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For other articles and previous issues click here. September 20, 2004 Applying Managed
Care Principles Resident physicians entering the healthcare arena should be equipped with the proper business acumen to make a difference when it comes to delivering care. In 1998, the Michigan Department of Community Health redirected $10 million from the Medicaid program and awarded it to universities affiliated with medical schools and residency programs in $1 million increments. The expressed purpose of the Graduate Medical Education Innovations Project was to upgrade and update medical school curricula in the areas of business practice. The expected outcome of this objective was to better prepare graduating physicians and healthcare workers on the realities of treating patients in the 21st century. The state recognized that physicians could no longer go into healthcare with purely altruistic objectives. Physicians would have to know reimbursement models, codes and fee schedules, and data profiles of patients, communities, and themselves if they were to survive in private and public practice. The knowledge domains of the managed care curricula were defined to be the following: • Health Systems Finance and Economics • Evidence-Based Medicine • Access to Care • Community-Oriented Patient Care • Management of Information • Quality of Care • Ethics • Patient and Provider Relationships • Leadership The academic institutions that were awarded this money were expected to develop learning objectives for these domains and incorporate them into existing courses. The Michigan Department of Community Health was not prescriptive in defining the details of the curriculum. It allowed each institution to develop what was thought appropriate for its location, patient type, and physician student type. Wayne State University, in collaboration with the Detroit Medical Center and The Wellness Plan, was one of the institutions that received a grant. These collective institutions decided to focus the curriculum on the primary care residency programs of family practice, OB/GYN, pediatrics, and internal medicine. A schedule of lectures, site visits, and hands-on applications were identified to apply the knowledge domains. Different sites and applications were constantly identified to make student doctors aware of current information and issues. Since the inception of this curriculum, several classes have graduated. How should these individuals be applying this awareness to their current employment situations? When will healthcare delivery improve? This article discusses five major business practice points that new provider graduates should be applying as they enter the healthcare arena. Know Your Place of Employment • What is the organization’s global structure? Is it a systemwide organization with multiple hospitals and facilities or a single entity? • What are the organizational structures of the administrative, clinical, and financial units? • With whom is the organization affiliated (eg, academic institutions)? How do these affiliations impact decision making and delivery of healthcare? • What is the organization’s mission? • What is the breakdown of patients according to age, gender, race, zip code distribution, diagnosis, procedure distribution, and other pertinent quality indicators? • What is the healthcare system’s case mix index? • What is the insurance breakdown of the patients served (eg, the percentage of Medicare, Medicare and Supplemental, Medicaid, commercial carriers, and managed care plans)? • What reimbursement model(s) are used to effect payment of delivered services? • What physician and facility fee schedules are used for reimbursing coded procedures? • Is the facility accredited? If yes, by what organization? • How does the accreditation status impact
reimbursement? • What were the results of the last accreditation survey? Do any deficiencies directly affect clinical practice? If yes, how? • What is the facility’s full-time equivalent employee component in its administrative, clinical, and financial units? • What outsource contracts exist in the administrative, clinical, and financial units? Are they considered temporary or permanent arrangements? • What compensation models, including bonuses, are used for the clinical staff? What are the formulas used in calculating these models? • What requirements must be met to ensure that providers are registered and receiving credit for all services delivered (eg, National Provider Identification process)? The answers to these and other questions provide clues to the organization’s strengths and weaknesses. Providers should be able to take this information and determine whether or not their career goals and philosophies are consistent with the organization. If the information suggests that this healthcare system or practice is not a good match, the provider should identify the specific points that are not acceptable. Establish parameters that can be used to identify specific attributes to define organizations to affiliate, but be aware that there will never be a “perfect” organization. Know Your Information Systems
Evidence-Based Medicine At a recent women’s seminar, three OB/GYN physicians talked about premenopause and postmenopause. The audience asked many questions about current treatments and the relationships between hormone replacement therapy and its dual role as both cause and prevention of heart disease and different cancers. The interaction between the audience and physicians was equal to the banter that transpired between the physicians themselves. Three generations of physicians were present and each discussed how they interpret the data, the treatment patterns they noticed in their respective practices, and how they used the information in treating their patients. They applied data findings to age, race, and complexity indicators from their personal practices. It was apparent that each physician spent time in reviewing current literature to apply to his or her clinical practices. Management of Information • Know the information system used by your
organization: • Know the medical staff bylaw of your organization as it relates to documentation. Discuss the Evaluation and Management guidelines for Current Procedural Terminology (CPT) coding and these bylaws to ensure that documentation is complete, concise, and adequate. • Keep abreast of documentation and coding regulations transmitted from the Centers for Medicare & Medicaid Services and key insurance carriers. • Know key individuals within your information technology and HIM departments so you can receive both technical (hardware and software) and content-based assistance on a regular basis. Know Access-to-Care Issues and
Consumer Demographics In the last five years, there have been many healthcare closures and reorganizations. From this chaos, many creative forums have evolved to provide healthcare. • In 1998-1999, the Detroit Transportation Authority, in response to employees’ growing waistlines, asked providers to visit the bus terminals to educate, screen, and offer guidance on maintaining good health. • A community center in the vicinity of a major trauma facility noted an increase in gunshot accidents, motor vehicle accidents, and general violence. Leaders responded by inviting physicians to come and talk to youngsters about emergency department trauma. After-school educational and leisure classes were organized for youngsters. • Local churches set up a network of programs so the homeless could receive breakfast, lunch, dinner, and a daily shower by progressing from one parish to the next. Social, dental, and medical services were included on certain days. Job placement opportunities were also provided to identify individuals with skills and attributes that may transition people into more healthful and normal living situations. • A local school system is offering Arabic
and Russian language courses as electives. A middle school student
who already knows she wants to be an OB/GYN is taking Arabic to
better communicate with a patient base she thinks she will eventually
serve. • What kinds of programs are offered in the vicinity of your practice? • Why do they exist? • What types of patients do they attract? • What are the outcomes? • Is your practice involved in any of these nontraditional access-to-care programs? Should it be? • What access-to-care issues exist within your organization/practice? • What can be done to improve access to care? Know Your System’s Quality-of-Care
Programs As providers, it is not uncommon to receive report cards or quality profiles outlining medication use, adherence with cancer screens, and support for indicators defined by insurance companies. These profiles serve as a rudimentary reminder that the indicators flag outlier cases where something may not be in compliance with a clinical guideline or standard of practice. There are different medical staff committees that focus on prospective and retrospective review of cases against clinical indicators for diagnoses and treatment. Ask your quality assurance (QA) advisor the following: • What QA committees exist at your facility? • What is the purpose of each? • What monitors or indicators do they track? • How can you participate on these committees? • What kind of data is used to flag outliers? • What data profiles are used to make decisions about clinical care? • What recommendations have been forwarded to leadership committees for information or action? Additionally, ask the QA department to help you conduct a yearly study that includes broad indicators that apply to all aspects of managed care as well as those that both confirm proper treatment and flag areas where improvements may be made. Use these findings to refine processes, staff, and equipment. Know Patient Finance Indicators
• Develop a good rapport with your business office. Work on developing the chargemaster to your particular service line and visit at least quarterly for coding, documentation, billing, and legislative updates. • Request quarterly reports from the billing and accounts receivable (AR) managers so you know what was billed, how it was billed, and the reimbursement received. • Ask the AR manager for a report of rejections by type. Use this information to assist coders, billers, and AR technicians in optimizing the return rate. • Work with QA and HIM staff to monitor outcomes.
Profile improvements made in each area. Examples: • Sponsor education sessions that include coding, business, and clinical staff. This will increase everyone’s level of knowledge and hopefully increase revenue. In January, DecisionHealth’s Part B News sponsored a two-day seminar on the latest Medicare regulations and the financial aspect of delivering care. The program reinforced that legislative changes made to Medicare Part B have financial ramifications. Every year, decisions are made to increase relative weight values for some CPT codes and decrease them for others—which directly affects reimbursement. The program was filled with sessions on evaluating physician productivity, which requires looking not only at the revenue generated for performing services but also the cost in performing them. Presenters stressed the need for good data to evaluate profit and loss margins. They also emphasized the need to profile practices regularly so quality, financial, and access-to-care adjustments can be made more frequently. The Michigan Department of Community Health reallocated direct healthcare dollars to the curriculums teaching our future providers so business and clinical practice principles could be integrated. The next step for any medical school that has retooled its medical school and residency curricula by incorporating business practice objectives is to assess whether or not there has been any improvement in corresponding healthcare delivery indicators. Benchmarks of quality, administrative, and financial indicators are available through state health associations, peer-review organizations, and third-party payors. Data should be reviewed at a policy level to assess whether or not progress is being made in each indicator category. Collaboration between academic institutions and different healthcare agency types should continue in order to keep academic preparation current and progressive. — Barbara Bosler, MS, RHIA, is a Michigan-based consultant in business practice healthcare functions. |
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