on the implications of likely scenarios for the major constituents (hospitals/health systems, payers, physicians, patients, and employers).
Case management, with its standards of practice of patient advocacy and resource stewardship and its role as a liaison between patients, payors, and the healthcare team, is in a unique position to support the revenue cycle and bridge the gap between a hospital's finance and clinical departments.
June 1, 2012 | Physician Organizations (American Health Lawyers Association)
On October 20, 2011, CMS issued the final Medicare Shared Savings Program (MSSP) rule. In response to the feedback provided, CMS narrowed the universe of measures from sixty-five to thirty three and worked to align the stands with those existing in other CMS quality reporting programs.
The use of an Embedded Care Manager to coordinate services within the complex healthcare delivery system is sharply increasing. Health systems and health plans embarking on clinical integration or targeting improvements in disease specific health outcomes see care management as a critical capability. Historically, the functions and responsibilities of a care manager have been as unique as the organizations that employ them. However, there have been overlaps or redundancies with the roles and responsibilities of the care manager and the patients they serve.
What happens immediately after a hospital enters a merger or consolidation is as critical as the planning and execution of the transaction itself. There are a number of issues that need to be considered and steps that hospital executives should take to ensure that the new system will be able to realize the intended benefits of the transaction.
Health plans around the country have slowly but steadily been reintroducing tiered and narrow networks to their product offerings as they search for ways to differentiate themselves and offer employers lower-cost products without significantly reducing benefit levels.
Now more than ever, hospital case managers play an important role in managing the cost per patient day by working closely with the patient and his or her family, along with the physician and the interdisciplinary healthcare team, to move the patient through the continuum of care with an eye toward financial reimbursement. How can you determine the financial performance of your organization's case management department?
A successful medical group does not happen by itself. Success takes leadership, planning, and hard work. In working with both
successful and unsuccessful medical groups for over 25 years, it has become clear that there are specific critical factors that drive medical group performance.
Many forces have driven healthcare mergers and acquisitions over the years. The result has been an increasingly consolidated profile for healthcare providers. Today, new forces are coming to bear that undoubtedly sustain and accelerate the movement towards ever-larger healthcare delivery organizations.
There hasn't been this much news and discussion of the payer and provider spaces coming together since the 1980s, when a number of hospitals and health systems decided to start their own health plans and compete as integrated delivery systems. There is much more to come; it's only a matter of time before integrated payer/provider organizations like Kaiser Permanente are more common across the country.
February 2, 2012 | Hospital & Health Networks Daily
Because CMS soon will penalize hospitals that see too many patients return within a month, now is the time to create strategies to avoid readmissions. To meet the challenge, hospitals need to take a structured approach to reducing readmissions - an assessment of the organization's risk and a comprehensive strategy that transitions the patient from the hospital to post-hospital care.
Since the passage of healthcare reform, there has been a lot of discussion and much ink spilled on preparing for accountable
care organizations (ACOs) and value-based purchasing. For most organizations, the magnitude of the change required to convert from a fee-for-service philosophy and business model to a business model based on global payments and value is daunting. Service lines can be an ideal bridge to this change.
Bundled payments, value-based purchasing, and ongoing efforts for healthcare reform will continue to challenge healthcare providers in 2012. Service line development for organizations participating in bundled payments will be critical for the successful management of an episode of care.
Whether clinical integration is targeted to achieve greater coordination around a single clinical condition or procedure or fully integrating a healthcare provider network, the benefits are clear. There are a wide range of approaches and strategies to achieve successful clinical integration, but regardless of the strategy, clinical integration, when designed and implemented correctly, offers tremendous potential to create efficiencies and improve healthcare quality and patient satisfaction.
Consolidation processes are complex, distract from core operations, and are fraught with details that can extend the process and increase both transaction cost and long-term operating success. Here are some common pitfalls to avoid.
Physician alignment has been a focus for healthcare leaders as they look to the future. Engagement of frontline staff can be a missed opportunity for alignment as organizations look for expedited ways to improve clinical care, systems, and patient experience. The following strategies can be used to facilitate service line staff engagement in a time of rapid change.
January 15, 2012 | The Governance Institute's E-Briefings
The future of healthcare has always been challenging to predict with precision. This prediction has gotten even more difficult as we shift into the implementation of healthcare reform, begin an election year, continue to have a struggling economy, and anticipate a pivotal Supreme Court decision regarding mandating health insurance coverage. Here is our best advice for board members and senior leaders to guide strategic thinking for 2012.
As hospital leaders look forward, they also need to reflect on major events in 2011 - the struggling economy, the decline in elective procedures and general softening of volume, and the introduction of value-based Medicare payment models - that will shape 2012. Here are the 10 health care trends that will make the biggest impact on hospitals and systems, plus the factors of which trustees should be mindful.
An organization's "care management model" is its approach to coordinating inpatient, post-acute, physician office, and home-based care for patients with episodic and chronic disease management needs. How each of the separate components of the Care Management Model functions independently and with each other to identify patients with gaps in care and "high-risk" patients is the integral component to realizing cost savings.
Interest in co-management agreements has increased dramatically over the last two years as hospitals explore various forms of physician integration, including bundled care, valued-based payment arrangements and accountable care organizations. Since much of the first wave of co-management agreements began in the mid-2000's, there are many "mature co-management arrangements from which to learn. Here are 10 lessons learned from those early ventures that paved the way for clinical integration in specific service lines.
As medical groups are increasingly paid based on value rather than volume, they will need to redesign their physician compensation models to align physicians' incentives with the medical group's new incentives. The first step is to determine whether now is the right time to begin changing physician compensation structures and incentives.
The national dialogue surrounding accountable care organizations seems to include a barrage of discussion pieces around the pros, cons, and requirements of becoming an ACO. While an important consideration for many, it is critical to take into account a much broader spectrum of strategic options that lay before healthcare organizations even in this era of reform.
Given the complex issues facing the healthcare industry, the nurse executive's role will by necessity emphasize collaboration with
all providers to operationalize the organizational changes required in the future. Here are the six healthcare trends impacting nursing.
How can we hope to "bend the cost curve" under our current fragmented, expensive, and unresponsive delivery models? The answer will be found in assessing the current delivery model and identifying ways in which physicians might be able to work together, even
when they are not in "formal" organizations, such as medical groups, staff models, or independent practice associations.
As regulations for the CMS Shared Savings Program and Value-Based Purchasing Program are finalized, hospital executives will continue to grapple with the long-term changes to the fee-for-service business model. But to be successful in the post-healthcare reform environment, executives must refocus on near-term strategies to improve their organizations' positions today.
Physicians are naturally and appropriately skeptical of the new arrangements under clinical integration or an accountable care organization that will impact not only how they get compensated, but also how they care for their patients. Here are 10 of the most frequently asked questions physicians have about clinical integration and accountable care organizations (ACOs).
Hospital case managers have been valued for their understanding of healthcare delivery and their ability to combine quality, efficiency and resource management in delivery of patient care. The need for an effective and responsive case management department has never been greater. Here are five indications a case management department needs improvement.
With the extinction of hospital risk pools and hospital capitation in most markets, one of the central questions for physician organizations considering ACO designation is, "How do I engage a hospital in ACO discussions when all they seem to care about is the volume of admits or outpatient referrals?"
Many payers are actively promoting patient-centered medical home (PCMH) initiatives through planning and development assistance, staff training, and ongoing financial support. Blue Cross Blue Shield of Michigan (BCBSM) has the largest PCMH program of its kind in the country and has been a leader in primary care innovation. This article describes the work of the BCBSM's medical home program and their early results.
To meet the participation guidelines and goals of healthcare reform and to access additional sources of revenue such as shared savings, it will be essential to follow the principles of a patient-centered medical home (PCMH). Here are 10 factors that payers and providers should consider in evaluating provider readiness for medical home.
January 17, 2011 | The Governance Institute's E-Briefings
Much of what we expect to see in 2011 will be an extension and continuation of trends and events experienced in 2010. While politicians and regulators sort out healthcare reform, the fundamentals will stay the same. The following represents The Camden Group's best advice for board members and leadership teams to chart strategic direction for 2011.
Rapidly following the lead of the Centers for Medicare and Medicaid Services, commercial payers are demonstrating heightened interest in bundling payments to providers to try and bend the cost curve. Here are six critical success factors to bundled payments that
every c-suite executive needs to consider.
Incentives can be a powerful tool to increase workforce capacity when patient volume or intensity increases. A sound and effective incentive program must be time limited, proactively initiated only when very specific predetermined conditions and criteria are present, and provide the type of incentive that motivates the target population.
As organizations evaluate their readiness for bundled payments, there are two categories of critical success factors to consider: care management infrastructure and physician integration. The following is a subset of diagnostic questions an organization should utilize in assessing if it is ready and well positioned to be selected for and achieve success in bundled payment:
While the ultimate future model for acute care providers and large medical groups may be to achieve ACO status, which is to provide all the healthcare needs to a defined population, a less risky first step is to increase an organization's abilities and competencies by first expanding its current service line approach to integrate the medical professional components into the pricing and cost structure of the organization.
Accountable care organizations (ACOs) and clinically integrated organizations are being formed across the country. Payers, including government, employers, and health plans, are taking notice of this trend and considering either beginning or expanding their participation with such organizations. The following are five reasons why hospitals, physicians, and payers should support and develop clinically integrated and "accountable" delivery systems or ACOs.
In this article we describe health care reform and the proposed payment changes in relation to hospital readmissions, some leading
practices designed to reduce heart failure readmissions in which nursing can play a pivotal role, and an approach to executing readmission reduction strategies for cardiovascular services.
Today, community cancer centers, oncologists, and the healthcare industry as a whole are refocused on survival in the midst of very turbulent times. While technical signs indicate that the country is emerging from the recession, the pace and degree of economic recovery for communities, physicians, and community cancer centers remains uncertain.
January 9, 2010 | The Governance Institute's E-Briefings
The year 2010 is about the recovering economy, continued high unemployment, and healthcare reform. Changes in payment structure, the economy, and delivery system changes are a catalyst to accelerate action and there will be winners and losers. The following ten trends and their impacts are The Camden Group's best advice to board members and senior leadership.
Improving operational effectiveness will be essential to delivering higher-quality care and improving financial performance. This environment may be seen as a challenge, but it is also an excellent opportunity for nursing services to further demonstrate their value in patient care outcomes and support financial performance.
Accountable Care Organizations ("ACOs") are being proposed as part of Medicare payment reform and are also being considered by some commercial carriers as a mechanism to shift responsibility to networks of hospitals and physicians for "bending the cost curve" and improving quality. Is your organization (either hospital or physician group) ready for a world of ACOs?
How has your physician practice fared this past year? Your responses to nine key trends determine how well your organization
copes with uncertain times. Here are suggestions to help your medical group succeed.
In order to successfully prepare for the challenges of impending healthcare reform and address the effects of the extended economic downturn, many hospitals and health systems need to not only improve their operating performance, but also should consider doing so within the context of enhancing clinical integration, service and process coordination, and aligning resource utilization across the care continuum.
Consistently providing high quality healthcare for everyone at a lower cost are the main concepts of healthcare reform. But how? The Centers for Medicare and Medicaid Services believes one way to achieve this is through accountable care organizations (ACOs).
It has been proposed that ACOs beimplemented in 2012 as part of healthcare reform. So, what does that mean for you?
This article examines the impact of the changing healthcare landscape on physician compensation plan design, describes the critical success factors in compensation redesign, and discusses how to create an effective process to successfully accomplish compensation redesign.
Speakers from Latham & Watkins, The Camden Group, Intelligent Healthcare, and Yale-New Haven Health System participated in a 90 minute webcast discussion of recent health care market trends and the potential of accountable care
organizations (ACOs) as a new model of physician / hospital integration. The authors presented during these webcasts, and the following summarizes the content of these presentations.
While there are glimpses of hope in the financial markets, it is likely that most of 2009 will be characterized by softer volumes and suppressed revenue streams for hospitals. For a successful turnaround, consider these strategies.
September 1, 2006 | Journal of Medical Practice Management
Practices continue to struggle with patient scheduling and assuring access to care for their patients. Consequently practices are seeking new, innovative ways to redesign practice operations to improve patient, physician, and staff satisfaction. One of the foundations of this redesign is Advanced Access.
Laura Jacobs, MPH discusses how new entrants - including health plans, technology companies, and pharmaceutical companies - are providing new products, opportunities, and resources that can help health care organizations become more accountable and respond to the challenges of the changing health care environment.
Metrics from 200 healthcare companies on accountable care organization (ACO) adoption, challenges and benefits in 2012. This second annual analysis by the Healthcare Intelligence Network (HIN) delves into ACO administration, size, and the model's impact on healthcare utilization and care delivery. Steve Valentine, MPH shares his thoughts.
Speakers from Latham & Watkins, The Camden Group, Intelligent Healthcare, and Yale-New Haven Health System participated in a 90 minute webcast discussion of recent health care market trends and the potential of accountable care
organizations (ACOs) as a new model of physician / hospital integration. The authors presented during these webcasts, and the following summarizes the content of these presentations.
A large independent primary care medical group (the “Medical Group”) with approximately 500 physicians in 200 primary care and 8 urgent care sites throughout the United States was committed to improving physician satisfaction. Therefore, it launched a major work flow assessment initiative including the use of surveys to identify issues and examining work flows in representative clinics throughout the country. Read more on how we helped.
A consistent trend has been emerging of medical groups continuing to consolidate and/or collaborate in new ways. Balancing the desire to operate independently, while taking advantage of the infrastructure and systems available through alignment with integrated networks, has made network participation a necessity – rather than an option – for most physicians. This need on behalf of physicians, coupled with the requirement for health systems and managed care payers to provide a robust scope of clinical services across a targeted geography, has driven the formation of many integrated delivery networks (“IDNs”) across the healthcare delivery system.
By Tawnya Bosko, MHA, MSHL, MS and Tina Pike, MBA, MSN, HCM, RN
It has been estimated that potentially avoidable hospital readmissions result in excess spending of $12 to $17 billion annually by Medicare. Potentially avoidable readmissions make up approximately 75 percent of all readmissions. In this report, The Camden Group summarizes the penalties associated with readmissions through the Hospital Readmissions Reduction Program and solutions for hospitals to reduce readmissions.
Skilled nursing facilities (“SNFs”) are a logical post-acute care partner for hospitals since they provide healthcare services to patients who require ongoing inpatient medical care, but no longer need the intensity of services provided by an acute care hospital. Given the potential financial incentives, hospitals must carefully evaluate five key areas when considering a SNF as a partner for episode of care management.
A well-managed hospitalist program can help a hospital improve patient safety and quality, maximize throughput and patient flow, and reduce unnecessary bed-days and resource utilization. At the same time, the vast majority of hospitalist programs require ongoing financial support from the affiliate hospital or another sponsoring organization. This has many wondering if they are deriving the maximum value from their hospitalist program, especially as hospital financial performance is under pressure and the move to value-based care accelerates.
With healthcare reform and the changing healthcare landscape, a "new" healthcare delivery organization is emerging - one with different payment models and an increased focus on hospital-physician integration. As you navigate the various models and options for integrating with physicians, this publication will provide insight on the best ways to transform your organization to respond to the evolving marketplace. Please contact us at firstname.lastname@example.org for information on how to receive a copy of this comprehensive publication.
Economic pressures on physicians and hospitals have increased attention on integration and collaboration between providers. This paper 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.
This paper examines key differences between nonprofit and for-profit hospitals, how each are reacting to the changing environment, potential drivers of for-profit conversions, trends in the formation of health conversion foundations, and considerations and implications for conversion.
In this paper, we provide a high a level summary of proposed rules for ACOs and the shared savings program most relevant to post-acute providers. We also share examples of how three leading post-acute provider organizations are preparing to be part of a new health care delivery and payment model.
Everyone has been anxiously awaiting for CMS to release its accountable care organization (ACO) regulations. Last Thursday, March 31, a coordinated release of proposed regulations and guidance from CMS, FTC/DOJ, ITS, and the HHS OIG was accomplished. Now begins the process of figuring out what these regulations mean and how they will affect the implementation of the many potential ACOs waiting in the wings.
Market and economic forces over the past 20 years have led physicians and hospitals to engage in a variety of approaches to achieve greater integration, with varying degrees of success. Physician-hospital integration has increased during periods when patterns of reimbursement align physician and hospital incentives, competition intensifies, or other economic or demographic changes require collaboration.