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Medical practice action plan: Overcome regulation overload

Health care is experiencing a major overhaul, and practices face the brunt of the changes. Careful planning is needed to guide practices through it all.

By — Posted May 6, 2013

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As physician practices face myriad changes and government mandates, they are having a hard time believing they will ever get back to a feeling of stability.

“Everybody's really struggling with just the multiplicity of projects or initiatives that are on the table from the government, as well as their own internal IT strategies,” said Michele Mann, principal at the Falls Church, Va.-based technology consulting firm CSC.

The three big changes most practices are dealing with are the conversion to ICD-10, adopting electronic health records to qualify for the federal meaningful use incentive program, and changing to a new practice model such as an accountable care organization or patient-centered medical home. These are piled on top of projects physicians are likely to be fully entrenched in already, such as Medicare's physicians quality reporting system bonus program (which turns into payment penalties in 2015 if doctors don't start reporting quality data in 2013) and the electronic prescribing incentive program.

Many are wondering how they can implement all of these changes and still manage the day-to-day demands of running a practice. Practices could benefit from borrowing strategies used in patient care, said Andrew Ritcheson, PhD. He is senior program manager and consulting psychologist at Dynamics Research Corp., an Andover, Mass.-based management and business consulting firm to state and federal government agencies, including the Veterans Health Administration.

Physicians can view project management in the same way as diagnostic consulting — by “looking at problems in a kind of sequential process of assessment, formulation, treatment and follow-up,” Ritcheson said. “Many of the tools they need to thrive and survive are already under their noses. They're just not being used in that way.”

Assessment: Inventory what needs doing

One tool used in patient care that can help in project management is the status board, like what is used in hospital rooms. It can keep track of projects, important milestones, things to watch and who is in charge of what.

Setting a priority for those projects is harder. But experts say practices can employ several strategies, starting with combining some projects, deciding which has the most impact on a practice's finances and determining which projects can lay the foundation for others.

Many of the projects practices face have one thing in common: increased use of an EHR system, said Tom Murray, director of the EHR solutions group at the health care consulting firm Arcadia Solutions in Burlington, Mass. Many practices are using EHRs for the first time to capture data that are required for government incentive programs as well as for efforts to increase quality and reduce health spending.

Some of the same clinical quality measures that practices will report on in stage 2 of meaningful use also will be required as part of a practice's participation in an ACO. In another example of overlapping, Murray said, the patient engagement tools needed for stage 2 of meaningful use are the same tools needed to be a patient-centered medical home. Identifying these overlaps will allow practices to tackle two or more things at once.

Even if physicians aren't working toward ACO participation, they still should keep tabs on what might be required of them if they were to join one eventually. Knowing which measures they would need to report as an ACO partner could help practices determine what measures they want to focus on for meaningful use, or vice versa.

Practices also should check with their contracted payers for any incentive programs they may have, Murray said. If an insurer offers an incentive, there is likely some overlap between what is required for that program and government-sponsored incentives.

Identifying the overlaps also will help save practices in training time and costs, CSC's Mann said. If physicians are being trained to capture certain data points at the time of care for one program, when other programs go live later, there won't be a reason to retrain them three or four times, she said. Tying projects together also helps doctors and other clinicians see the big picture of why certain changes are being implemented.

Overlap is also a consideration in purchasing technology. Even though ICD-10 may appear to be more focused on the business and billing side, it will require having an EHR that can capture the ICD-10 codes. So as practices adopt or upgrade their EHRs for meaningful use, they should talk to vendors about their plans for the ICD-10 conversion to avoid a scramble to meet the deadline down the road.

Formulation: Develop a game plan

The first step in formulating a plan is identifying people in the practice who will lead each project.

In physician partnerships, there is always someone who has better business acumen than the other partners, said Gray Tuttle, principal of Rehmann Healthcare Management Advisors with headquarters in Saginaw, Mich. That person is counted on for a lot of business-related leadership within the practice. But when it comes to taking on major projects, physicians should play more of a guidance role than a hands-on leadership role, he said. Practices make money by having physicians treat patients. If a doctor is pulled away from treating patients to take on a project leadership role, “you make no money,” Tuttle said. That's why the role of project leader often falls to the practice manager.

“But in a practical situation, you can't lean on the same person for everything,” he said, because then he or she won't meet primary job responsibilities.

In small practices, the choices may be limited by staff size. Physicians may be more likely to assume a hands-on leadership role than in larger practices. But whatever the size of the practice, expertise and enthusiasm for the project are both important traits for a leader, consultants said.

Some projects, such as ICD-10 conversion, involve changes that will occur mostly on the billing side, while others, such as meaningful use, will affect the clinical side. With overlap, some leaders may be involved in multiple projects either as a leader or a committee member who helps with oversight.

Even though each project will have a point person, Ritcheson said, implementing it should be everyone's responsibility. Regular updates, perhaps through a status board hung in a prominent area in the practice, will help employees see the progress and keep them energized.

Treatment: Check projects off the list

Once leaders are identified, they will help prioritize the order in which projects are tackled. Prioritization will take into account non-negotiable deadlines as well as financial considerations for a practice.

Some government mandates come with a compliance deadline to either earn money or lose it. Therefore, practices should look at where they can make the most or stand to lose the most, Tuttle said. “Everything has a financial consideration.”

And just because a project doesn't have a government-mandated deadline doesn't mean it shouldn't have a practice-imposed finish date, experts said. Tuttle said he assumes most practices already participate in the voluntary physician quality reporting system programs to earn incentives, but if not, they should be. As practices adopt EHRs to meet meaningful use, he said, the cost to participate in PQRS no longer outweighs the benefit. Tuttle said it's now “low-hanging fruit” involving data collection and reporting that practices must do for other programs anyway, so they should set a deadline for themselves to get started.

Once the projects are separated according to deadline dates, practices must decide whether to tackle the hard tasks of each project first or gain early momentum by accomplishing easier tasks. Murray recommends knocking off whatever tasks will help lay a foundation for future ones.

Follow-up: Stay organized and on task

Change is the one thing that remains constant through all of the new programs and initiatives, said Dotty Bollinger, chief operating officer of the Laser Spine Institute, a national endoscopic spine surgery center chain. Therefore, it's very important for practices either to have someone in-house who will stay on top of everything or to partner with the right people who will help.

Bollinger said small practices may want to consider hiring a consultant who is knowledgeable about the compliance piece and will stay informed of the necessary changes. Practice managers also can network with others facing the same challenges. This may mean partnering with local hospitals, other practices or outside organizations. She said online networking groups also can help.

As practices navigate their way through regulation overload, Bollinger said, customer service always should remain the primary focus.

“My advice, even to small practices, is don't forget why you went to medical school. Don't forget what you love about being in that clinical room, interacting with that patient, and don't forget about patient-centered care,” she said. “Don't get so blindsided by the regulatory and payer environment that you forget what you were called to do, and that is to provide great care and great service to that consumer who is seeking out your help.”

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5-step checklist for individual projects

Health care consultant Gray Tuttle, principal of Rehmann Healthcare Management Advisors, uses a management action plan to help guide practices through the accomplishment of long-term and short-term goals. This road map is made up of a checklist of tasks and the target date for each. When items are completed or terminated, they are moved to a separate list. Checklist elements include:

  1. Selection: Choose and prioritize specific objectives from a universe of possibilities that can be accomplished with a specific time frame.
  2. Definition: Define the chosen objectives in terms that are specific and measurable. The objectives must be well defined so that it's clear when the project has been completed.
  3. Assignment: Assign a specific individual to supervise, complete and be fully accountable for the completion of the task.
  4. Scheduling: Give the project a deadline that is communicated to the accountable person, and gets that person's consent for the deadline.
  5. Review: Periodically review and evaluate each project at regular intervals between assignment and completion.

Source: Gray Tuttle, principal of Rehmann Healthcare Management Advisors

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Major changes confronting practices

Physician practices are facing a lot of changes due to government mandates and incentive programs aimed at improving the quality of care while reducing costs by eliminating waste and redundancy. Some programs can earn physicians more money, while others will cost them through penalties for noncompliance. Some of the programs:

  • Electronic prescribing incentive program: A federal program that encourages the use of electronic prescribing tools. It pays incentives for those who e-prescribe to Medicare beneficiaries. Payment adjustments went into effect in 2012 for those not e-prescribing.
  • ICD-10 conversion: By October 2014, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced with ICD-10 code sets. The change is required by everyone covered under the Health Insurance Portability and Accountability Act.
  • Meaningful use incentive programs: Physicians can earn up to $44,000 through Medicare and up to $63,750 through Medicaid for meeting requirements in the use of electronic health record systems. Medicare payment adjustments for noncompliance begin in 2015.
  • Physician quality reporting system: A federal reporting system that pays incentives to physicians to encourage the reporting of quality measures for Medicare services. Payment penalties will go into effect in 2015 for eligible physicians not participating by the end of 2013.
  • Practice/payment model changes: Many practices are changing models of care to be part of a group providing coordinated care to patient populations. Some models include accountable care organizations, patient-centered medical homes and Medicare shared savings plans.

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External links

Physicians quality reporting system, Centers for Medicare & Medicaid Services (link)

Electronic prescribing incentive program, CMS (link)

Meaningful use incentive program, CMS (link)

ICD-10 conversion, CMS (link)

Accountable care organizations, CMS (link)

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