Clinical integration (CI) also 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.
Balancing the tension between government compliance and financial viability takes effort, and it is even more challenging when the physician resists cooperation. Too often, practitioners do not know their weaknesses and vulnerabilities in coding and documentation. 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. 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 pro-active education and support.
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.
Risk adjustment in healthcare: Essentials that all providers should know (Co-Authored with Nuance)
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 MSSPs. 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.
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.
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.
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.
Balancing the tension between government compliance and financial viability takes effort, and it is even more challenging when the physician resists cooperation. Too often, practitioners do not know their weaknesses and vulnerabilities in coding and documentation. Knowledge is power, as the adage goes—the more you know, the more you can control events. And what you don’t know can hurt you, particularly about the compliance and financial matters of your medical practice. 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 pro-active education and support.
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 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, addresses what healthcare executives need to do to manage through these payment changes and remain successful in a more value-based care delivery model.
Private practices and health systems alike continue to evaluate their options for working together during the continuing evolution of healthcare delivery. Over the past five years, many physicians from all specialties and practice structures have completed transactions with health systems. Many, if not most, of these arrangements are through employment vehicles. However, growing in prevalence are professional services agreements (PSAs), which are the model and structure of choice for thousands. Readers will learn why PSAs could be the best option for alignment for many organizations in the emerging landscape of “volume-to-value” reimbursement.
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.