Joining forces with a like-minded, larger medical practice may afford economies of scale, but physicians should be aware that it could be at the expense of patients, who are becoming more cost-conscious.
Now that King v. Burwell is no longer a distraction and millions of Americans' healthcare subsidies are safe, hospital and health system leaders can spend their energy preparing for the inevitable shift toward value-based care and all that move entails, which has included the search for similar care partners willing to enter into a joint-venture with or outright acquire.
The trend of hospital consolidation and physician group acquisition isn't expected to slow down. In fact, healthcare leaders believe that consolidation, whether it is with hospitals, physicians, or post-acute care providers, is a means to impact the financial goals of hospitals and health systems.
According to this year's HealthLeaders MediaAnnual Industry Survey, respondents placed more importance on partnerships and alliances than investments in new care models and IT when evaluating how healthcare systems and hospitals would meet their financial targets over the next three years.
Nearly half, (44%) reported that physician-hospital alignment would have the biggest influence on financial targets, while 36% said it would rely on strategic partnerships with payers; 35% said strategic partnerships with providers would help them meet financial goals.
What those data points show is that healthcare executives realize that partnering for the future is almost a requirement, not a recommendation. In the race to grow larger in order to survive, however, special attention should be paid to the overall impact of that growth.
"In healthcare, as in many business scenarios, there is often strength [and leverage] in numbers," says Jim Stone, president of The Medicus Firm, a Dallas–based physician staffing and recruitment firm that also tracks physician trends.
Less Control
"Over the past few years, physicians have been increasingly acquired and hired by hospitals and health systems, and/or are merging with other groups to form larger entities. As part of a larger system, physicians may not feel as stressed about potentially being put out of business by increasing overhead, competition from larger systems, or decreasing reimbursements. However, as physicians become employees (vs. partner/owners), physicians do relinquish some control in exchange for perceived security," Stone says.
Some of the control that physicians may give up is negotiating with insurance companies. That's not necessarily a bad thing, negotiations with payers are typically headache inducers. But there is a downside (that has a short-term upside), but could have a long-term negative impact.
A study recently published in Health Affairs shows that market concentration among orthopedic groups is associated with higher physician fees for total knee replacements. That suggests that growing bigger may afford economies of scale, but at the expense of patients who are expected to become more cost conscious, says Eric Sun, MD, a practicing anesthesiologist and instructor of anesthesiology, pain, and perioperative medicine at the Stanford University School of Medicine who co-authored the study.
"Total knee replacements are a common procedure, and it's expensive," says Sun, explaining why the study focused on total knee replacements. "More physicians are practicing in larger groups. [They] may lower overall costs, but [they're] charging more money."
In the past, when patients were charged more, the extra cost largely went unnoticed because the patient's insurance company bore the brunt of the increase. Patients are more conscious of healthcare costs now that there is more cost-sharing, a trend that is also likely to continue.
Sun's study looked at two data sets to determine the relationship, if any, between consolidated markets and physician fees. First, researchers studied market concentration of orthopedic groups over time between 2001 and 2010; second, they looked at physician fees charged over the same period of time by examining administrative claims data for patients with private health insurance.
Researchers calculated the amount of consolidation annually for 311 U.S. counties using the Herfindahl-Hirschman Index, a well-researched and commonly accepted measure of market concentration.
ACOs Coordinate Care, and Higher Prices
The study found that as the orthopedic group market became more concentrated, through affiliation or acquisition, the fees physicians charged also went up, either by 3.86% or by 6.63%, depending on the amount of market concentration over time. Markets that had the most concentration growth over the time period had the biggest increase in physician fees—$168. In contrast, in markets where there was no significant concentration, physician fees for total knee replacement fell by $261 over the same time period.
"I hope what this paper brings forward is [discussion] of the costs and benefits of changes in physician structures the Affordable Care Act is trying to introduce," says Sun. "Accountable care organizations can coordinate care, but they can also coordinate things like higher prices."
The additional fees collected in consolidated markets could be a bridge for organizations to use as financial footing while transitioning to a value-based care model, but relying on that long-term is doomed to fail because patients are already shopping for hips and knees like consumers are shopping for cars. It's not a sophisticated market now, but it will be, and unless the quality is better, physicians will be forced to explain their higher prices or reduce them on demand.
"Physicians have been able to be blind to [cost] because it's never part of the conversation with patients," says Intermountain Healthcare System's CHIO. That will have to change if population health is going to succeed.
At the heart of population health efforts is the hunt for a way to give physicians the ability to improve patient outcomes at a lower cost. At this year's HealthLeaders Media Population Health Exchange, executives in charge of overseeing physicians, specialty practices, quality, IT, and transformation, said transparency within organizations is a hurdle that needs to be cleared to meet patient demands and to move their systems closer to population health's goal.
Some organizations, such as the American Gastroenterological Association (AGA), are pursuing ways to give patients more price transparency. Larry Kosinski, MD, chairman of the AGA's practice management and economics committee, and owner of Illinois Gastroenterology Group, says the auto industry's Monroney sticker, which is on the window of every new car detailing price, crash rating, and cost for options, provides a good template for one of the most common procedures GI doctors perform.
"Every car dealership has a Monroney sticker," he says. "We are in the process of creating one at the AGA for a colonoscopy because the consumer needs to know, 'What is a colonoscopy? What should be in a quality colonoscopy?' We have to think this way."
Physicians need to start thinking this way because it's the new mindset of patients, especially those who are participating in high deductible plans. In previous years, when a $10 or $20 co-pay was all patients paid out-of-pocket, patients acquiesced to physicians ordering tests, procedures, etc. Now that more money is coming out of patients' pockets, they want to know how much services cost, says Sameer Badlani, MD, chief health information officer for Intermountain Healthcare System in Salt Lake City.
Sameer Badlani, MD
"For the first time in my life, I'm on a high deductible health plan," he says. "I look at things closely now. I never looked at my bill before, and that, in my mind, is the start of patient engagement."
Badlani says his experience as a high-deductible plan consumer gives him insight into new expectations for doctors. "Physicians have been able to be blind to [cost] because it's never part of the conversation with patients," he says. "As a physician I have the responsibility to answer [patients'] questions."
Intermountain is working on a transparency project that gives its physicians quality data, but Badlani would like to eventually create a dashboard that shows physicians how their decisions are affecting cost, which in turn, impacts their own reimbursement.
Patient Demand?
Even when physicians know where patients can find a better price for a follow-up service, it doesn't mean patients are ready to choose.
"It's remarkable," says Brian Yeaman, MD, chief medical informatics officer for Norman Physician Hospital Organization in Norman, Oklahoma. "In practice, I'll say, 'I need you to get an MRI, where do you want your MRI done?' They say, 'I don't care, wherever you want me to do it.' "
Brian Yeaman, MD
After Yeaman tells them price differences, patients still aren't ready to make a decision. "Patients still defer to the provider. As a family doctor, I see it nonstop."
The state of Massachusetts made price transparency for patients a top priority in 2014, requiring healthcare providers to give price information to inquiring patients within two business days. Prices varied for patients, depending on their insurance provided. But, so far, the law doesn't seem to have made patients or providers more aware of price, according to a report released Wednesday by The Pioneer Institute, a Boston-based public policy research organization.
To gauge how well healthcare providers were able to respond to patients' price requests, Pioneer called 32 providers (22 hospitals, 10 free-standing clinics), and asked for the price of an MRI for a left knee with no contrast.
"We chose an MRI because it is such a common procedure," states the report.
All but one hospital was able to provide the price for, but the length of time varied from 10 minutes to six days (average response time was two to four days), and most providers seemed caught off guard by the request.
Data Transparency for Physicians
Price transparency for patients is not well developed, yet, but the move toward transparency is necessary for population health, say healthcare leaders. That's because doctors, who are on the frontlines of care, need to be armed with quality data on themselves and post-acute providers to manage patients' health.
Some organizations share HCAHPS scores or patient experience measures with physicians. It's time to bring doctors into the conversation about other quality indicators, too, which, inevitably could include price. That kind of transparency is transformational, but it's also a tough culture change that requires looking beyond the walls of a hospital or clinic.
"Our medical groups are much more advanced," says Ken Lawonn, senior vice president and chief information officer at Sharp HealthCare, the San Diego–based integrated healthcare system with seven hospitals, two medical groups, and a health plan.
"But the hospitals are seen as the center of attention, and [they] don't want to give up reimbursement and patient volume. If we're going to get at real population health, we've got to get away from the silos. The key is how we align incentives."
Incentivizing physicians for the quality of care provided instead of the quantity of care provided is tricky, too. Some groups are increasing the amount of compensation tied to quality, but not many have gone the way of Cleveland Clinic, with its straight salary model.
The point is not lost on Badlani, who says that physicians are not likely to change their behavior without major changes.
"We talk about shifting from volume to value, but our physician contracts are fee-based," he says. "We may tell them, show them all the data, but the message we send every two weeks in their paycheck is 'You are appreciated based on the number of patients you see.' You can say we have some quality aspects to the contract, but to me, that's like putting lipstick on a pig. Until we turn our physician contracts into truly value-based contracts, little will change."
Another major change that needs to happen is physicians giving up some control over their patient panels, and allowing other mid-level providers to be part of the care team.
"Changing the work environment, and making sure every person is working at the top of his or her license is going to be key," says Assaad Sayah, MD, chief medical officer of Cambridge Health Alliance, a health system with three hospitals, 15 primary care practices, and operator of the Cambridge Public Health Department.
"When doctors are conducting the orchestra, and not playing every single instrument… that's when they'll be efficient and not pushed toward an RVU productivity model. They'll be pushed toward to the total care quality of the panel that they're managing."
It's time for GI practices to step out of the procedure-heavy comfort zone to prepare for value-based reimbursement and an aging population.
This article appears in the June 2015 issue of HealthLeaders magazine.
When Katie Couric underwent a colonoscopy on live television in 2000 as host of the Today show, she not only heightened awareness of the important role colonoscopies play in detecting colon cancer, but she actually boosted the rate of colonoscopies among men and women. Jay Monahan, Couric's husband, died from colon cancer at age 42, and the experience led to Couric's efforts to raise awareness about screening for the disease. The strategy worked and subsequently ushered in a boon to GI practices.
While there are other less-invasive screening tests available for colon cancer, such as the fecal occult blood test (FOBT) or fecal immunochemical test (FIT), which can be done at home annually, colonoscopies are regarded as the gold standard and are the most commonly used screening test to detect polyps that can turn into colon cancer.
"Gastroenterology started gaining traction because of the volumes from the 'Couric effect,' " says Yousif A-Rahim, MD, PhD, chief medical officer for Nashville-based Covenant Surgical Partners, owner and operator of 28 ambulatory surgical centers, most of which are GI-focused, across the country. "We've enjoyed a relatively sanguine era since 2000."
The AMA elects a new president, supports state efforts to remove personal and religious preference exemptions for immunizations, and seeks a hardship exemption for doctors who have problems transitioning to the ICD-10 coding system.
The American Medical Association wrapped up its annual meeting of its House of Delegates this week in Chicago, having elected a new president, and weighed in on ICD-10, vaccine exemptions, workplace violence against healthcare providers, and behavioral health, among other topics.
While the AMA doesn't make federal policy, the resolutions adopted by its House of Delegates wield considerable influence over Congress, which views the AMA as the primary voice of physicians in the US.
New Leadership
The AMA this week officially elected its youngest president in 160 years, Steven Stack, MD, a 43-year-old emergency physician from Lexington, KY. He takes over from outgoing AMA President Robert Wah, MD.
Stack breaks with tradition another way, by becoming the AMA's first emergency physician president. He previously held positions on various AMA committees, including an elected post on the AMA Board of Trustees in 2006.
In other voting, Andrew W. Gurman, MD, an orthopaedic hand surgeon from Hollidaysburg, PA, was elected president-elect of the body. He is to assume the office of president in June 2016.
An ICD-10 Grace Period
One of the AMA's top issues is its opposition to the federal government's implementation schedule for ICD-10. In Chicago, AMA members voted in favor of asking for a two-year grace period from penalties that could occur because of ICD-10 implementation. The AMA's policy asks for a hardship exemption for doctors who had problems transitioning to the new coding system.
Hospitals and physician practices are just a few months away from the October 1 deadline to transition to ICD-10, and there have been complaints about the administrative burden all along the way.
The deadline has already been extended twice. At the opening session of this year's meeting, outgoing AMA President Wah told audience members that the acceptance rate of Medicare claims would fall to 81% based on early tests of the new codes.
During his term as AMA president, Wah emphasized how the sloppy implementation of various CMS programs contributed to physician burnout telling me last year that programs such as Meaningful Use, electronic prescribing, and physician quality reporting are good ideas individually, but that the different schedules, phases, and rounds of incentives and penalties present a big problem for physicians.
"The bottom line is that ICD-10 will significantly overwhelm physician practices with a 400% increase in the number of codes physicians must use for diagnosis, which will take time away from the valuable one-on-one patient-physician interface that is the hallmark of taking the best care of patients," said Russell Kridel, MD, an AMA board member, in a statement released to the media.
Robert Wah, MD
A Call for Fewer Vaccination Exemptions
One of the highest profile policies the AMA adopted at this year's annual meeting was aimed at parents who do not vaccinate their children because of religious or personal preferences. The AMA voted to support state efforts to remove personal and religious preferenceexemptions for immunization.
"When people are immunized, they also help prevent the spread of disease to others… protecting community health in today's mobile society requires that policymakers not permit individuals from opting out of immunization solely as a matter of personal preference or convenience," said Patrice A. Harris, MD, AMA board member, in a statement.
The AMA's new policy states that vaccinations exemptions that should be granted only when medically necessary.
Earlier this year, approximately 173 people from 21 states and Washington, DC, became infected with measles, a disease that can be deadly, especially to small children who can't be vaccinated because they are not old enough or because of a compromised immune system.
The Centers for Disease Control estimated the outbreak stemmed from an infected traveler who went to Disneyland, and was spread easily because of the low vaccination rates in some surrounding communities.
Integrating Behavioral Health & Primary Care
Some policies adopted by the AMA are meant to encourage a new way of practicing medicine, such as the policy supporting the integration of behavioral health and primary care in order to improve access and outcomes for patients with mental health needs.
This is a subject I have written about extensively because behavioral health needs of patients are increasing while resources to take of them are decreasing.
The AMA's policy encourages commercial payers as well as Medicaid agencies to reimburse healthcare providers for primary care and behavioral health services that are delivered on the same day. Medicare has extended its behavioral health reimbursement somewhat, but it is still far away from covering the costs of treating patients with a behavioral health need.
While the AMA's policy cites cost as a reason to improve the integration of these two services, one barrier that often exists has nothing to do with cost, but everything to do with time.
Primary care providers do not feel equipped to handle the mental health needs of their patients. They want to help their patients, but don't have the resources—whether it is time or expertise or even a referring physician—to send their patients to for additional services, so instead of asking, the need goes undetected and exacerbated.
Workplace Violence
In response to violent incidents in care settings, the AMA voted in support of a study on the matter. The vote came less than six months after Michael Davidson, MD, was shot and killed at Boston'sBrigham and Women's Hospital. His assailant's family believes the gunman held Davidson responsible for the death of their mother, who had been his patient.
"Given that there are currently no clear interventions proposed to ensure a safer and more secure environment for healthcare providers, the AMA is committed to taking the necessary steps to help shed light on the various protocols, procedures, and mechanisms that can be put in place to do so," said AMA Board Chair Stephen R. Permut, MD, JD, in a media statement.
Visit AMA 2015 Annual Meeting for a complete list of the AMA's new policy statements, as well as video of the speeches delivered by AMA leaders.
Data limitations don't give an accurate picture of what Medicare reimbursement really means for physicians. But patients are increasingly aware of healthcare costs, and physicians should not shy away from a conversation.
The report released this week by the Centers for Medicare and Medicaid Services detailing that over 950,000 providers were paid $90 billion for medical services they provided to Medicare beneficiaries in 2013 has spawned sensational headlines about Medicare's millionaire doctors. The headlines aren't wrong, but it's a small group of physicians that are garnering the attention of many. To prevent an inaccurate narrative, doctors may need to prepare for patients' questions.
This is the second time CMS has released physician-specific data for Medicare payments in an effort be more transparent. In a prepared statement, American Medical Association President Robert Wah, MD, commended CMS for its effort, but criticized the agency for giving so little context to what the data means for patients.
"Specifically, the data released today do not provide actionable information on the quality of care that patients and physicians can use to make any meaningful conclusions … [or] enough context to prevent the types of inaccuracies, misinterpretations, and false assertions that occurred the last time the administration released Medicare Part B claims data."
It's true that the data has many limitations. For one, there is no information that gauges quality. It also shows information only on Medicare services. Depending on the payer mix of a physician office, Medicare beneficiaries could be a minority or majority. Geographic variation in payment amounts isn't accounted for.
Despite the criticism and the limits of the data, however, CMS's broad conclusions offer some insight into patient patterns. For example, the average number of office visits was six per enrolled Medicare beneficiary. States with the highest utilization rates include Texas, Florida, New York, and New Jersey.
One major improvement in the report is that drug reimbursements are separated out from physician services. That was not the case when data for 2012 was released to the public, which falsely inflated medical services reimbursements for some specialties.
Do patients care?
Consumers are demanding more price transparency for medical services. Does this report give them that information? Not really, says Anders Gilberg, senior vice president of government affairs for Medical Group Management Association (MGMA), the national organization that represents 33,000 practice administrators who are part of 18,000 healthcare organizations.
"The value of these data to Medicare patients is indirect at best," Gilberg told me. "Unlike private health plans, physicians are paid by Medicare under a fully transparent fixed Medicare fee schedule that anyone can look up on the Internet. There is little relevance to Medicare beneficiaries between physician charges and actual Medicare payment rates, especially with the additional widespread use of Medigap plans. The information can be misleading since using data on the frequency of procedures from any single payer provides a small snapshot into a physician's practice and is not a proxy for quality."
The datasets limitations are explained by CMS, but I think the only people who read the fine print are physicians, journalists, and data crunchers looking for trends.
"I have not found the CMS data interesting to patients," says Thomas Bat, MD, CEO and founder of North Atlanta Primary Care, who adds that patients are much more likely to complain about the rate hikes from their insurance company. "I find it interesting, as do physician leaders, but the rank and file do not."
One aspect of the report that caught Bat's attention is the reimbursement for specialty care in 2013.
"Last year's statistics showed that joint replacement consumed a greater amount than all of the primary care in the U.S.," Bat told me. "Primary care consumed less than 5% of the Medicare budget. I look forward to seeing the breakdown this year again."
Thomas Bat, MD
Still, physicians should expect some patients to raise questions about the report, says Andrew Ziskind, MD, managing director of clinical solutions at Huron Consulting.
"None of these numbers have to imply a physician is doing anything wrong," says Ziskind. "But it does require a higher level of explanation. Physicians should look at the information and consider how to communicate with patients in a way that is meaningful, relatable, and timely."
The AMA went to the trouble to issue guidelines on how physicians should respond when patients question them about the Medicare payment data. Most of the suggestions point to physicians clarifying for patients what the data does not say about them or their practice.
For example, physicians can remind patients that the data doesn't include information on the quality of care received. It could also be helpful to tell patients that other healthcare providers can file Medicare claims under a physician's Medicare identifier, such as residents, physician assistants, and nurse practitioners.
Cost as a catalyst
The CMS report could be a springboard to conversations among physicians, leaders, and healthcare staff about how to answer patient questions about cost, which physicians are increasingly fielding.
"Conversations about out-of-pocket costs are being driven by patients," says Ziskind.
The CMS report is not an accurate reflection of what it costs a physician to provide medical services, and it's important to point that out to inquiring patients, if they ask.
The CMS report created the data from Part B claims that were submitted for reimbursement in 2013 by physicians, ambulatory surgical centers, labs, and ambulance providers. If a provider had 10 or fewer Medicare beneficiaries for a particular service, the data was not used. CMS also released payment information on the 100 most common hospital stays as well as some outpatient procedures at hospitals.
The CMS payment report has its limits, but if it generates publicity around healthcare costs, then physicians should not shy away.
A physicians practice learns important lessons about its referral and patient care patterns from a project that measures cost and resource data—and lets physician leaders see the reports.
When Portland, OR-based Family Medical Group Northeast found out that it had a high rate of patients showing up in local emergency departments because of behavioral health issues in 2013, leaders at the practice were confounded.
The primary care clinic is a Tier 3 Primary Care Home, a state designation that is similar to but separate from the NCQA's patient-centered medical home initiative, and has worked hard to coordinate care for its patients across multiple settings.
"It took us a couple of times before we said, 'What's going on?' " says Lisa Kranz, practice administrator for Family Medical Group Northeast.
Kranz was able to look at the practice's referral patterns, not only to area emergency departments, but also to specialists, because of a cost and utilization report made available to them and other healthcare providers by the Oregon Health Care Quality Corporation, Q Corp. is a Regional Health Improvement Collaborative (RHIC) that is part of a pilot project headed up by the Network for Regional Healthcare Improvement (NRHI) that measures the total cost of care. Kranz is on the cost of care steering committee at Q Corp.
Lisa Kranz
"One of our aims with this project was to not only measure total cost, but also resource utilization," says Elizabeth Mitchell, President and CEO of NRHI. "We wanted to make sure groups had information about cost, and that they can see what is being driven by price, [and] what is being driven by utilization."
The main driver of Family Medical Group Northeast's high rates of behavioral health visits to the ED, says Kranz, was ultimately two-pronged. Physicians were not comfortable treating depression or other behavioral health issues that came up during a primary care visit because they didn't have the resources to do so.
And, there were no appointments available for patients at area behavioral health providers. "We sent them to the ER, which is a bad way of triaging, but it was the only thing we had in place," says Kranz. "Now, we have an agreement with a behavioral health provider who has agreed to take our patients within a week, and they can assess emergencies over the phone."
Kranz says physicians are also now getting trained on using the PHQ-9, a depression screening tool. She credits the total cost of care report as helping the practice improve the way it treats patients with a behavioral health need.
"As a primary care provider, we refer patients [to other providers] all the time, and we have no idea what cost is like," says Kranz. "Now that we are finally getting numbers, conversations are starting among physicians. They're asking, 'Are we doing the right thing?' "
Though the cost of care pilot program began prior to RWJF's ambitious initiative to build a culture of health, Tara Oakman, senior program officer at RWJF says giving healthcare providers better and more transparent access to the cost of the care they are providing fits into the framework of the organization's broader goal.
"We want information to be useful at multiple levels: for consumers, provides, payers, and communities," she says.
The pilot just received another $1.9 million from RWJF for an additional 18 months, and Mitchell says it will expand the project to include three additional RHICs that haven't yet been named.
The method NRHI uses to calculate the cost of care at sites that are part of the participating RHICS is called Total Cost of Care (TCOC). It was developed by HealthPartners, the integrated health system in Bloomington, Minnesota, that includes seven hospitals, dozens of primary care clinics and urgent care centers, and a health plan. The TCOC was endorsed by the National Quality Forum as a validated measure of healthcare affordability in 2012.
The TCOC methodology uses administrative claims data to calculate a cost index and resource usage index. It's a simplistic explanation of the complex algorithm HealthPartners made public for other organizations to use, but essentially, the two indices are used together to give practices a more complete view of the care their patients are receiving.
For example, at Family Medical Group Northeast, Kranz says that all services its patients used were attributed to a primary care physician at the practice. Any time a patient visited an outpatient site, or an emergency department or had a medication order, that claim data was rolled up into a cost index that showed individual physicians and practices how they compared to their peers, both on costs paid by the payer, and resources utilized.
Cost Transparency
"It's something we never had before," says Kranz. "We never saw what the costs were when a patient went to another provider."
Mitchell echoes Kranz's statement, and says it's a problem because physician groups can't make meaningful improvement toward costs in a vacuum.
"Physician groups rarely have this information," says Mitchell. "We hear from physicians that they want and need this information to be effective, especially as they take on risk, but it's not being made available by payers."
RHICs such as Q Corp. are in unique position because they are neutral third parties that bring together multiple stakeholders such as payers, providers, purchases, and consumers to start discussions about sharing claims data that can create pathways that will lead to improved cost, quality, and outcomes.
"All of the regions that participated had not only earned the trust and/or the authority to receive this data, but have demonstrated the ability to manage it responsibly," says Mitchell.
Adding Medicare Data
The next phase of the project is integrating Medicare data into claims databases. NRHI is made up of more than 30 RHICs, and 10 of them are qualified entities (QE), which means they are certified by CMS to receive Medicare claims data in order to aggregate it with commercial claims to get a more accurate view of cost. For some, that is the missing piece, says Mitchell.
"It's going to be difficult," says Mitchell. "But we have 10 of the 12 qualified entities, so they are already doing that as part of their day-to-day work."
Q Corp. is already one of the QEs, which was able to provide Medicare data in its reporting that helped Family Medical Group Northeast improve its referral pattern and cost of care for behavioral health. Kranz says 18% of its patients are on Medicare, and 2% are on Medicaid. The remainder rely on commercial health insurance.
"In the past, we were moving the quality measure up without looking at cost," says Kranz. "These reports have emphasized opportunities for us to look at our processes."
Improving patient flow through a busy emergency department does not have to be as expensive or as complicated as the cases that come through the door.
This article first appeared in the May 2015 issue of HealthLeaders magazine.
The effective and efficient triage of patients is key to the flow of an emergency department. Not only for practical reasons but also because a new survey measuring patient satisfaction in the ED is on the horizon. ED-CAHPS—similar to HCAHPS, the survey that allows patients postdischarge to rate hospitals on communication, noise level, and other factors—is in development now.
Providers originally expected the Centers for Medicare & Medicaid Services to begin using ED-CAHPS this year, but delays have pushed it back to 2016. Still, hospitals and health systems that have made patient experience a priority are not holding back on preparing for ED-CAHPS.
But surveys are not the only driver, nor even the main driver, of organizations' repeated attempts to reorganize processes for better throughput. When EDs are crowded with patients who can be treated elsewhere, it prevents patients with acute needs from being seen quickly, which can impact cost and quality.
The chief physician officer of a five-hospital system explains how she allayed the concerns of skeptical physicians after the organization partnered with a virtual physician service provider.
MultiCare Health System, the Tacoma, Washington–based nonprofit with five hospitals, numerous outpatient clinics, and more than 10,000 employees, is not new to offering its patients access to virtual care. It has well-developed telemedicine initiatives in genetic counseling, obstetrics, stroke, and ICU.
Instead of leveraging its experience to expand into virtual visits for patients needing a primary care doctor, however, MultiCare executives have decided to outsource the task.
Despite its technological expertise (MultiCare hospitals and ambulatory clinics recently won Stage 7 HIMSS awards), the system is partnering with San Francisco-based Doctor on Demand, a virtual physician service provider that gives patients access to a doctor via smartphone, tablet, or computer.
The service is meant for patients with common ailments such as colds, sore throats, eye infections, rashes, and the like; it is not intended for patients with chronic conditions or cancer. The cost is just $40 per virtual visit and the virtual physicians can prescribe most medications.
"The reason [for partnering] is speed to market," says Claire Spain-Remy, MD, chief physician officer at MultiCare. "It takes a while to build the physician population. They have experience, and we know patients want it."
Claire Spain-Remy, MD
The drive to satisfy consumer demand for virtual physician visits is accelerating at a quick pace. In addition to MultiCare's move, UnitedHealthcare recently announced that it will cover telemedicine visits for most of its members by next year.
As the nation's largest commercial health insurer, UnitedHealthcare often sets the tone for coverage decisions by other health plans. That means hospitals, health systems, and physician practices that are absent in this space now will need to start considering the implications of offering in-person visits only.
Spain-Remy says MultiCare was "constantly" thinking about expanding its telemedicine services into its primary care settings, and the initial discussions were about doing it themselves. Ultimately, she says, a partnership accomplished MultiCare's main aim of rapidly giving its patients greater access to primary care services.
"To build something out, you have to develop technology, you have to make sure you can grow clinical staff, and manage it, as well," she says. "If you have a willing partner who can do that, [you can] get to market in a short period."
Physicians are Skeptics
Selling MultiCare's physicians on the idea that their patients would be getting care from someone other than them was greeted with uncertainty. Spain-Remy says she expected a natural amount of skepticism because "it always happens with new technology."
So to get physicians on board, she made sure that MultiCare's standard of care protocols would be followed. For example, MultiCare physicians do not want patients with viral colds treated with antibiotics because that's not the care pathway MultiCare follows. "We made sure that they [Doctor on Demand] complied with our standards to avoid the patient shopping around," says Spain-Remy.
MultiCare's contract with Doctor on Demand is for three years. The health system will measure the company's effectiveness by looking at how many patients were referred elsewhere, the amount of time before a patient is seen, overall satisfaction, and quality outcomes. Interestingly, Spain-Remy says MultiCare will not measure the virtual care visits against its telemedicine program metrics.
"We are measuring them against what we think is important for patient access," she says. "We are looking at number of patients served and monitoring the quality of care."
Fad or Future?
The promise of telemedicine raises many questions, though a big one—coverage by insurers—has been answered with UnitedHealthcare's decision. The remaining unknowns center on coordination of care and patient demand. Will virtual visits replace the doc-in-the box option made popular by retail drugstores? Is it a passing fad that, once the novelty has worn off, will send patients back to physicians' waiting rooms?
Whatever the prevailing opinion is in doctors' offices now, healthcare systems are ready to invest in telemedicine. In the 2015 HealthLeaders Media Industry Survey, 56% of respondents said they believe telemedicine is a strategy to reach future financial targets and said that such an initiative requires a major investment.
For the patients with very limited access to care, such as the 115,826 Texans who live in counties with no doctors, virtual visits may be not only a solution to the shortage, but the solution.
An increase in emergency room visits doesn't mean a healthcare system is failing. Rather, policy makers are focused on the wrong thing, says the American College of Emergency Physicians.
A report from the American College of Emergency Physicians disputes the need to focus on reducing emergency department visits. A short online survey that captured the opinions of 2,009 emergency physicians (a 9% response rate of its membership) showed that ED physicians had seen increases in ED traffic over last year.
The sample size of the survey is small, but it reflects the reality of rising ED rates across the country.
Atlanta-based Grady Memorial Hospital,part of Grady Health System and one of the largest public health hospitals in the country, had a record number of 126,000 ED visits in 2013. The hospital is one of the largest public health hospitals in the country.
"Overall volume has gone up," says Hany Atallah, MD, chief of emergency medicine at Grady, noting that Grady's nearby walk-in clinic, which is within walking distance to the hospital's ED, has helped offload patients who don't have a true emergency. "We explain they'll get faster care," he says.
The urgent care clinic opened last year to coincide with the expected increase in patient volumes due to more people having access to health insurance through health insurance exchanges. The fact that the urgent care clinic hasn't made a significant dent in Grady's ED traffic is also indicated in ACEP's survey.
Part of the reason that retail clinics and urgent care clinics may not be diverting ED traffic from large urban hospitals may be due to the fact that patients who use an ED for less acute needs are used to that particular care site.
Grady is trying to educate its patients, but for the 316,000 Georgians—and the 8 million who enrolled in health plans nationwide in 2014—navigating the healthcare system with insurance coverage is new. It's too high of an expectation to expect them to adopt new usage patterns, too.
Different Site, Same Story
Another Atlanta-area hospital that has seen its ED volume grow is WellStar Paulding Hospital, a 53-bed hospital (it will expand to a 112-bed hospital in 2016) that is part of the WellStar Health System, a nonprofit health system with five hospitals, seven urgent care centers, and a medical group practice.
Located in Hiram, GA, about 32 miles from Atlanta, Wellstar Paulding opened a new ED in 2014 that can accommodate 80,000 visits a year.
"We're tracking 70,000 now," says hospital president Mark Haney. "We expected we'd see 45,000 [patients] when we moved in [the first year]." Haney says the hospital has seen an increase in Medicare patients using its new ED.
"We saw a 40% increase in new patients, and we can surmise that we are so close to Atlanta that some of the patients decide to come here," he says. "It could also have to do with high deductible health plans."
To accommodate the unexpected spike, Haney says the hospital added nurses and readjusted the ED physician shifts. Grady is also planning a new emergency department. An additional 15,000 square feet of space will be ready by late next year.
Having two hospitals that are close to each other with similar ED facilities suggests that although ACEP's sample size for its survey is small, the results shouldn't be dismissed.
Implications for Patients
ED physicians work diligently to quickly attend to patients; however, a patient's experience in an emergent situation can color the rest of their stay if they're admitted to the hospital. Grady and WellStar Paulding are paying attention to the patient experience in their EDs. Grady is focusing on reducing its door-to-provider time, which is down to 98 minutes from 133 in 2013.
At Wellstar Paulding, they're aiming to see 75% of patients in under 180 minutes. As of February, they were making strides, seeing 10% of patients in under 90 minutes. The hospital received three stars from CMS for patient satisfaction. Grady received two stars. The best rating a hospital can get is five stars.
While patient satisfaction and experience in the ED isn't formally being measured by CMS yet, it is an important component of the total hospital experience, and an important site that patients will continue to demand care from, and can't be ignored, says Angela Gardner, MD, FACEP, past president of ACEP, and an associate professor of emergency medicine at UT Southwestern Medical Center in Dallas. She believes the survey results ultimately show that diverting ED patient is ineffective.
The Right Care at the Right Time
"Spending on emergency care only accounts for 2% of the federal health care budget," she says. "Eliminating unnecessary visits as defined by policy makers, would only save pennies. Because people may not be able to determine whether something is an emergency or not without medical evaluation, potentially very sick people may be denied access to care."
The concern over treating patients appropriately is very real, says Haney. WellStar Health System has a total of seven urgent care clinics, and there are plans to add more, but the level of its ED patients' acuity is growing, which those types of clinics can't handle.
"Our patients need to get to the right place," he says.
According to HealthLeaders Media research, an increasing number of health systems and physicians enter into clinical integration arrangements to gain expertise in population health management. Leaders who are developing clinical integration networks say the strategy is helping align physicians, metrics, and goals of care, but planning on the front end is crucial.
This article first appeared in the April 2015 issue of HealthLeaders magazine.
Clinical integration allows independent/private practice and employed physicians alike to jointly develop clinical initiatives with hospitals or health systems, aiming at patient care that's higher quality, more efficient, and less costly.
These agreements also allow providers and care partners to formally align and collaborate on the critical requirements of care coordination: evaluation and concrete improvement of clinical performance, reduction of unnecessary service utilization, and management and support of high-cost and high-risk patients.
