Nearly every healthcare organization and affiliated clinician group faces challenges when working to meet new models of care and payment delivery.
"There are standardized themes happening, whether that's value-based purchasing, reform initiatives such as ACOs or regulatory changes. It's just the way we're moving, and it's happening rapidly," said Robert Hitchcock, MD, a practicing physician and VP/CMIO with T-System, Inc., a company that helps clients facilitate patient care, boost workflow efficiencies and maximize revenue in the emergency care setting. "Each group is interpreting these changes differently, and that can be difficult. While some of these initiatives have yet to implemented, they are beginning to alarm people."
Hitchcock outlined the six actions that emergency department physician groups can take to remain financially viable and strengthen their alignment between hospitals and physicians.
1. Reconsider "economies of scale" and increase revenue. It's becoming harder and harder to maintain projected revenues. "Health groups need to look for two operational issues," explained Hitchcock. The first is "economies of scale." Smaller, independent physician groups need to examine more closely where they're leveraging day-to-day activities that relate to sustaining revenue such as group purchasing of high-cost items (medical malpractice insurance), billing, coding, HR and risk management. Combined, they have the opportunity to reduce overhead costs and increase bottom lines.
The second thing is just that: increase revenue. "It's not the easiest thing in the world to do, but there are many options available to groups such as hiring a full-service revenue cycle company with proven results. If you do outsource coding and billing, though, you'll want to look for a company that provides feedback on documentation, percentages of down coding, charts that could have been coded better, deficiencies and educational opportunities for providers to improve documentation," said Hitchcock. "Revenue is all about what's documented in the medical record. It really has less to do with care and more so with the description of care and the concluding diagnosis."
2. Partner on process changes. Process change is something that neither physician groups nor hospitals can do themselves. It takes a concerted effort on both parts. In the ED, the focus is on throughput – the more patients you can move through the ED in a shorter time, the more opportunity you have to expand business volume and the less likely you are to have patients walk out. There are several changes that can improve patient throughput, including leveraging technology to measure data points of patient flow. If you can't consistently monitor your successes and failures, you won't know where to tweak the processes. Lean management is also to be considered for optimal process changes. "Patient arrival, initial evaluation, detailed evaluation, workups, clinical decision making, treatment, disposition... It's more artful than this, but the ED visit is a fairly structured workflow," explained Hitchcock. "If you could focus on just one element of process change in the ED, it should be the door-to-physician time. Shortening that time can raise patient satisfaction, reduce incidents of medical malpractice and open the lines of communication so that patients are less likely to sue."
3. Focus on patient satisfaction. As mentioned above, patient satisfaction is critical to a hospital's financial survival. Dissatisfied patients don't return if they have a choice. If clinicians know what's being measured in patient satisfaction surveys, they can address those topics during a patient's visit. It's important to get the entire team focused on satisfaction and to learn to effectively communicate openly with a patient during a visit about what's physically wrong with them, what you – as the doctor – are going to do, what the outcomes could be, what their current stats are, potential follow-ups and what they should expect during the healing process time.
4. Improve communication between ED doctors and referred clinicians. One of the best strategies to help retain patient loyalty within a healthcare system is to focus on care coordination. It's easy to refer a patient to a doctor within the network of the hospital. The challenge lies in making sure the patient actually has that follow-up appointment. There are several actions a clinician can do to ensure that this happens. Instituting technology to proactively share real-time information with both the patient and the downstream clinicians as to when the patient was first seen, what care was originally provided, when the follow-up was scheduled and providing them with a patient's contact information can help. This allows patient movement in a system to be tracked so that no one slips through the cracks. The healthier a patient can be kept and the more that can be done to manage their care, the less costly it is to the system; it also creates an opportunity to generate revenue.
5. Choose the best environment possible. There's a tremendous amount of pressure placed on hospitals by insurers to see patients in the right venues of care. Some insurers won't reimburse providers because certain visits didn't require the delivered services. As a result, it's important to ensure that patients receive care in the best environment possible. Sometimes that means redirecting ED patients to their PCP. "If the patient doesn't need the services, the visit actually ends up burdening the ED. It ties up valuable, expensive resources in providing care that's unnecessary. If you can redirect those patients to the right place for care, you can allocate resources more wisely and optimize them for the jobs that really need to be done," Hitchcock said. "For insured patients, it's also often less costly to see their PCP, anyway. Co-pays can be very expensive for ED visits. And when you save patients money, you drive satisfaction and have repeat customers."
6. Direct alignment around impending changes. CMS is increasingly allotting reimbursement based on outcomes of care. It's important for physicians and hospitals to report their compliance with defined quality measures to maximize revenue and reimbursement. ED teams must do their part collecting and documenting information to demonstrate that a patient's care is being provided within the scope of CMS. Another element of alignment is using the ACO model. ED physicians are not directly motivated by the risk/reward model of ACOs, but their hospitals will be or already are affected. So decisions an ED doctor makes can have a profound effect on the financial stability of the accountable care organization. Total healthcare expenditures will be analyzed against national benchmarks, which means hospitals will either share in savings or be penalized for excess compared to those set standards. An ED physician's decision to send a patient home or admit him or her to the hospital is the single most influential cost decision that a physician will make. "By putting someone in the hospital when the patient could have been managed in a less dramatic environment... well, that's thousands and thousands of dollars spent right there," noted Hitchcock.