4 things practices will have to assess in the new healthcare environment
Imagine healthcare delivery in the slowly waning, fee-for-service model as the Hawaiian Islands, with each island representing a different specialty practice or hospital. Patient Jones visits the Big Island for his annual exam, where a potential medical problem is discovered that has to be treated by a specialist on Kauai. Jones goes to Kauai, where it's determined that he needs surgery. So he's referred to Maui for that. After a brief post-surgical stay on Maui, Jones returns to Kauai for a post-op and is asked, "What's the nature of your appointment?" Then, months later, he goes back to the Big Island for his next annual exam, where he's asked, "So how'd that thing on Oahu go?"
OK, we know this doesn't happen in your practice, but, unfortunately, in our highly fragmented healthcare system, physicians sometimes fail to communicate with each other about shared patients. In the future, when reimbursement is based more heavily on quality, and physicians in different practices might have to carve up a global payment for an episode of care involving a single patient, tracking patients throughout the system will be imperative. Practice leaders, regardless of specialty, will need to take specific steps to ensure they can function in a value-based environment, says Laura Palmer, FACMPE, and Joan Hablutzel, MBA-HA, both senior industry analysts, MGMA Innovation and Product Design.
"Medical practices will all be in the same camp, but they'll have different responsibilities," Hablutzel says.
Specialists will have to pay more attention to things that used to be the exclusive realm of primary care (PC) doctors (i.e., monitoring blood pressure), and PC clinicians will have to pay more attention to what the specialists are doing, Palmer says, adding, "The lines are going to be blurred."
To bring clarity to the blurry new world, Palmer and Hablutzel say that all practices will have to assess:
Physicians will have to collect, analyze and manage a lot more information about patients. Then they'll have to refine or implement processes for following up on that data. This entails having the right tools – EHRs, patient portals, practice management systems – and the right processes for patient flow, testing, following up and sharing test results, etc.
This refers not only to communications among physicians and staff in one organization, or from the organization to its patients -- this also includes communications flowing from practice to practice and practice to hospital.
Although communications might be among the most critical yet most daunting aspects of the future, simplification could be a key to success. For example, Donald Stumpp, CPA, MGMA member, manager of payer contracting, American Health Network Inc., Indianapolis, says his 150-physician, multispecialty practice took a simplified approach to communicating with accountable care organizations (ACOs).
"The ACOs we work with all have single tax identification numbers," he says, as opposed to each practice within a single ACO having a unique number. “There is just the one participating 'group.' We purposely did it that way to avoid issues related to coordinating among different groups. Plus, there is the financial aspect that if group A does well and saves money but group B doesn't, then the ACO savings are diluted and group B has dampened the return on investment for group A.
Because collaboration across all specialties will be required to improve care and maintain reimbursement, doctors in different practices and specialties will have to agree on expectations related to patient care. For instance, Hablutzel says, using the blood pressure example, if a specialist notes that a patient has suddenly developed high blood pressure, what are the expectations for dealing with it? Will he or she simply relay the information to the PC doctor? Will the specialist be expected to take immediate action and then let the PC doctor know after the fact? Those things will have to be predetermined by clinicians.
If your practice decides to join or form an ACO, your referral network might change based on the members of the ACO and its payer mix. Also, do your physicians share the same values as other physicians in your alliance, be it formal or informal? Will your doctor accept, as part of the care team, a chiropractor or a PC clinician who believes in the value of biofeedback?
These are the questions practice professionals should consider as they approach a system built on collaborative patient care.