As experts in the healthcare arena, our team members frequently publish white papers and articles to help our clients and subscribers have a better understanding of the industry’s foremost issues. Our white papers often appear in the industry’s top-ranking publications.
White Papers and Articles
The current documentation guidelines that are in place for hospital inpatient, hospital observation, emergency department, nursing facility, and home or residence services are over 25 years old.
They were first released in 1992, revised in 1995, and again in 1997 with specialty guidelines.
With the 2021 and 2023 documentation and coding requirements for Evaluation and Management (E/M) services, CMS and the American Medical Association (AMA) have updated the requirements to streamline the process and address the administrative burdens. In addition, the upcoming changes also allow CPT and CMS to align whenever possible.
Balancing the tension between governmental compliance and financial viability takes effort. It is even more challenging when the physician resists cooperation or does not engage in the review and educational process afforded by ongoing coding and documentation reviews. Too often, practitioners do not know their weaknesses and vulnerabilities in coding and documentation, including with their use of EHR templates. Knowledge is power, as the adage goes—the more you know, the more you can control events. What you don’t know can hurt you, particularly about the compliance and financial matters of your medical practice or for hospitals and health systems, the practice of your employed providers. When you know your vulnerabilities, you can take appropriate action. An effective coding audit can result from a well-thought-out compliance plan, a customized approach, and investment in the time and energy to create an atmosphere of proactive education and support.
Experiencing a breach can have a significant financial and reputational impact on healthcare facilities. Although all breaches are not preventable, a facility’s best first step is to take a deep dive into its security posture by performing a Security Risk Analysis and identifying where they are vulnerable before cybercriminals exploit such vulnerabilities.
If you experience a significant breach followed by an investigation by the Office for Civil Rights (OCR), your risk management process will be scrutinized. Often, Civil Monetary Penalties result from a lack of due diligence and a failure to accurately and thoroughly assess potential risks and vulnerabilities within your organization.
There is no one way to perform a security risk analysis (SRA). However, this paper will provide tips and options to navigate the process successfully.
This paper will provide background information on the Department of Health and Human Services requirements to complete a security risk analysis (SRA), explain why you should conduct an SRA, describe key elements of the analysis and explain the importance of creating a follow-up corrective action plan and tracking process.
The development and retention of talented leaders are fundamental to the success and stability of any organization. Post Covid-19 and the pandemic, a great deal of emotional and financial stress has been placed on leadership creating a new paradigm for work. Leaders must recognize these changes and adjust their thinking to a world that is now both virtual and in-office with less local control without losing touch with their teams and business focus. How leaders make decisions in this new shift is critical to their success and the success of the organizations they lead. This paper describes key decision-making characteristics that are critical during times of dramatic change. Through a case study, readers will learn how to develop leaders into making sound choices in the new world post-Covid-19.
Professional services agreements (PSAs) continue to be one of the most frequently discussed alignment models for Coker, with both hospitals and practices seeking partnership and realizing there are countless ways to effectuate such through the use of a PSA. Specifically, PSAs are attractive to entities that wish to structure a contract that stops short of full employment, yet still offers many of the benefits of a fully aligned relationship.
The last decade has been incredibly impactful for the healthcare industry, with the present-day looking almost entirely different from that of even the early 2010s. From the sharp uptick in hospital acquisitions and employment to the growth in health systems through mergers, the introduction of the Affordable Care Act and an increasing shift from volume to value, and most recently, the COVID-19 pandemic, healthcare leaders have had to retool their operations, increase their knowledge, and find effective ways (often through trial and error) to remain responsive to the ever-changing dynamics.
Fragmented provider compensation structures risk significant negative financial impacts. There is a high potential for provider investment to outpace productivity and risk of turnover as high productivity, low compensation providers seek employment alternatives.
Medical groups must juggle numerous competing pressures as they design provider compensation structures, including 2021 MFPS changes, PSA arrangements, employment contracts, professional collections, key income statement metrics, industry trends, etc.
Medical groups which grow quickly and significantly often inherit a medley of various provider compensation agreements. Such groups can benefit immensely from an overarching provider compensation philosophy.
Read the case study for financial performance observations and recommendations.
The impact of restrictive covenants on competition and economic growth has long been a source of debate among economists, politicians, employers, workers, and state courts. The Workforce Mobility Act of 2021 introduced in the U.S. House of Representatives on February 25, 2021, aims to limit the use of non-compete agreements to certain circumstances, such as with the sale of a business or for senior executives.
Regardless of the resulting overall impact of these recent efforts, restrictive covenants are currently ubiquitous in the American economy and should be reviewed thoroughly as employers and employees navigate the changing landscape.
Within the article, the authors explain why and how non-compete agreements are applied and enforced, and the value of the non-compete agreement.
Physician employment opportunities stand out within the rapidly evolving healthcare landscape due to their disruption of industry norms, significant financial implications, and platform for driving further growth.
While private physician practices seeking employment have numerous options, acquisition by Private Equity can be desirable. This opportunity not only results in a sizable upfront cash windfall for physician owners but can also improve physician work-life balance by reducing administrative burdens and revitalizing engagement around enhancing clinical outcomes.
Physicians across the country seem to agree, as acquisition by Private Equity has become increasingly common. Medical Groups grow larger as market forces encourage consolidation, and partnership with Private Equity enables physician practices to compete in this new paradigm.
Download the white paper to understand why this acquisition model is so common and how it impacts the future.
Healthcare organizations such as hospitals, home health agencies, skilled nursing facilities, physician practices, and third-party medical billing companies are constantly exposed to new compliance risks. We attribute this to our current world of continually changing healthcare laws and regulations coupled with these organizations evolving their operations to adapt to this ever-changing environment.
Now more than ever, these organizations must maintain an effective compliance program. The industry recognizes conducting a compliance risk assessment regularly as one of the key elements of an effective compliance program. An ongoing compliance risk assessment will identify and evaluate these risks and empower an organization’s leadership to address the risks to the organization proactively.
This paper will define a compliance risk assessment, explain why you should conduct a compliance risk assessment, discuss how to develop a compliance work plan, and why you should monitor the work plan and track progress.
Management services organizations (MSOs), entities that provide various administrative support services to physician groups, have grown significantly. While this trend is primarily linked to the influx of private equity (PE) activity in healthcare, many independent physician practices are considering their own MSO strategy. MSOs can be valuable vehicles through which PE firms or independent physician groups acquire or partner with multiple practices, scale services, and achieve operational efficiency for members.
Despite previous iterations of MSO-like companies failing in healthcare (i.e., physician practice management companies in the 1990s), the current wave of MSO activity may be in a better position for success. The shifting landscape of value-based reimbursement, the increased need to leverage technology to achieve efficiency, and the expansion of consumerism in healthcare all provide opportunities for MSOs to thrive in the current environment if properly executed.
This paper details the drivers that are leading to the recent MSO revival. Next, we outline the characteristics, structures, and strategies that define many MSOs in healthcare today. Finally, we explore unique MSO growth strategies for the current healthcare landscape.
CMS recently released Part II of an interim final rule (IFR) to the No Surprises Act (NSA) of 2020, providing more detailed implementation requirements for last year’s highly publicized surprise medical bill legislation. The IFR components provided to date will significantly impact providers, health plans, and patients in the area of out-of-network reimbursement as soon as January 2022. We believe it is critically important for physicians providing out-of-network (OON) services to prepare for the administrative and financial impacts of the IFR next year.
In an ideal world employed physician enterprises would have a clear compensation strategy with appropriate governance protocols so that their employed physicians would be on a consistent, well-designed compensation structure. Unfortunately, the realities of what brought together physicians under an employed structure differ significantly from this utopian vision. Compensation design and redesign is a delicate process that encompasses both scientific reasoning to support the economics of the physician enterprise as well as artful politicking to engage physicians properly throughout the process.
In this paper, we evaluate the most common components of physician compensation plans and offer best-practice insights on them. Additionally, we provide commentary surrounding the core structures necessary for physician engagement throughout the compensation planning process.
Earlier this year, we published a blog post regarding the impact we were expecting with the release of 2020 compensation and production surveys. In short, the blog reviewed trends in compensation and production results from 2020 that we were examining for hospitals, health systems, and medical groups. Based on the data we were studying, many providers had their compensation protected in 2020 amidst the COVID-19 pandemic while simultaneously seeing large reductions to patient volumes, leading to lower wRVU productivity and a spike in compensation-to-wRVU ratios. Therefore, we posited that compensation survey benchmarks would likely experience an abnormally sizeable upward shift in compensation-to-wRVU ratios resulting from the impact of COVID-19.
The data is now available for several major national surveys, and broadly speaking, the results are as predicted. To demonstrate the survey results, we will focus much of this article on compensation and production measures averaged from the Medical Group Management Association (MGMA) and American Medical Group Association (AMGA).
Compliance effectiveness, a buzzword in the industry, continues to be a focal point of compliance programs and governmental investigators. There continues to be significant compliance concerns across the healthcare industry as evidenced by ongoing DOJ settlements, new corporate integrity agreements, and other findings and activity. Although many organizations and providers adopt compliance policies and procedures, many neglect to operationalize them fully in their day-to-day operations. This inaction presents a significant problem and risk to these organizations/practices.
Coker’s white paper, Compliance Program Effectiveness, written by Coker Group Senior Vice President and Director of Coding & Compliance Services Rosalind Cordini, explores what it means to be effective, what constitutes a well-designed compliance program, and the barriers to implementing an effective program.
The market today, more than ever, with the movement towards value-based medicine as well as population health management, requires that health systems understand their demand for physician services. Gaining that understanding necessitates that the organization takes a deep dive into their marketplace and how the current and projected medical community is meeting its needs. This comprehensive assessment into physician demand and need should serve as an underpinning to the overall physician strategy of the organization.
The COVID-19 Pandemic in 2020 and afterward sent devastating shock waves through our nation, threatening our lives and livelihood. Healthcare was not immune from the devastation as the industry sought to mobilize resources to address the pandemic while feeling the financial impact of the corresponding shutdowns. As we advance, healthcare organizations must find a way to recover from 2020 while offering quality care to a significantly more financially stressed population. The need for more value in healthcare has never been greater. As the key drivers of health system resource utilization and the focal point for patient engagement, the physician enterprise must serve as the primary path to greater value. Unfortunately, with the continuing trend in reduced professional fee reimbursement, most health systems’ efforts are focused on physician enterprise financial sustainability rather than pursuing the benefits of enhanced alignment. Hospitals’ and physicians’ challenge is to transform the physician enterprise into an efficient, high-performing system to focus their efforts on making value-based care advances. Consider implementing these seven components of a high-performing physician enterprise to support this transformation.
The transition from 2020 to 2021 brought with it several changes to the healthcare marketplace. New final rules for the Physician Self-Referral Law (Stark Law) and the Anti-Kickback Statute (AKS) have provided significant flexibility for the healthcare industry to develop new business models to care for patients. The 2021 Medicare Physician Fee Schedule (MPFS) saw the Centers for Medicare and Medicaid Services (CMS) finalize new coding provisions for outpatient evaluation and management codes while reducing the conversion factor used to calculate reimbursement paid under the MPFS. These changes provide a significant opportunity for industry participants while also introducing new complexity. Understanding these changes and how they will impact your organization is key to a successful future.
A county health system (CHS) in the Southeast engaged Coker Group to assess and improve financial and operational performance. CHS employs 40 multi-specialty providers and has a primary hospital location with roughly 150 licensed beds.
Initially, we conducted a revenue cycle assessment for the employed provider network and provided recommendations related to performance improvement, resource and staffing needs, and IT system utilization. Our analysis and recommendations highlighted multiple areas of opportunity directly related to the revenue cycle and indicated broader opportunities across medical group operations.
Download the case study to learn more about our approach and review our performance improvement team’s results and tactics.
While some crises begin as a dim light down the track that you can see getting brighter over time, others arise suddenly in the middle of the night when you haven’t been expecting them at all. Regardless of how and when they arrive, crises happen all the time and can take many different forms, including environmental (such as a hurricane), technological (for example, a data breach), physical (like a fire within a building), or reputational (such as a public scandal). When a leader finds themselves amid a crisis, no matter what type it is, they should take several steps to assess the situation and limit its negative impact.
Throughout this paper, we will use a series of case studies to discuss actions to take throughout the crisis, what to do after the crisis has passed, and preparatory measures to take before the next one arises.
November 2 is compliance day for the Office of the National Coordinator (ONC) for Health Information Technology and the Centers for Medicare and Medicaid Services’ (CMS) final rules on interoperability and information blocking.
The ONC’s 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program and CMS’ Interoperability and Patient Access final rules will impact virtually every healthcare organization with access to electronic health information (EHI) and empower patients and caregivers with greater access to and control over their health information.
Starting with information blocking, this article will focus on the structure of the final rules, which stakeholders will be affected, and how to comply with the regulations.
Article from Journal of AHIMA on October 5, 2020 published by the American Health Information Management Association (AHIMA). All rights reserved. To learn more, please visit journal.ahima.org.
The COVID-19 pandemic has created unique circumstances for health systems and healthcare providers that will permanently impact patient care delivery. Across the U.S., hospitals and medical practices stopped elective procedures and limited their care to essential services as cases grew in April 2020. Ambulatory clinics, emergency department (ED), and surgical services are the gateway to the acute care setting, and as volumes dropped, revenue dropped. The healthcare industry is reporting losses up to $50 billion per month due to the loss of elective surgeries and procedures. Each access point provides a steady stream of patients to the health system, and hospitals must address new challenges for them to remain financially viable.
Coker’s latest white paper, Managing Health System Access Points in the Wake of COVID-19, offers operational considerations and strategies for the road to recovery.
The COVID-19 outbreak resulted in the need to practice social distancing, remain in our homes, and apply technology in new ways to accomplish daily life and work tasks and provide patient care. Remotely caring for patients is not new; telehealth has been prevalent in some aspects of healthcare for years. According to the American Hospital Association, prior to COVID-19, “76 percent of U.S. hospitals connect with patients and consulting practitioners at a distance through the use of video and other technology.” In the American Health Insurance Plan 2019 Virtual Care Survey, 94 percent of commercial plans, 92 percent of Medicare Advantage Plans, and 62 percent of Medicaid plans offered virtual care. However, with the need for social distancing, the use of telehealth was significantly expanded to provide patient care remotely to help protect both patients and providers from infection.
Article from The Value Examiner July/August 2020 issue published by the National Association of Certified Valuators and Analysts (NACVA). All rights reserved. To learn more, please visit www.NACVA.com/ValueExaminer.
The onset of COVID-19 and the resulting public health emergency moved the country and, indeed, the entire world, into a period of significant uncertainty. The US Government has taken significant actions as a result of this uncertainty to aid the economy; however, the date and levels of economic recovery are uncertain. With this backdrop, appraisers must still perform their work to determine value. Company management can play an important role in helping appraisers determine value.
The current environment is unprecedented, and the future is uncertain. Generally, uncertainty lowers value due to an increase in perceived risk. However, through communication, management can help appraisers understand entity-specific risks to determine value appropriately.
Coker’s latest article will explore the uncertainty appraisers face when expressing an opinion of value of a business, and how management should take an active role in communicating with the appraiser to determine value appropriately.
With Baby Boomers retiring at an accelerated rate, estimated to be 10,000 per day, younger generations are rightfully taking their place in the healthcare industry. Providers, administrators, executives, entrepreneurs encompassing every element of the healthcare industry are stepping up as new leaders. Next-Gen-era workers will soon dominate healthcare. Currently, approximately one-third of the United States’ labor force are Millennials, having eclipsed the Gen Xers as the largest generational group in the workplace.
Coker’s latest white paper, Healthcare and the Millennials, explores the generational differences between Millennials and Boomers and how these changes will affect healthcare leadership throughout the next decade.
In a time when our nation’s healthcare delivery processes are at a point of unprecedented change in clinical practice and policy, urgent care clinics serve an essential role. They can provide urgent and primary care services to communities while also providing relief for overcrowded emergency departments. To this end, urgent care clinics continue to experience material growth driven by their convenience, high-quality standards of care, and demonstrated ability to lower the cost of and enhance access to care in communities across America. This growth has fueled an increase in transactions within the urgent care space.
The white paper will explain the definition of an urgent care center and the current transaction environment. Author David Walline is a senior manager in Coker Group’s finance, operations and strategy group, with a specific focus on business valuation. His business valuation career spans over a decade, with the past eight years focused on the valuation of entities within the healthcare industry.
Rural hospitals serve a unique population. According to the American Hospital Association (AHA) 2019 Rural Report, approximately 20 percent of Americans live in rural areas and tend to be more disadvantaged, older, sicker, and poorer than the national averages. Because of this, rural hospitals face a challenging patient and payer mix, with the most significant payers typically being Medicare and Medicaid. As the healthcare landscape keeps changing, new challenges arise at rural hospitals adding to the existing challenges they already face. Per the AHA 2019 Rural Report, these challenges include access to technology, staff recruitment and retention, and increased operational costs. Further, the shift to value-based reimbursement is adding increased pressure to hospitals that are already struggling.
From a patient perspective, one of the primary reasons patients in rural communities do not seek medical care is because of the distance of healthcare facilities from patients’ homes and the limited transportation options available. Various forms of alignment can address or partially mitigate these challenges, as we discuss in this article.
The COVID-19 pandemic has, in essence, turned the world upside-down. Healthcare in the United States and around the world will never be the same. At its core, this transformation applies to all aspects of clinical care, especially with the rapid adoption of telehealth as a viable alternative to a significant portion of in-office patient-physician visits and a greater focus on remote monitoring as an alternative to in-hospital observation. Likewise, we believe that the economic and transactional sides of the U.S. healthcare system will change as well, both in temporary and permanent ways.
So, it is safe to say that everyone—providers, investors, and, especially, the American consumer, have suffered significantly through the COVID-19 pandemic. As we begin to plow our way out of this crisis, we ask the question, “Which way is up?” By this, we consider what the strategies for affiliation among the players will be as we emerge from the pandemic and reestablish life under our “new normal.” This paper will carefully consider affiliation strategies and strategic planning.
The onset of the COVID-19 pandemic has compelled the practice of medicine to incorporate the use of technology at a previously unimaginable rate. Until now, the healthcare community was tiptoeing into the telehealth delivery mindset, with reluctance to commit. Thoughts were that remote access would first be for physicians and other providers with patients who lacked access to healthcare due to rural hospital closures, areas with a shortage of clinical providers, and as a response to the increasing costs of care delivery.
Among the various types of transactions and the participants involved in them, the presence of private equity within the healthcare services space is not a new concept. Healthcare entities have been partnering with private equity investors for decades. Likewise, healthcare providers have been a high-valued target for these types of private capital investment firms for many years, and the current market trends indicate that such interest will likely continue to grow into the future.
In this paper, we look at some of the current trends in healthcare private equity, and we dive into some key elements of the overall discussion around private equity deals involving healthcare services organizations. This discussion begins by breaking down what “healthcare private equity” is and what it means for organizations that might consider engaging in a transaction with a capital partner, now or in the future. Then, we dive deeper into some of the nuances that we see and, in many cases, have dealt with directly in our work with clients on both sides of the private equity transaction. Finally, throughout our teams’ decades of experience working in healthcare transactions, we address some common themes and characteristics in the current healthcare private equity deal marketplace, which are helpful to understand and consider for both buyer and potential sellers exploring such transaction options.
In the past, transactions involving hospitals and physician groups have typically fallen under a few common structures. Although there are several alignment models that hospitals and physicians can pursue, a significant increase in activity is occurring where practices are selling to private equity (PE) firms (or private equity-backed platform companies). However, these deals typically involve vastly different structures and terms compared to typical hospital-physician transactions.
Coker’s latest white paper, Pursuing the Private Equity Model for Hospital/ Physician Transactions, explores private-equity “like” structures when performing transactions related to hospitals and physicians. Now, as many groups consider their options to sell, they are looking at potential buyers other than hospitals. If the consensus among the physicians selling their practice is to maximize the valuation paid at the time of the transaction and ultimately forego their independence to an outside organization (hospital or PE firm), then the PE model may likely be the best option.
News breaks daily about cybersecurity breaches across all industries, with the latest report appearing to top the previous event in expanse and damages. Healthcare organizations are not immune to the same threats facing other industries, though the damages from exposure may exceed other business entities due to the nature of the information. The state of cybersecurity in healthcare is improving, but there is still lots of ground to cover in order to have robust protection.
Coker’s latest white paper, The State of Cybersecurity in Healthcare: Still Much Ground to Cover, addresses the problem of cybersecurity breaches, sources of threats, CIO responsibilities, working with third-party vendors, and conducting privacy and security risk assessments. The information will help your organization take proactive steps to gain ground in developing and maintaining a strong cybersecurity posture.
The adoption of artificial intelligence (AI) in healthcare is on the rise and assisting in solving a variety of problems for patients and providers. While we do not see A.I. taking the place of all humans, the ethics and risks of machine involvement in patient care over traditional methods have yet to catch up to the technology. The Use and Ethics of Artificial Intelligence in Healthcare, focuses on the ethical questions that arise when considering the use of A.I. in the healthcare industry, as well establishing a strategy for implementing A.I. in your organization.
The May 2019 issue of HCCA’s Compliance Today Magazine included an article by Coker Group’s Rosalind Cordini, JD, MSN, RN, CHC, CHPC, and Randy Gott titled Physician Compensation Governance. The article focuses on improper compensation arrangements and new legislation that requires individual executives be held accountable for their role in noncompliance. They review the pertinent laws and regulations that affect healthcare organizations. The article can also be viewed on the Compliance Cosmos website. [Copyright 2019 Compliance Today Magazine, a publication of the Health Care Compliance Association (HCCA)].
Strategic planning is essential for all organizations to shape their future success. However, with the significant shifts occurring in the healthcare industry, organizations need to prioritize forward-looking initiatives now more than ever to prepare for and address these impending changes and challenges. In this whitepaper, we focus on the overall construct of strategic planning, as well as provide practical methods for formulating and communicating an effective plan.
Clinical integration (CI) is often confused with accountable care, and clinically integrated networks (CINs) are sometimes called commercial accountable care organizations or ACOs. The formation of a CIN is a critical first step for any group of providers who wish to succeed in an environment that is inexorably moving toward pay for value and away from pay for volume.
This paper will concentrate on the concept of value-based care delivery and how CI is essential in the creation of a healthcare system that reliably provides high quality per unit of cost. This way of looking at CI is becoming more critical as providers attempt to re-tool care processes and procedures to operate successfully in a reimbursement environment in a value-based healthcare marketplace.
The increased recognition of project management as an effective means of completing numerous and complex project efforts has prompted many larger healthcare organizations to create a Program Management Office (PMO). The primary goal of a PMO is to yield positive results from standardizing project management processes, policies, reporting, and communication methods. For the office to be most useful, it should reflect the organization’s culture and overall vision and strategy. This white paper will discuss the steps to develop a PMO and identify its rewarding benefits. It will also address alternatives to launching a PMO independently that involves engaging an experienced project manager to oversee the initiative from beginning to completion.
The date is rapidly approaching when providers who are participating in MACRA will be subject to adjustments in payments from Medicare. However, many providers may not be ready for the significant changes that will soon occur. This paper presents a step-by-step guide to preparing for MACRA participation.
As data information, and its supporting technologies have appropriately permeated into every aspect of healthcare organizations, governance of an organization’s use and management of its information resources, systems, technologies, and staff must become a critical and necessary component of every executive’s and Board’s agenda. Boards fulfill these oversight and governance roles by asking management–and themselves–tough questions about information technology (IT) that demand clear, straightforward answers.
This paper examines five key questions that today’s astute Boards are asking senior management and other relevant parties regarding the use of IT throughout their organizations. The kinds of questions that Board members should be asking depend extensively on the organization, its use of IT, and the competitive environment in which it operates. The issues outlined in this paper should begin to prompt and sustain serious dialogue among executives, physicians, and Boards to help ensure that the organization is effectively governing its IT Assets.
Organizations that invest in developing a talent pipeline as part of their strategic business planning will find that the process can increase employee engagement, build loyalty, reduce turnover, and lower costs. When coupled with adding top external talent to the pipeline to fill positions that cannot be placed internally, the strategic value will only be enhanced. Employers that keep a steady source of talent maintain an advantage over their competition through their ability to sustain the growth and development of the current and future leaders of the organization. What’s in your pipeline?
As the healthcare industry continues to shift from volume-based to value-based care, it will be critical for organizations to understand and control their cost drivers and determine ways to improve quality. One of the primary methods to increase success in the value-driven environment is by ensuring physicians understand the overall goals and their responsibilities in achieving them. Physicians, as the frontline caregivers, have the unique ability to drive bona fide change in their organization and deliver tangible results. Alternatively, if they are not working with the organization to meet shared objectives, they can easily undermine the potential success of the initiative. Thus, it is imperative for organizations to understand how to empower and engage their physician leaders across all settings. This awareness involves understanding their current level of engagement on an ongoing basis and determining methods to improve engagement going forward.
In this paper, we use a real-world case study to illustrate the signs of an in-danger RC that can be overlooked. Further, we explain how Coker helped one organization turn around its Patient Accounting System resulting in a 14 to 1 return on investment (ROI). We will review the health system’s situation to show their struggle with their RC as a newly-hired Chief Operating Officer (COO) questioned why things were not moving ahead smoothly for the several-hundred provider organization.
The understanding of patient panel is essential to achieving success in a value-based environment. Payers have begun providing financial rewards and penalties to providers based on panel management and associated outcomes. In this white paper, we discuss the importance of identifying a patient panel as well as practical strategies for aligning provider compensation with a patient panel as a means of encouraging provider and organization alignment.
Key Areas of Focus:
- Define a Patient Panel
- Explain Why Patient Panel is Key to Achieving Success in a Value-Based Environment
- Explore How Patient Panel can be Leveraged to Gain Clinical Efficiencies
- Understand Impact of Patient Age, Gender, and Acuity on Patient Panel
- Learn Common Panel Calculation Methodologies
- Use Patient Panel as a Provider Compensation Strategy
In days past, hospitals, healthcare systems, and their medical staffs could afford to exist in separate but parallel tracks, intersecting only when necessary to deliver clinical care. As value-based reimbursements, especially those involving both upside and downside risk, become more the norm and providers realize that, like it or not, risk is being shifted onto them, they will need to learn how to manage risk more effectively. In today’s healthcare industry, providers of all types face the overarching challenge of improving value (quality per unit of cost) for the consumer of healthcare services, an integrated approach is not only preferred but necessary for success.
Mergers and acquisitions (M&A) is not a new concept for hospitals and other healthcare industry organizations, particularly during the era of hospital-physician alignment. Making M&A transactions work, however, is an entirely different exercise and increasingly challenging in today’s marketplace.
The foundation of this discussion is to first define what we mean by “makes a transaction work.” Here, we are referring to a transaction that results in long-term value creation for all stakeholders, and evidence shows that this is a more challenging achievement when evaluating hospital mergers compared to assessing short-term success. Measuring the true success of a transaction requires a look far beyond the initial perspective of fit and financial returns, focusing instead on whether the affiliation resulted in compelling value realized over an extended period.
So, how can we ensure such strategies are resulting in long-term value for these organizations, as opposed to just short-term tactics implemented on a reactionary basis? This is where effective post-merger integration comes into play. This paper offers vital points that organizations should follow when pursuing long-term value from transactions.
Most healthcare providers have not been intimately involved or even aware of the risk adjustment methodologies used in common Pay-for-Performance risk contracts, such as Medicare Advantage (MA) and Medicare Shared Savings Programs (MSSP). This, however, will need to change as the Medicare Access and CHIP Reauthorization Act (MACRA) and its Quality Payment Programs (QPPs) roll out. Both quality and cost performance metrics used in MACRA QPPs are to be risk adjusted using the same methodology currently used for MA and the MSSP. Consequently, the MACRA QPPs will affect a much larger number of providers than either MA or MSSP.
Hospital strategic planning is important in even the most stable of times. In these days of uncertainty, it is critical for every organization that wants to remain viable to prioritize strategic planning.
In Part One of this White Paper Series, we tackled the issue of how to effectively complete strategic planning for a medical practice. In this second part, we address how hospitals and/or health systems should approach strategic planning. Specifically, we will discuss how hospital administration should engage their physicians to develop a comprehensive strategic plan that meets the needs of all constituents, beginning and ending with the patient. While hospitals may be more prepared to weather the sweeping changes prevalent in the healthcare industry at this time due to their size and scope, they still need to be actively considering how to structure themselves, respond to the concerns of their employees, and address competitive forces. This whitepaper outlines the primary benefits of hosting strategic planning sessions and the results you can expect, both for your organization and your employees.
Many hospitals continue to bleed red ink via their employed physician networks (EPNs) because the “here and now” of their shrinking margins consume them. They focus on the losses that continually nibble at their profit and loss statements (P&Ls), and they fail to see and take the long view. Often, the C-suite is so engaged in the present and applying Band-Aids to the shrinking margins that they fail to consider the painful, yet lifesaving, surgery that needs to be performed. This action includes revamping the structural integrity of the EPN. As impending changes in payment methodologies are spawned, they essentially reward health systems for keeping patients out of the hospital and managing them in the ambulatory outpatient clinics.
With the proper design and implementation of a strategy, gentle tending to the EPN, the hospital and provider relationship can flourish.
The devil is in the details when examining the health of the Revenue Cycle (RC) ecosystem. Sometimes figures and reports don’t tell the entire story. What may look like a sound days in accounts receivable (AR) measurement (e.g., 30 days), can actually mask systemic problems in processes and procedures. If data reported are inaccurate, miscalculated, or outright corrupt, leadership may not learn about the issues until revenue wanes.
This paper will use a real-world case study to illustrate the signs of an in-danger RC that can be overlooked and how Coker helped one organization turnaround a 14 to 1 return on investment (ROI). The health system’s situation will be reviewed to show their struggle with their RC as a new Chief Operating Officer (COO) wondered why things were not moving ahead smoothly for the several-hundred provider organization.
How often are we completely consumed by our day-to-day activities and fail to see what else is going on around us? Most of us are busy these days, particularly in the healthcare industry. We get caught up in the daily grind of emails, conference calls, meetings, clinical functions, and addressing patient needs. These activities consume countless hours, and without realizing it, an entire day, week, or month will disappear. With this momentum carrying us through our daily professional life, it is important to carve out time for higher-level thinking. In this whitepaper, we examine the active process of strategic planning specifically for a medical practice. The goal is to assist your strategic planning efforts to ensure that when you do take the time for a retreat, you will make the most of it.
Immediate replacement versus interim management is a consideration for every executive team that must fill a vacancy in its high-level leadership positions. Management turnovers, especially at the C-Suite level, are prevalent in the healthcare industry. Realistically, the recruitment and hiring of replacements for departing healthcare leaders often take considerable time to accomplish even with the engagement of a search firm, leaving an organization vulnerable during the time the position is vacant. A growing trend in the healthcare management market is to fill these vacancies with an interim solution instead of seeking an immediate full-time and permanent replacement.
This paper presents advantages and disadvantages for both immediate replacement and interim management. The purpose is to assist you in your approach to executive staff replacement and to offer the pros and cons of provisional management models. Careful consideration of the advantages and disadvantages should provide some valuable insight into determining which process will work best for the organization.
The Medicare Access and CHIP Reauthorization Act (MACRA) is perhaps the most significant change to healthcare in the last half-century. Though the proverbial and long-anticipated volume-to-value shift in the industry has not yet materialized in most markets, MACRA will make this change real as CMS, the country’s largest payer, dramatically changes the way they pay participating providers.
The question, then, becomes how Medicare providers should prepare to operate successfully under MACRA? What must be done to optimize ones’ chances of receiving payment enhancements, as opposed to payment penalties, by 2019?
This paper outlines a step-by-step approach for providers both to prepare for and to thrive within the MACRA payment models of the future.
While uncertainty abounds on the details of the healthcare plans under the current administration and Congress, the trends toward value-based reimbursement are apparent. Successful organizations that break through the value barrier must have a strong vision backed by a unified leadership team, well-trained and motivated employees, and efficient work processes that eliminate duplication of effort. This paper highlights key health information technology (IT) trends and innovations that Chief Information Officers (CIOs) and other health leaders must know as we quickly progress through 2017. By understanding some of the important health IT innovations and trends, CIOs and other executives can better position themselves to adopt one or more of these advances to help transition their organizations toward high-value care.
Service Line and Specialty-Specific Clinical Integration Programs: A Novel Model for Hospital-Physician Alignment
All providers, regardless of specialty, are now subject to the Medicare Access and CHIP Reauthorization Act (MACRA), which puts them at significant risk for payment adjustments based on their performance across four categories of quality, cost, and other measures. Furthermore, bundled payments are being rolled out by many payers, especially by the Centers for Medicare and Medicaid Services (CMS). Several hospital service lines, particularly cardiology and orthopedic, seem to be affected most directly by CMS’s move toward value-based reimbursements (VBRs).
Any service line restructuring, particularly cardiology or orthopedic service lines, should consider these new payment models and how these areas of operations might best operate in a move to a VBR environment. This paper describes how the development of a service line-specific clinical integration program (SSCIP) can serve as a viable answer to this query. Further, it will address how to go about setting up such a model of care delivery.
Healthcare Executives: Should They Stay or Should They Go? The Two-sided Dilemma of Continued Employment
Executive retention is one of the most important tenets of an organization, particularly at a time when the talent pool is stretched thin across the healthcare industry. In addition to identifying and hiring the right person, it is equally essential to coach the executive to perform at the highest potential and to explore areas of dissatisfaction. Your greatest and most valuable investment are your leaders. As a leadership team is often only as good as its weakest member, it is equally important to evaluate and determine when it is time to let go. This paper discusses when and why it may be time to change leadership. It considers the high cost of turnover and the value of focused executive coaching to retain tenured executives. Additionally, it examines the importance of having leadership who fit personally, professionally, and culturally in your organization. Employers must ask themselves questions about potential costs, long-term performance, and organizational morale. If and when a decision is made to dismiss an executive, it is crucial to have a replacement plan in place.
Ramifications for the Healthcare Industry: The Move to Value-Based Reimbursement – Published by Becker’s Hospital Review
With the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, it is clear that the transition from a fee-for-service (FFS) reimbursement model, based on volume, to a fee-for-value (FFV) approach or value-based reimbursement model, based on quality and cost, is well underway. At its core, value-based reimbursement inherently will require providers to manage the health of certain populations of patients, rather than managing the health of one patient at a time (as under the FFS reimbursement system).
With value-based reimbursement linking provider payment to outcomes, providers and payers should be aware of new transaction types and characteristics relevant to value-based reimbursement. Under contemporary models, much of the financial and clinical risk shifts from the payer to the provider and providers are held accountable for leading the care continuum. Providers are rewarded based on the quality and efficiency of the care they deliver, as well as their ability to contain costs.
As the healthcare industry continues to shift from fee-for-service to fee-for-value, it is critical to examine the use of technology and the processes and procedures for revenue cycle management (RCM). Many organizations with currently stable information technology (IT) solutions and RCM processes will find these solutions and processes out-of-date in the context of MACRA/MIPS and bundled payments. Will your RCM and IT backbone be ready and able to administer these matters to ensure good data, sound billing, and accurate and timely follow-up? Now is the time to review your baseline and your IT system’s capability for both traditional and global reimbursement models.
- Learn how the fee-for-value shifts are affecting healthcare IT systems and the RCM process.
- Understand the connection between technology and revenue in the context of a fee-for-value marketplace.
- Identify the steps needed to position their healthcare organizations for success in the future landscape of healthcare.
Bundled payments are likely to become more commonplace in the healthcare industry. Bundled payment methodologies are being used to incentivize improved care coordination, quality, patient safety, and cost efficiency in a system that is badly in need of improvements in these areas. This paper outlines the mechanisms underlying bundled payments and helps guide providers who may be considering this payment model to optimize their performance by mastering certain key capabilities. Readers gain an understanding of bundled payment methodologies, how their uses affect healthcare organizations, and how to incorporate the needed capabilities to maximize effectiveness and efficiency under this payment model.
The healthcare industry is held to a higher standard than other industries when it comes to the use of technology. Further, mistakes can result in greater consequences. Healthcare organizations rely on technology for day-to-day operations and functions, and the decisions on which vendors and products to use have organization-wide consequences.. Appropriate research should be conducted and decisions should be dealt with carefully to avoid future problems with technology. This paper highlights five healthcare information technology (IT) decisions that can be fatal to your organization, and it provides essential information to avoid these issues or correct existing concerns.
As healthcare organizations, operating in a shifting landscape, begin to recognize the importance of alignment and integration in this new “accountable care era,” many leaders hold an erroneous belief that pursuing one particular model, i.e., employment, is the only answer. However, multiple alignment models are available that can advance the agenda for provider organizations to remain viable and control their destiny while also meeting the needs of their hospital partner. Clinical Co-Management Agreements (CCMAs) are often discussed, though their relevance is regularly masked by a broader strategy, i.e., employment, professional service agreements, and/or clinical integration. These agreements are a moderate form of alignment and represent an arrangement wherein providers become actively engaged in setting and managing the clinical direction of a particular service line. CCMAs are frequently consummated between hospitals’ service lines and their medical staff members, whether they are employed or contracted. A CCMA can serve as a method of accomplishing “win-win” volume-to-value outcomes for both the physician and the hospital, without losing all independence and autonomy or becoming overly capital intensive, thus, driving value for all stakeholders.
With the passage of the Affordable Care Act and MACRA, the transition to value-based reimbursement is underway. As such, hospitals and health systems will need to consider various alignment options, such as whether or not to enter into employment agreements with physicians or physician practices. Unfortunately, such employment arrangements typically result in the hospital or health system incurring substantial and continuing losses. This White Paper will examine the reasons for and dangers these losses present, as well as discuss strategies for mitigating losses.
For a hospital or health system to continue to meet the healthcare needs of its community, that hospital should have a program that allows for the recruitment of high-caliber physicians that is compliant with the various Stark and IRS regulations. This paper will discuss the Stark and IRS regulations as well as provide tips to providers on how to navigate these regulatory challenges.
In today’s marketplace and with healthcare organizations, in general, all transactions do not automatically lead to success, regardless of how success is defined. And even the realization of short-term objectives does not guarantee long-term value will come from the deal.
So how does an organization’s board, management team, and key stakeholders ultimately ensure their deal targets will result in long-term value creation? It is true that even the best plans, road maps, outside experts, and financial resources can still result in missing the projected targets for that deal strategy. However, we can look at some of the trends from various deals that have taken place in the current marketplace, and assess the key characteristics that resulted in success versus failure.
Modern healthcare systems have been consolidating or growing via acquisitions, mergers, and professional services agreements in an effort to adapt to new value-based reimbursement models while centralizing their healthcare technology to analyze data and to drive down costs. With high adoption rates, new emerging technologies, and trending reimbursement models, it’s not difficult to see that legacy technologies will be casualties of patient-centered models of healthcare. So what is an ideal resolution? Application Retirement Solutions can serve as data repositories for active or retired applications extending the value of the data while the applications may have lost their rate of exchange.
Ambulatory Surgery Centers (ASCs) consist of many moving parts that must operate effectively for the ASC to flourish. If even one of these components malfunctions, the ASC will suffer. Left unchecked, the financial health of the center will deteriorate. To maximize operational and financial efficiency it is important to understand the basic components at work and discern how well each is functioning. Only then can changes occur that reverse the trends.
Using a case study, this paper will describe the decline of one ASC and the discovery of dysfunction throughout the center. Then, it will outline the positive turnaround in financial and operational actualization that resulted from addressing each component that was off track and on the verge of breaking apart. The study also reports on the creation and deployment of a broader strategic plan to help the ASC expand its procedural breadth.
In all healthcare entities—whether private practice, employed physician networks (EPNs), or academic medical centers—patient needs outpace provider supply at almost every turn. Based on that premise, the question becomes: With limited resources, how do you meet patient demand for access?
Most people think that patient access problems can be remedied through examination of a few areas of practice. However, an effective solution only can come from a multilevel and comprehensive review of every area to discover how all the “systems” mesh or where they fracture. Without a full-scale assessment of the practice operations, the discovery process is impeded, and the possibility for remedies are thwarted. From a recount of a recent assignment by an academic medical center, calling for the use of a limited platform for assessment, this paper will communicate the optimal results that can come from extensive review as well as the consequences of restricting the charge to the evaluator. In these parameters, we were tasked with pushing the boulder uphill.
Articles abound about the prevalence of theft in the business world, yet few writers give sufficient examples and safeguards against losses for implementation in the medical practice realm. The losses due to theft are startling and more damaging than many practice owners may realize. With the pressures of the evolving healthcare system, physicians have little time to monitor many of the business aspects of their practices and naturally prefer to entrust their finances to their few employees. This article, using credible statistics, establishes the astounding losses and exposes the vulnerabilities that are typical of many smaller medical practices. Case studies present examples of how theft occurs and how to discover it, whether as minimal pilfering or as major embezzlement schemes. Finally, this white paper provides reasonable safeguards to minimize the opportunity for financial losses to occur.
Identification and retention of talented leaders are fundamental to the success and stability of any organization. The financial burden of lost leadership can reach into the millions, depending on the organization and lost position, but the costs can be even higher as it affects the team morale, operations, and future strategy. Thoughtful selection and the development and retention of individuals in leadership roles is essential to the overall success of the organization. This paper describes key characteristics of quality leaders. Through a case study, readers will learn the process for placing and retaining the optimal candidate to ensure the ever increasing success of the organization.
The passage of the Affordable Care Act in 2010 has generated extensive activity to organize providers into clinically integrated organizations (CIO). Further, many government and commercial payers have introduced value-based reimbursements in recent years. Incentives such as the value-based purchasing program for hospitals have hastened the pace of organizational and structural changes around clinical integration. The approach outlined in this paper provides a unique set of services that focus on the clinical care process unit and recommends standardizing the approach to care delivery/process improvement. Readers will discover a comprehensive and systematic methodology for operationalizing CIOs, which, in turn, will allow these structures to attain the overarching goal of clinical integration.
The Medicare Access and CHIP Reauthorization Act (MACRA), passed in April 2015, is a landmark piece of legislation that represents a dramatic change in the way CMS will pay healthcare professionals. While complex and not entirely defined, all providers should learn as much as possible about MACRA to avoid costly under- or overreactions to the new requirements. The reader will receive definitions of many unfamiliar terms and acronyms that are a result of the legislation. This paper addresses the significant changes in quality reporting systems, billing systems, and most importantly, care delivery systems that will be required to operate successfully under MACRA rules and regulations. Preparation should start immediately in provider organizations affected by MACRA.
Hospitals and physician practices can benefit from using operations management techniques, such as Lean Process Improvement and Variability Management, proven to be useful in other industries, particularly in the manufacturing sector. Understanding these methodologies is necessary to apply them appropriately to an organization’s operational challenges. This article defines both methods and describes operational issues within healthcare facilities that can be best remedied by using one or the other approaches, or sometimes both. A case study will show the results of using Lean Process Improvement and Variability Management in healthcare operations management.
Cybercrime, a form of online terrorism, is now threatening the very safety and well-being of our nation’s healthcare system. No hospital, physician, or other healthcare provider is immune to the operational chaos, harrowing events, and potential financial ruin that can result from sudden cybercrime attacks. Safety nets and other safeguards are available to minimize these risks, but many providers do not know how vulnerable their IT systems and networks are until it is too late. This paper defines today’s most devastating form of cybercrime–ransomware–and outlines concrete methods for mitigating this risk.
Many healthcare executives remain reluctant to prepare adequately for value-based payment models. The prevalent attitude continues to be that somehow “this too shall pass.” Thus, expending the time and resources to re-tool the care delivery enterprise so that it functions as well in a fee-for-value reimbursement environment as it has in a fee-for-service reimbursement environment doesn’t seem to be worth the effort. This paper outlines several payment changes in the current marketplace. Also, it addresses what healthcare executives need to do to manage through these payment changes and remain successful in a more value-based care delivery model.
Revenue is the lifeblood of any business and is essential for its survival. Without income, regardless of the market segment or service line, an enterprise cannot thrive. Whether a privately-held or publicly-financed (e.g., stocks/equity, bonds, etc.) entity, the inflow of revenue and efficient operations are prerequisites to the viability of any business. Stunningly, some institutions continue to under-invest or disregard the significance of revenue cycle management (RCM) and its accompanying components. In this case study, we explore the situation of a hospital system and Coker client that struggled with their RCM until the point that their financial inattention caught the C suite by the tail and threatened the fiber of the organization, forcing them to seek outside investment. Many lessons are available from a review of this interesting case study.
On November 9, 2017, Management in Healthcare Vol. 2, 4 published an article written by Coker’s Senior Vice President, Justin Chamblee. The healthcare industry is changing from a reimbursement perspective, in that
reimbursement is still predominantly fee-for-service but includes value-based elements. This dual system is widely affecting providers by pushing more of the payment and cost risk onto them (versus insurers). In short, the current reimbursement environment is confusing and disordered.
The Perpetual (Upward) Shift of the Median: How Physician Compensation is Increasing in an Age of Decreasing Reimbursement
Certain trends that are occurring in healthcare in terms of the application and use of benchmark data are leading to increases in physician compensation. Increases in compensation based solely on benchmarks rather than alternative methodologies are likely to undergo more scrutiny as hospitals experience more pressure to lower costs. This paper examines the merits and consequences of the significant focus on the median compensation per wRVU ratio to establishing a compensation model and its long-term feasibility. It also presents some clear modifications that can be made when developing wRVU-based compensation models that will address the issues of using benchmark data to derive compensation that aligns with productivity levels and general market trends.