HOW TO ASSESS AND MAXIMIZE YOUR PRACTICE S VALUE

Transcription

1 HOW TO ASSESS AND MAXIMIZE YOUR PRACTICE S VALUE RICHARD LANDER, MD, FAAP Conflict of Interest Resources in Physician s Management Services Consultant to Pediatric Management Institute 1

2 Why do this? What are the benefits? The most important reason to do this is because the entire way we receive payments for our services is beginning to change. We are moving away from payments based on the number of patients (basically quantity) seen to a value based system (quality). Stating this differently we will no longer be paid on the number of patients seen but on how well we manage their health issues. This will include preventing illness and injury, minimizing the side affects of the illness or injury, how effectively we prevent relapses or repeat injuries and how well we follow guidelines on evidence based medicine. 2

3 In my opinion this cannot be cut and dry since there are factors out of our control which will influence our outcomes. Some of the factors out of our control are: patient compliance because of financial circumstances geographical movement lack of comprehension on the importance of the issues 3

4 Factors out of our control Insurance influenced medications and their tiers prior authorizations lack of understanding of Pediatric issues Now that we have seen some of the things we cannot control let s look at what we can control pharmacy costs x-ray utilization emergency room, surgicenter usage referral rates hospitalization admission rates 4

5 Pharmacy do you always write no substitution do you write for antibiotics like they are h2o do you check the MCO formulary first X-ray utilization which comes first the examination or x-ray if you hear the rales, why the x-ray x-ray or ct or mri or ultrasound following evidence-based medicine? 5

6 ER, Urgicenter visits have you educated your patients about this availability of office hours evening appts, weekend appts, walk-in hours, patient self scheduling Pt followup when not seen in your office call pt and ask why were they seen elsewhere when you were in the office if seen somewhere after-hours why didn t they call you first for advice do they need a followup appt in your office for strep throat, otitis media, asthma, pneumonia, severe gastroenteritis 6

7 How do you manage your pts with ADHD evaluate in office (Connor, Vanderbilt) or refer out medicate or he/she will grow out of it followup-monthly, q3m, q6m, yearly How do you manage your pt s asthma do you treat them or refer them out do you order pulmonary functioning testing what medications do you initiate at the first visit do you bring your asthmatics back for followup 7

8 what % of your chronic asthmatics are on inhaled steroids how many refills on B agonists and inhaled steroids do your asthmatics obtain per year what % of your asthmatics seek care in an er or urgicenter and how many times per year what % of your patients with pharyngitis who received an antibiotic had a strep test what % of these patients had a positive test 8

9 what % of your patients have a bmi performed and noted in their chart what % of those patients with a high bmi received an action plan-diet, exercise, nutritional counseling what % of those patients were brought back for reevaluation Well care what % of your 2y/o are fully immunized for those that are not fully immunized why what % of your adolescents have the required/suggested vaccinations 9

10 What % of your total population is properly immunized do you have protocols in place to catch up the under immunized use of lost opportunities in the office recall- , text, phone, snail mail Well care what % of patients over the age of 2y/o have annual well visits broken down by age what % of patients have age appropriate screenings-vision, hearing, mental health and developmental 10

11 Bolstering well care visits by scheduling the next well visit during the current well visit scheduling the overdue well visit during a sick visit having staff call (more effective than , text, snail mail) patients overdue for well visits Some of the information you are seeking can be supplied by the insurers you have contracted with to deliver services to patients The insurers are already comparing you to your peers on some of the issues we have discussed here 11

12 The insurers will talk to you about metrics Dr. your vaccination rate is currently 70% and we want that rate to be 90% next year if what they are asking for is unrealistic either 1. go for a lower number 2. ask to do a % increase, i.e. 10% above this year s 70% or 3. just say no What happens if you fall short of the set metric if you meet or exceed their other desired metrics ask the insurers to take that into consideration when determining $$$ for you if as we first talked about earlier you don't reach the desired metric because of factors outside your control and you can prove it, fight hard not to be penalized 12

13 Are the insurers metrics correct? who checks your roster-you or an employee are the pts listed really in your practice are all your pts are the right roster if someone was on the roster last month and not now, do you call them to verify Do you know which of the patients on your roster picked you or were auto-populated Do you keep non-compliant patients or do you have them removed from your roster Did you know that the insurers think that a good attribution rate is 60%! 13

14 If you already outperform your peers or if after you have instituted changes in your performances you then outperform your peers, show this to your payers. Let them see the quality of care you provide to your patients and the cost savings you provide to the payers and then ask for a % of those cost savings be shared with you SUMMARY Participants have learned to utilize quality initiatives to enhance their clinical performances Participants have learned to identify clinical parameters to enhance their standings with managed care organizations Best next steps: Review current practice guidelines and choose those that need to be enhanced 14