 |
||
October 11-14, 2009 | Denver
The MGMA Annual Conference is the largest professional development and networking conference for medical practice administrators. Held in conjunction with the 53rd Convocation of the American College of Medical Practice Executives, the event brings together thousands of attendees – including administrators from various specialties, physicians, medical vendors and high-profile keynote speakers. Follow blogs from H&HN Managing Editor Bill Santamour and contributing writer Richard Haugh for daily updates from the meeting. All comments are welcome and may be posted to the blog. Comments may be edited for clarity or length. Click here to return to the H&HN blog homepage. |
The new generation gap
by Richard Haugh @ 2:15PM
The last session of the last day of a conference is usually as empty as the high plains between Denver and the Kansas border. Not so today. It was standing room only as author and consultant Cam Marston gave his dynamic Gen X take on the new generation gap in the workplace.
Everyone certainly knows the Baby Boom generation. But Marston explained that there are four distinct generations in today’s workplace, each with its own values, objectives and ways of doing things. Each of those generations has an impact on the workplace—and not understanding what motivates each and how they interact can lead to ... shall we say, suboptimal results.
Marston’s PowerPoint presentation included three commercials and one magazine cover capsulizing the four generations. A mid-1940s Life magazine cover featured the medals and decorations achieved by Audie Murphy, epitomizing what Marston dubbed the “matures,” or what former newsman Tom Brokaw called “the greatest generation.” The 1970s commercial of young people singing about giving the world a Coke represented the Baby Boomers. Generation X (30-44 years old) saw themselves in a Cars.com commercial about a Voodoo priest who shrinks heads. And Generation Y (those 29 and younger) was captured in a Diet Pepsi commercial featuring a mosh pit at a concert.
Baby Boomers, and to a large degree the Gen Xers, share many workplace traits such as loyalty and hard work. Gen Y, on the other hand, will work hard if there’s a value and goal they believe in. However, the mantra of the Boomer/Matures group that largely leads and influences society today is “the patient comes first, and they own our time.” For Gen Y, though: “It’s my time, and you rent it from me for 40 hours a week.”
Successful leaders, Marston says, learn that blending the motivations and characteristics of each generation is key. “All these generations are coming through your doors,” he says.
Submit a Comment | Back to Top
'We have islands of greatness'
by Bill Santamour @ 11:45AM
It’s been a busy few days here in Denver. Here are some random thoughts as we close out our MGMA annual meeting coverage:
You all know that around $2.3 trillion is spent in the U.S. on health care every year. To put that number in perspective, White House health policy wonk Ezekiel Emanuel, M.D., noted that there are a million seconds in about a week and a half; roughly 1 billion seconds ago, Richard Nixon resigned the presidency; and that if we went back a trillion seconds ago, we’d be living in the year 30,000 BCE.
A quote from Emanuel: “We don’t have the best health system in the world. We have islands of greatness.” One of the islands is cancer care, according to Emanuel, an oncologist. But, he pointed out, the U.S. ranks second behind Cuba in the quality of its cancer care and we’re No. 3 in the world when it comes to colorectal cancer care.
T.R. Reid said that different countries with universal coverage include different drugs on their lists of approved medicines. If the drug is on the list, the patient gets it for free or at very nominal cost. If it’s not on the list, the patient pays full freight. Britain’s list, Reid noted, includes Viagra, probably because it was invented by a British scientist who has since been knighted by the queen. When he asked a health official in France why their list doesn’t include that particular drug, she said, “Because ze French men, zay don’t need ze Vee-ah-grah.”
Matt Montgomery, who described how health care organizations can make better use of data to identify their ideal patient and better market they’re services, has spotted an interesting trend: medical groups and hospitals are hiring more people from outside health care—like the retail industry—who are experienced at collecting, analyzing and using data to promote their business.
Montgomery, an advocate of direct marketing campaigns, was asked if providers should consider social media to reach consumers. “Everybody’s still trying to figure out how to leverage Facebook and Twitter,” he said. “Nobody has been able to show yet if this is a successful strategy or not.”
David Cook’s presentation was on hospital acquisitions of physician practices. He offered one rationale for why doctors are considering selling now: Baby boom physicians came out of school into solo practices and built them into significant-sized groups. They spent a lot of money on hiring, on technology, on building the practice. And now they’re wondering: Is this the last chance to cash out?
Cindy Dunn lamented the alphabet soup that plagues health care providers trying to understand digital health care. And she said that even though there are distinct definitions for EMRs, EHRs and PHRs, she always types in EMR when she’s doing online research into the topic. “And I’ll do that as long as Microsoft turns EHR into HER,” she declared. “Isn’t that annoying?”Submit a Comment | Back to Top
Can hospitalists prove their worth?
by Bill Santamour @ 10:30AM
Hospitalists command big salaries, and they need to continually convince hospitals that they’re worth it. That means going beyond hard ROI numbers, say Leslie Flores and Anna-Gene O’Neal, who presented a session titled “What Have You Done for Me Lately? Demonstrating Value in Today’s Environment.”
Hospitalists don’t directly cover their costs for a number of reasons, Flores said:
- Their workload is unpredictable. Unlike in a medical practice where patient appointments are scheduled and known ahead of time, patient flow in a hospital cannot be controlled.
- Because they are on site all the time, hospitalists get lots of interruptions, which makes their workflow inefficient.
- Hospitalists see the bulk of uninsured and underinsured patients who come in for care.
However, there are many ways hospitalists can demonstrate their value, Flores and O’Neal said. For instance, they reduce readmission rates because they are available to meet with patients before discharge to make sure they’re well enough to go home, to educate them on follow-through steps when they get home, and to determine whether, indeed they should go home or if another care setting is more appropriate.
Hospitalists nearly always achieve reduced length of stays for patients and improve the case mix. As hospital employees, they’re also more apt to practice evidence-based medicine and comply with clinical protocols than independent physicians are.
Flores and O’Neal urged hospitalists to participate in quality improvement efforts and other initiatives in the hospital—and to take leadership roles on those kinds of committees—to demonstrate their commitment and value to the hospital.
Submit a Comment | Back to Top
MGMA's Washington wish list
by Richard Haugh @ 9:20AM
MGMA’s legislative agenda is as long as any health care interest group’s, but its members may be facing one of the most threatening issues of any group short of the American Medical Association.
Legislation a few years ago that was designed to balance the federal budget also mandated reductions in Medicare reimbursement to physicians. Because doctors make up a powerful lobby on Capitol Hill, those cuts have been postponed year after year. Now, unless something is cobbled together again this year, physicians face a 21.5 percent cut in reimbursement next year.
While it’s unlikely docs will take such a large hit—and their medical group practices along with them—what’s uncertain is how the issue will be addressed this year, and what impact health care reform legislation may have. Legislation approved yesterday by the Senate Finance Committee would provide a one-year fix in the form of a 0.5 percent increase for 2010. But that would leave even steeper cuts to be dealt with in 2011.
House legislation would repeal the sustainable growth rate formula and link it to other indexes in future years. MGMA estimates that if that were to pass, it could free up $228 billion over 10 years—money it hopes could go toward restoring proposed reimbursement cuts.
Also, both houses of Congress are tinkering with pay formulas to reward general surgeons or to penalize imaging—a target lawmakers think is rife with overspending. And legislation is on the table to reward doctors for quality reporting initiatives (House) or provide some rewards for reporting and some stiff penalties for non-reporters (Senate).
That penalty option has lobbyists worried. “It may be an indication of what may be coming in other reporting initiatives,” noted Robert Bennett, MGMA government affairs representative.
Submit a Comment | Back to Top
What is culture?
by Bill Santamour @ 8:00AM
Admit it: Your eyelids start to droop every time somebody mentions the word “culture.” It’s one of those things you know you probably ought to fix if only you could figure out exactly what it is.
Three presenters at an MGMA session called “Creating a Culture of Safety and Reaping Its Rewards,” made a good case for why culture matters if your organization wants to improve the quality and safety of the care it provides. They defined it in a straightforward way, mostly minus the mushy consultant-speak that makes many of us want to take to our beds.
Culture is a shared world view among members of an organization, said Radhika Nath, a senior research scientist at MGMA. They agree on what attitudes and behaviors will guide them in their work.
Sometimes the culture is dysfunctional, discouraging camaraderie and cooperation.
But a culture that promotes quality and safety efforts comprises a collegial atmosphere with a team approach to patient care and open communication among all members of the organization, said John Kralewski, professor emeritus at the University of Minnesota. Kralewski said he’s “amazed” at how segmented certain organizations are. There’s no cohesion in how the members in the group are expected to do their jobs, and so there’s no way to establish procedures and protocols for quality control.
Tim Palm, senior vice president of MercyCare Community Physicians in Iowa, said patient safety is the guiding force in the culture of his organization. For instance, they’ve instituted a “stop the line” policy in which any staff member at any level at any time can interrupt the care process to voice misgivings.
He described one practice in which a doctor prescribed a certain medicine to a patient. Outside the exam room, the nurse told the physician they’d tried the medicine previously and it had not been effective. The doctor insisted they stick with what he’d ordered, then reconsidered, “huddled” with the nurse and changed the prescription.
In a more dramatic example, a nurse administered a wrong dosage to a young patient. Distraught, she immediately informed the physician, and the two of them huddled with the pharmacist on site, who determined that there was minimal risk. The physician, pharmacist and nurse then met with the parent to explain what happened, to apologize and to tell her what reactions to look out for back home. The nurse was still in tears about the potential danger she had put the patient in and was convinced she would be fired, but when the quality leaders arrived from the main office, they told her, the doctor and the pharmacist that they had done exactly the right thing.
An audience member asked if they would have reacted the same way had the risk to the patient been more serious. Palm said they would have sent the patient to the hospital and called in a specialist. But their message to the original care team would have been the same: “You did the right thing.”
A nonpunitive culture encourages a staff member to acknowledge an error as quickly as possible. Moreoever, meeting with the patient or the family, admitting the mistake and apologizing for it reduces the prospects of malpractice claims.
Submit a Comment | Back to Top
Hospitals can help doctors, themselves capture stimulus funds
by Richard Haugh @ 3:15PM
The federal stimulus bill approved this spring has a tidy incentive for physicians to adopt health information technology. Doctors can receive $44,000 over five years from the Medicare program, or $63,750 over five years from Medicaid (but not both). There are a lot of strings attached, and the feds have yet to nail down particulars of the program. Plus, MGMA officials say many physician groups can’t afford to take on the cost of IT systems, putting the full amount of the subsidy in jeopardy.
But there’s some good news for hospitals. While hospital-based physicians aren’t eligible for the stimulus money, medical groups that hospitals have other contractual arrangements or joint ventures with still may benefit from the new program—and in the process, so could hospitals. Policymakers in 2006 paved the way for hospitals to give financial assistance to physician groups wanting to electronically connect to hospitals’ electronic health records (within Stark limits). Now thanks to those changes, hospitals can subsidize a portion of medical group investments in IT that qualify for the 2009 stimulus money.
“Cost-sharing deals with hospitals are still alive,” said David Schoolcraft, a health care attorney. “It’s kind of like a double-coupon deal.”
Data released at MGMA’s annual conference show medical group revenue on a slide, leading many groups to shelve capital expenditures—including EHR investments. So hospitals and health systems that invest in struggling medical groups that want to modernize may be just what docs need right now—and it can also boost hospital efforts to computerize the health record.
Hospitals can share up to 85 percent of the cost of computer hardware and technology, support, maintenance and related services. If that tips the scales in favor of a medical group investing in an EHR, hospitals could benefit. “It leads to very good integration potential,” Schoolcraft said.
A possible added benefit for hospitals with doc deals: MGMA studies show that the more physicians spend per doctor on IT, the more profitable those doctors are. Not a bad deal if you’re sharing in the success.
Submit a Comment | Back to Top
Deja vu?
by Richard Haugh @ 2:30PM
What’s old is new again. Or is it the other way around?
“Integrated Delivery Systems: The Red Ink Problem,” was a 20-minute interactive session on the floor of the MGMA booth. It looked at the sometimes-huge losses hospitals suffer when they buy and absorb physician practices.
This story could have been written 10 years ago. In fact, I did write it then. Apparently, little has changed in the last decade—except that the numbers are bigger now. Robert Bohlmann, an MGMA consultant who works on physician-hospital integration issues, noted that the average hospital-purchased doc practice now loses between $30,000 and $200,000 per physician. That’s more than the $50,000 to $100,000 per doc I wrote about so many years ago. So what’s changed?
Mostly the economy, it seems. Instead of hospitals chasing doctors on their turf, now it’s just the opposite. The environment has evolved, Bohlmann said—now docs are banging on hospital doors seeking refuge. “It’s a different world, and mom-and-pop practices won’t survive much longer,” he predicted.
Yet the same problems persist. The financial model at smaller, more nimble physician groups doesn’t mesh with the size, bureaucracy and complexity of the much larger hospital systems. Strip out the ancillary incomes doctors used to pad the top line, add a layer of hospital overhead cost allocation, and even tack on amortization of the costs of the deal, and let the red ink flow.
Still, Bohlmann is optimistic that with hospital board education and creative collaboration, hospitals and doctors have a chance to get it right this time. Let’s hope. The stakes are a lot higher this time around.Submit a Comment | Back to Top
It's time to do the right thing
by Bill Santamour @ 11:00AM
As a congenital skeptic, I’m having a hard time processing all the optimistic talk around health care reform coming out of the MGMA conference. While acknowledging the many things that are wrong with the system today and the fact that one powerful force or another is ready to block nearly every proposal for change, speaker after speaker has professed a belief that we as a nation can come together—and, in fact, we are coming together even now—to fix what needs fixing.
Today’s self-declared optimist (at least the first of the day; it’s early yet) is William Jessee, MGMA president and CEO. “I’m bullish on America! I’m all fired up!” he boomed in a blast of enthusiasm not universally shared by conference attendees at 7:30 in the morning.
Jessee said there are five “outstanding attributes” to address in health care today, none of which should surprise anybody:
- The system is fragmented; primary care physicians are too few and specialists are ever more specialized, patients shuttle between providers but their records don’t follow; hospitals don’t communicate with each other or with other providers.
- Costs are too high.
- The system is inequitable.
- Quality is spotty.
- The payment system is “perverse.”
But, “we’re having more discourse and dialogue” about possible solutions, he claimed, and “much of it is even civil.”
For example, on the payment front, he said consensus seems to be building that reimbursing for more services is “irrational.” Instead, the system should reward results, institute “sensible” spending caps, strip out “our ridiculous” administrative waste and eliminate overuse.
Jessee cited real-life examples of health care systems around the country that are test-driving possible solutions for the field’s big challenges, often with amazing results and often in partnership with payers.
The overarching question being asked, he said, is can we afford to change the system? Improving quality, getting people the right kind of care when they need it, encouraging behavior changes and so on will cost money upfront, but in the long run will produce savings, he insisted. “The real question is, can we afford not to do it?”
Jessee repeated Winston Churchill’s well-known quip that Americans will always do the right thing—after they’ve tried everything else. “Well,” he said, “we’ve done everything else. Now it’s time to do the right thing.”
Even the skeptics among us can only hope.
| Comments: |
October 13, 2009 “The overarching question being asked, he said, ‘is can we afford to change the system?’ Improving quality, getting people the right kind of care when they need it, encouraging behavior changes and so on will cost money upfront, but in the long run will produce savings, he insisted. “The real question is, can we afford not to do it?” Who is going to make the decision concerning the comment in italics? I hope and pray that everyone understands that it cannot ever be the government. —Mark A. Wishard If you accept the five areas needing fixing in your Blog article, then it should be easy to take each section of a health care reform bill and identify how it will address one of those areas. If we don’t fix the inherent cost shifting in the system, reform will not work. If the OIG is waiting to pounce on physician-hospital alignment as Stark violations, we will not achieve integration of services. Try the “5 fix” review of current proposals and I think you will find little to address the fundamental broken areas you have identified. This has and continues to be one of the major flaws in the debate. —Ed Gamache, administrator/CEO, Deckerville (Mich.) Community Hospital |
Submit a Comment | Back to Top
What? Docs give health plans good grades?
by Richard Haugh @ 10:00AM
Here’s a man-bites-dog story for you: Physician practices are pretty happy with the way health plans are performing on a number of administrative measures.
MGMA recently surveyed its members on how satisfied they are with how quickly their plans pay claims and the mean score was roughly equivalent to a B+.
How willing the insurer is to fork over details of the fee schedule under which they pay doctors: A-.
Their favorite payer: Medicare. Aetna and Cigna were second and third. That’s the overall ranking; Medicare came in dead last when ranked on provider credentialing.
“Even though Medicare consistently underpays and places member practices in an increasingly difficult financial situation, our members are positive about how the Medicare program is administered,” says William Jessee, M.D., MGMA’s president and CEO.
This is the second year of the survey (http://www.mgma.com/payerperformance09), which asks group practice managers’ attitudes about payer interactions. Seven payers were rated: Aetna, Anthem, Cigna, Coventry Health, Humana, Medicare Part B and UnitedHealthcare. The study focused on satisfaction with payer communications, provider credentialing, contracting, payment policies, system transparency and overall satisfaction.
Standardized and transparent administrative processes generated high satisfaction scores. Medical groups universally said they are frustrated with the claims denial appeals process, contract negotiations and ratings system transparency. Medicare’s poor showing on physician credentialing apparently results from the government’s refusal to participate in the standardized physician credentialing system (called CAQH Universal Provider Datasource) that’s widely used in the private sector.
There may be a punch line to this story after all. The study didn’t address medical groups’ satisfaction with how well their insurers paid them. And ranking dead last in insurer ratings: How much leverage the group practice has during contract negotiations.
Submit a Comment | Back to Top
It's time to start using demographics on steroids
by Bill Santamour @ 9:30AM
Want to know a secret? Too bad. There aren’t any anymore. What there is is data—and when it comes to the American consumer there’s a whole lot of it. Many people—or more to the point many businesses—know not only basic demographic information like your age and gender, where you live and work, the level of education you’ve achieved, your marital status, how many kids you have and their age and gender. They also know which TV shows you watch, which magazines you subscribe to, how many times you dine out each month and where, which stores you frequent. They might even be able to tell that you are willing to spend money to look younger, that you are a ski buff and that you prefer to go to an urgent care facility when you need primary care.
Matt Montgomery calls it “demographics on steroids” and as scary as that sounds, it’s too late to panic about it. All that data and a whole bunch more is already being collected—much of it by you as a business organization and as a health care provider. Now, he says, it’s time for physician practices and hospitals to dig in, analyze the data and use it to your advantage. You can use the data to reach specific types of patients you want to attract and to better gear your services toward those patients.
In an MGMA session called “Not All Patients Are Created Equal,” Montgomery, senior vice president of the health care division of Buxton Consulting, said health care lags behind other industries when it comes to using existing data to understand the marketplace. He talked about things like segmentation and psychographics, which dig deep into data to paint a detailed picture of the population. Organizations can then target their marketing dollars to a much narrower set of consumers.
Providers can outsource the work of analyzing data, and the fees will vary according to how much and what kind of information you want. To get started, Montgomery suggests you conduct a needs assessment of the data you now have and what you think would come in handy. He also suggests “patient profiling” to develop a real understanding of your current patients and those you have your eye on.
Submit a Comment | Back to Top
Negotiating the finer points of a hospital-physician deal
by Bill Santamour @ 8:50AM
Hate to disappoint you, doc, but you ain’t gonna get rich selling your practice to a hospital. So before you think about the dollars, think about whether you’ll really feel comfortable in that new setting. Do the hospital’s mission and vision match your own? Will you be able to practice in a satisfying way? Is the hospital going to feel that you are a good fit once you’re on board?
Those were some of the key points coming out of a Monday afternoon session titled “What to Expect When You Negotiate with a Hospital System.” The presenters are experienced in physician practice acquisitions. Casey Sturkie is assistant vice president of physician support services at Lexington Medical Center in West Columbia, S.C. David Cook is chief administrative officer of Waukesha Elmbrook Health Care in Wisconsin and previously ran the employed physicians area of an integrated health care system.
In a sign of the times, the session drew a large and very vocal audience, which included physicians, medical practice managers and hospital leaders. When the PowerPoint equipment temporarily failed, Sturkie and Cook took the opportunity to ask why those on the doc side were considering selling to hospitals.
“Money,” was the first reply, “We want to cash out before it’s too late.” But a laundry list of other reasons followed: reimbursement for certain specialties had dropped and those specialists could now get paid more for the same services in a hospital setting; a desire for long-term security in an uncertain economic and policy environment; running a practice has become too much of a grind; younger physicians don’t want to put in the hours and money it takes to build and maintain a practice, and many more. One audience member said that in her market “the vast majority of primary care physicians are employed by a hospital so my doctors already feel like they are employed by the hospital because that’s where all their referrals come from.”
Sturkie and Cook warned that physicians often spend all their time thinking about the initial acquisition—with dollar signs blurring their vision—and no time thinking about the long-term relationship with the hospital. That’s wrong-headed for two reasons. One, hospitals are legally limited in what they can pay for practices by fair market value regulations. Two, no amount of money is sufficient in an unhappy work environment. “Deal with governance, decision-making, compensation methodology and so forth before considering the specifics of physician compensation,” they urged. “Get the numbers out of your head,” Sturkie said. “Until you know how much control you’re giving up, how do you know how much to ask for?”
Among the myriad seemingly small details doctors and hospitals should work out prior to an acquisition: Who will make hiring decisions for the practice? How many receptionists will it have and what is their pay rate? Will physicians work with an RN or medical assistant? Which exam rooms will be used? Who will OK small equipment purchases? And, perhaps most critically, who will run the billing department for the practice? If those responsibilities are delegated to the hospital human resources department, physicians will probably regret it, Sturkie said. “A hospital that tries to run a physician practice as a small hospital or a department is setting itself up for trouble.”
One attendee added that physicians should make sure the hospital guarantees a dedicated IT staff to the practice. “Otherwise, you’ll always be last on the priority list,” he said.
Naturally, compensation is a critical issue, and the speakers outlined several considerations, including:
- Whether physicians want to be paid a set salary or based on productivity
- How long physicians can expect to receive a guaranteed minimum salary; typically it’s one to two years, though Cook said, “practices that are swinging market share from one system to another” can negotiate five- or even 10-year guarantees.
- Signing and retention bonuses may be options, “but they will be taxed heavily,” Sturkie stressed.
- Physicians will have to sign a noncompete clause “if they want to get value for their practice,” Cook said. However, Sturkie added, physicians should make sure they have a way out if circumstances change, for instance through a change in ownership of the hospital itself. “The last thing you want to do is sign a noncompete clause with a not-for-profit hospital and six months later you’re working for a for-profit hospital.”
Submit a Comment | Back to Top
Economy accelerates growth in hospital-owned practices
by Richard Haugh @ 2:50PM
The weak economy is driving medical groups into the arms of hospitals—and that trend is likely to continue.
MGMA released results of its 2009 member cost survey at a press briefing today. Data was for 2008 operations, and 2,077 MGMA members (about 10 percent of the group’s total) responded to the Web-based survey.
Multispecialty groups saw a 1.9 percent drop in medical revenue in 2008—the first time MGMA has seen a drop in the last 10 years of surveys. That drop may be tied to smaller patient volumes and increasing bad debt due to patients’ financial hardship, according to MGMA President and CEO William Jessee, M.D.
Survey results showed a 9.9 percent drop in patient procedures and an 11.3 percent drop in the number of patient visits between 2006 and 2008. Bad debt from fee-for-service charges was up 13 percent. To combat falling revenue, groups reduced support staff costs by 1.5 percent, but didn’t reduce staff. Instead, staff likely went without raises or bonuses, or took pay cuts.
“These data demonstrate the trickle-down effect of the tough economy,” Jessee said. “Even in a good economy, many of our member practices have trouble staying financially solvent.”
The economy is also taking its toll on this year’s MGMA conference. Jessee reported that there are 2,150 paid attendees this year, down 21% from 2008; 324 companies are exhibiting at the conference. “That’s about in line with what other associations are seeing around the country,” Jessee said.
The good news for hospitals is that the economy, proposed reimbursement cuts and uncertainty surrounding health reform is pushing doctors to exchange the risks of their practices for the relative security of hospital ownership and employment. MGMA reports that between 2003 and 2008, the number of hospital-owned groups increased 20 percent and now accounts for 10 percent of MGMA’s membership.
During that same time, the average number of doctors in physician-owned practices grew to 18.8 from 16.4, a 15 percent increase. The average number of physicians in hospital-owned groups grew to 76.3 from 64.3, a 19 percent increase.
“The trend in the industry is definitely toward more integration and more hospital-owned practices,” Jessee said.Submit a Comment | Back to Top
More complex compensation arrangements on the horizon
by Richard Haugh @ 12:15PM
By one consultant’s prediction, in 10 years as many as 90 percent of physicians will have a new employer—a hospital. “Clearly, that’s where the trend is headed,” said Max Reiboldt, president and CEO of the Coker Group, Atlanta.
In the meantime, medical group practices are employing more sophisticated strategies in contracting with hospitals to provide their services. He outlined some of those tactics in a presentation this morning at MGMA’s annual conference. They include some tried-and-true methods like per-diem payment, joint ventures and hospitalist arrangements. OIG scrutiny has forced other arrangements such as gainsharing out of favor.
Compensation arrangements are evolving to keep up with the creative new strategies. One gaining favor is based on a form of relative value scales, Reiboldt said. A defined unit of work for, say, an orthopedist and a rate of compensation for each RVU is agreed to, based on benchmarks produced by MGMA and other groups. Doctors like the system because it often means more revenue for them each year. Hospitals like them because they make for an efficient way to measure productivity, Reiboldt said. An added bonus: Many contracts call for hospitals to assume the revenue from ancillary procedures such as infusions and imaging that previously went to the doctor.
However, the increasing complexity of these doctor-hospital work arrangements boosts the risk of regulatory scrutiny, he added. He urged medical groups and hospitals to adhere strictly to the concept of fair market value when setting compensation deals. That’s particularly true when it comes to ED call arrangements, an area that is clearly the most prominent issue facing physicians and hospitals—so prominent, in fact, that MGMA recently issued its first survey on call arrangements.
The activity around ED call negotiations has not escaped the OIG’s attention, and Reiboldt said there will be a plethora of opinions on the topic from the watchdog agency in the future. “This is far from being fully vetted,” he said. “Many hospitals are really struggling with this.”
Submit a Comment | Back to Top
Should universal coverage be a national goal?
by Bill Santamour @ 12:11PM
Do you think the health care debate in Congress will lead to significant change this fall?
Former Washington Post reporter T.R. Reid, whose new book, The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care, looks at countries around the world that provide universal coverage to their residents, seems a little more sanguine now than in July when he spoke at the Health Forum-American Hospital Association Leadership Summit. “They’re going to pass a bill and the Democrats will call it reform,” Reid told an early-morning session at the MGMA conference. The final legislation will make U.S. health care “somewhat better,” he said, but it will still leave 20 million Americans uninsured by 2013.
Will this country ever guarantee health care for everyone? “I’m optimistic that the United States, the world’s richest country, can get to universal coverage at reasonable cost,” Reid said, but when he asked the audience, made up primarily of medical practice management professionals—people who spend much of their energy on insurance issues—if they shared his optimism, the response was less than enthusiastic.
Now I’m posing the same questions to you. Do you think the United States will ever provide universal health care coverage? Do you think it should even try?
Submit a Comment | Back to Top
"It's not all socialized medicine"
by Bill Santamour @ 12:00PM
In researching his new book, what did T.R. Reid find among countries that provide universal coverage? “In the first place, it’s not all socialized medicine,” he said, noting that many systems have private physicians, private hospitals and private health care plans. “And it doesn’t have to be single payer,” he said, citing, among others, Japan, which has 3,000 payers but manages to cover all its citizens while spending a lot less on health care than we do.
All the countries Reid visited face the same daunting issues as the U.S., including an aging population and tremendously promising but expensive advances in technology.
He cited four models of health care worldwide, ranging from true socialized medicine in Great Britain to the Bismarck model in Germany, which he says is even less socialized than the American health care system. Germans are required to carry private insurance; the insurance companies, in turn, are required to cover everybody and to pay for all care deemed appropriate by physicians. In France, which uses the Bismarck model, insurers must pay every claim within three days—a concept that awed the MGMA crowd.
Canada uses a third system—what Reid calls the national health insurance model, in which doctors and hospitals are private but the payment system is public. He said critics are correct when they point to lengthy waits to get treated for non-acute issues in Canada, which purposely limits the number of specialists and certain medical procedures, such as MRIs, to control costs. But Taiwan, which uses the Canadian model, has shorter wait times than the United States for most medical care.
The fourth model Reid cited is the “out-of-pocket” system, common in the Third World: If you don’t have money, you don’t get care. “It’s a brutal, simple fact of life in most countries,” he said.
The U.S. employs all four models, Reid said: Native Americans and veterans are covered under a socialized system similar to Britons; working people with employer plans are in a German-like insurance system; Americans over 65 use the Canadian system, with private providers paid with public funds; and the 47 million uninsured are in an out-of-pocket system.
“All other countries have settled on one model for everybody,” Reid said, which is “vastly cheaper. You have one set of rules and, in some countries, one set of prices. The savings are huge.”
He called the American private insurance system “the most expensive, least efficient” system in the world, asserting that administrative costs can add up to 30 percent to a health care bill. In the countries that provide universal coverage, administrative expenses are no more than 5 percent of health care costs. “The Government Accountability Office found that if we could get down to France’s administrative costs, we could pay for all the uninsured in the U.S.,” he said.
Because other countries cover citizens from cradle to grave, Reid said they are much more incentivized to provide preventive medicine. Americans with employer insurance average just five years with the same plan, and those with private coverage average 18 months with the same plan. No wonder insurers aren’t motivated to help foot the bill for preventive care that would only pay off over a long term.
Reid said he began to research his book with a very objective question in mind: how do other countries cover all their residents while spending so much less on health care than the U.S.? But ultimately, a more subjective question came to the fore: Why do they do it? And, more to the point, why has the United States so far refused to do it?
In every other country, guaranteeing health care for everyone is a moral issue, Reid said. It’s no less a moral issue here, he claimed. “If you never sit down and decide you want everybody to get health care, maybe you get a system in which rich people get the best care in the world and tens of millions of people are left out.”
On the other hand, he says, “if the United States could find the political will to provide health care for everybody, the other rich countries of the world could show us the way.”
Reid’s book is The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care.
Submit a Comment | Back to Top
Can 'high-touch' medicine control costs?
by Bill Santamour @ 10:15AM
Picture this: Doctors spend more time with patients and sometimes even make house calls, prescriptions are delivered right to patients’ homes, medical office staff proactively telephone to make sure patients are following through on their treatment plans—in some cases, limousines are dispatched to pick up patients at home and bring them to their physician’s office.
Is that any way to control health care costs? Ezekiel Emanuel, M.D., thinks so. He noted real-life examples of organizations—both health care systems and employers—using some or a combination of those seemingly counterintuitive tactics to at least moderate the crippling rise in medical costs. Emanuel, who is on loan from NIH to President Obama’s reform team and is brother to White House Chief of Staff Rahm Emanuel, calls it “high touch medicine”; giving more personal attention to chronic care patients who use the vast majority of health care services, and shifting from a volume-driven payment system to one that rewards coordination and complete episodes of care. By providing adequate resources on patient care upfront, the nation’s health care system would realize huge cost savings in “potentially avoidable complications” that lead to unnecessary emergency department visits, hospitalizations and readmissions, Emanuel says.
During his keynote address at the MGMA conference, Emanuel cited studies showing that more than half of patients readmitted to hospitals did not visit a doctor’s office between their initial discharge and their readmission; that a startlingly large number of patients fail to get their prescriptions filled, some for cost reasons and many because they could not or would not get to a pharmacy; and that 65.2 percent of ED visits are preventable.
Among the steps to high-touch medicine: extended physician office hours and same-day appointments; more on-line communication between providers and patients; better data collection and analysis; and clinical guidelines that allow nurse practitioners and others to alleviate some work that physicians now do.
Patients also need to be empowered, he says: through education about their conditions, letting them share in decisionmaking about their care and by having them work with coaches to change—and maintain changes—in their lifestyles.
To achieve such high-touch medicine, Emanuel said we need to find a way to encourage physicians to go into primary care and to step back from a fee-for-service payment system to one that rewards quality of care by aligning incentives and bundling payments. The latter, he seems to think, is inevitable.
Submit a Comment | Back to Top
The elephant in the convention hall
by Richard Haugh @ 8:26AM
MGMA's 2009 annual conference kicked off Sunday at Denver's convention center. Much was as you would expect: the hoopla and excitement of the opening reception, the bustle of crowds in the cavernous exhibit hall and the gathering of colleagues. Yet overshadowing the event this year is the struggling national economy.
In his remarks opening the conference, Ezekiel Emanuel, M.D., senior advisor on health policy at the White House Office of Management and Budget, spoke convincingly of achieving the goal of an improved health care system that will benefit patients, physicians, hospitals and other stakeholders (see Bill Santamour's post about Emanuel's speech). Yet as William Jessee, M.D., MGMA president and CEO, noted in his introductory remarks, one-third of the association's members report hiring freezes, budget cuts and decreased capital spending. A third of members also say they are experiencing decreases in patient volumes and a corresponding decrease in revenue.
A sample of attendees and exhibitors shows the same angst bubbling just beneath the surface. While MGMA won't report the number of attendees at this year's conference until later today, several exhibitors think attendance is down this year, among members and exhibitors alike. Many attribute it to cuts in travel and education budgets.
For some MGMA members, the economy is taking a personal toll. One northeast U.S. practice administrator related that her job had been eliminated in recent weeks when the economy drove her four-doc group to merge with several other struggling small groups—a trend she is also hearing from cohorts around the country.
And in shades of the 1990s, physician recruiting firms—of which there are a good number on the exhibit floor—report that many doctors are exploring employment with hospitals. “Everyone wants to be employed,” one medical headhunter said. “No one wants to be on their own anymore.”
Yet beneath the anxiety driven by the sour economy, optimism still percolates. As a southeast U.S.-based health care consultant said, medical groups and hospitals are making plans for the future. “Business is good, and it looks like it will be for a while.”
Submit a Comment | Back to Top
Health care isn't for wimps
by Bill Santamour @ 7:30AM
Health care is not for wimps. Want proof? Arctic weather staged a surprise attack on Colorado over the weekend, forcing Major League Baseball to postpone a playoff game between the Rockies and the Phillies. But it couldn't keep thousands of physician practice administrators and other hardy health care types from descending on Denver for the start of the Medical Group Management Association's annual conference.
How wicked was the weather here Saturday and Sunday? To paraphrase the late newspaper columnist Mike Royko, it was so cold I saw politicians with their hands in their own pockets. I flew in early and drove down to Colorado Springs to attend my nephew's homecoming game, and as much as I enjoyed watching Will and his Discovery Canyon High School teammates notch the win, by halftime my nasal passages had frozen shut and I was dreaming of balmy Chicago—words I will no doubt eat come January.
Back in Denver Sunday afternoon, my colleague Rick Haugh and I met up at the convention center downtown to set our blogging strategy for the bulk of the MGMA conference. Our big goal is to focus on why this meeting matters to our core readers—those of you involved in leading hospitals. As it turns out, the agenda is rich in discussions that touch on physician-hospital relations, with sessions slated on everything from coordinating care to bundling payments to cooperating on quality and safety initiatives. One hot topic, of course, will be how hospitals can help electronically connect physician offices to create an electronic medical record. Big names speaking at the conference include T.R. Reid, author of "The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care" and Dr. Ezekial Emanuel, bioethics chair for the National Institutes of Health and senior advisor on health policy at the White House Office of Management and Budget.
Oh, and by the way: As everybody was leaving the first general session Sunday afternoon, a fire alarm blared throughout the convention center, repeatedly interlaced with a stern announcement that the fire department was on its way to investigate. That didn't seem to phase anybody in the throng making its eager way to the opening reception. Health care folks are tough.
Submit a Comment | Back to Top
 |
Materials Management in Health Care // Buyers' Guide for the Healthcare Market
|
Copyright ©2010 Health Forum. All rights reserved. H&HN is published by Health Forum, Inc.
an American Hospital Association information company. |