Physician groups what goes wrong, how do we avoid it? Subtitle: Physicians, Change, and Maximizing Employed Physician Performance

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1 Physician groups what goes wrong, how do we avoid it? Subtitle: Physicians, Change, and Maximizing Employed Physician Performance Thomas Ferkovic Managing Partner SS&G Healthcare Chicago

2 Learning Objectives Identify the traits of high performing physician practices Identify the format that provides physicians most useful data to be successful Describe the KPIs that change physician behavior

3 In the historic words of our president. No longer will older Americans be denied the healing miracle of modern medicine. No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime so that they might enjoy dignity in their later years. No longer will young families see their own incomes, and their own hopes, eaten away simply because they are carrying out their deep moral obligations to their parents, and to their uncles, and their aunts.

4 Those were the words of President Lyndon B. Johnson at the signing of the Medicare Bill on July 30, The more things change, the more they stay the same

5 Health Reform 5

6 A compounding problem Has anything really changed with ACA? AMA Medicare and the Sustainable Growth Rate 6

7 Successful Physician - Health System Integration Group Formation for Leverage Developing Efficiency through best in class Operations Reducing Variation and managing care Impact on Cost,Quality, and Profitability Mission, Sites, Services Joint Negotiations w/ Payers and suppliers Access to Capital Shared Clinical Systems Share expertise Across business units Shared Operating Standards Rationalizing Care Sites and Delivery Triaging Patients Across sites Must Raise the Bar And Bend the Curve.. Degree of Business Integration

8 Why Not?????

9 Snapshot of your Peer Organizations Remember we are looking at $15,000,000 to $30,000,000 Companies!

10 Hospital Medical Group Growth Pattern

11 Investment per Physician MGMA($187,930) SS&G Benchmarks ($147,000) Worth it?

12 Corporate Overhead Overhead includes: Billing, corporate management, coding, finance and systems. Private practice physicians: < 8% of revenue Hospital Employed Physicians: 8-11% of revenue

13 Dakota Tribal Wisdom: When you discover you re riding a dead horse, the best strategy is to dismount. However in healthcare, we often try other strategies with dead horses.: -Author unknown. Modified by SS&G Healthcare

14 Dakota Tribal Wisdom: Healthcare 1. Buy a stronger whip. 2. Threaten the horse with termination. 3. Say things like, This is the way we have always ridden this horse. 4. Arrange to visit other sites to see how they ride dead horses. 5. Lower the standards so that dead horses can be included. 6. Appoint a tiger team to revive the dead horse. 7. Ride the dead horse outside the box. 8. Create a training session to increase our riding ability. 9. Name the dead horse Paradigm Shift and keep riding it. 10. Ride the dead horse smarter not harder. 11. Change the Dead Horse s compensation model. 12. Harness several dead horses together for increased speed. 13. Do a time management study to see if the lighter riders would improve productivity. 14. Call the dead horse a joint venture and let others ride it. 15. Purchase additional dead horses and call it an integrated health system. 16. Form a quality circle to find uses for dead horses. 17. Get the horse a Web site.

15 Evolving Healthcare Dynamics... How will this affect how we manage performance? What do we know? Continued downward pressure on reimbursement Significant expansion of Medicaid Physicians pay models not tied to actual cash Increased dependence of health systems on employed medical staff Continued focus on compliance is essential (CMS/OIG) Co-payments and deductibles are increasing and falling on providers to collect

16 Evolving Healthcare Dynamics... How will this affect how we manage performance? What don t we know? Timing and models of bundled payment Final form of ACOs Timing and specific impact of growth in health care entitlements Future regulatory and legislative actions

17 Reviewing how we got here... Where we came from understanding our strategy Maintaining an institutional memory... Is a challenge Crisis motivated decision making is often counter productive Avoiding past mistakes and missteps

18 Practice Comparison Hospital Owned All payers Payer Mix Private Practice Preferred payers All services Dynamic Enterprise Focus Growing Scope of Service Practice size Practice Focus Charity Care Optimized services ( profit margin) Stable (or stagnant) Internal Focus Minimal

19 Physician Performance Numbers are important but only a starting point... YTD Physician New Established Gross Net Total Operating Base Salary Specialty Visits Visits Charges Revenue Expense Margin Adjustment A FP 270 1,878 $ 406,672 $ 211,665 $ 336,912 ($125,247) ($135,469) B IM 116 2,865 $ 446,554 $ 254,049 $ 315,509 ($61,460) ($32,054) C FP.75fte 389 2,105 $ 452,519 $ 226,382 $ 311,911 ($85,529) ($103,870) D FP 386 3,113 $ 504,756 $ 258,978 $ 280,253 ($21,275) $12,291 E IM 149 2,297 $ 725,058 $ 396,252 $ 375,691 $20,561 $7,721 F IM 127 3,516 $ 967,148 $ 579,678 $ 511,554 $68,125 $13,295 G IM 42 1,731 $ 892,839 $ 487,951 $ 421,992 $65,959 $80,537 Region 1 Average Loss per Physician: $38,119 (45 doctors) Region 2 Average Loss per Physician: $92,673 (77 doctors)

20 Current Business Process KPIs in Hospitals Inpatient Mortality Rate CMS Core Measures Harm events per 1,000 days Readmission Rate Occupancy Rate Ave Length of stay Patient Satisfaction Total Operating Margin A/R days outstanding A/P days outstanding Claims Denial Rate Days cash on hand ETC., ETC. ETC.

21 What gets measured, gets done! For Patients: Lab Results Blood Pressure Why not for doctors?

22

23 heart monitor for workouts

24 Health System - FY2011 Perfomance Indicators Dr. Smith Site: Location X Specialty: Surgery - Vascular - Primary Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun YTD FY2011: Established Visits New Visits Consults Other Eval & Mgmt New Visits/Total % 3% 21% 25% 16% 17% 25% 14% 9% 21% 24% 0% 0% 19% Total Visits ,050 Medicine Procedures ,528 PathLab Procedures Radiology Procedures Surgery Procedures Total Procedures ,893 1,800 1,600 1,400 1,200 1, WRVUs Analysis Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun FY2011 FY2010 MGMA50 MGMA75 MGMA90 12 Month Rolling Average Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun YTD FY2011 FTEs #N/A #N/A 1.0 FY2011 Work RVUs 1, ,066 1, , ,353 1,198 #N/A #N/A 10,772 FY2010 Work RVUs , , , ,299 11, Month Rolling Average ,034 1,049 1,068 1,060 1,041 1,039 1,082 1,061 12,245 MGMA50 Benchmark ,972 MGMA75 Benchmark ,100 MGMA90 Benchmark 1,136 1,136 1,136 1,136 1,136 1,136 1,136 1,136 1,136 1,136 1,136 1,136 13,628 These percentiles were derived from MGMA 2010 report using 2009 Data Productivity Calculation: YTD Average wrvus per Procedure 2.77 YTD Average Procedures per Business Day 18 Next Percentile 90% YE wrvus at next percentile 13,628 Current YTD wrvus 10,772 YE wrvus for next percentile 2,856 Additional Procedures per FTE per Bus. Day 5.64 FY2011 wrvus MGMA Percentile 86% 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 - YTD WRVUs Analysis Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun FY2011 FY2010 MGMA50 MGMA75 MGMA90

25 Health System - FY2011 Perfomance Indicators Dr. Smith Current Period FTE 1.0 Specialty: Surgery - Vascular - Primary % % % % % % % % 0 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun AR Days AR Days - Specialty AR Days - Site AR %> 90 Days AR %> 90 Days - Specialty AR %> 90 Days - Site 0.00% AR Trending Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun AR Days #N/A #N/A AR Days - Specialty #N/A #N/A AR Days - Site #N/A #N/A AR %> 90 Days 45% 55% 54% 47% 63% 70% 37% 48% 38% 42% #N/A #N/A AR %> 90 Days - Specialty 50% 59% 54% 55% 57% 56% 22% 31% 30% 31% #N/A #N/A AR %> 90 Days - Site 50% 59% 54% 55% 57% 56% 22% 31% 30% 31% #N/A #N/A AR Days are calculated net of bad debt. AR % greater than 90 days includes bad debt. AR Aging: FY % 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% 0 to to to to to to AR Aging % AR Aging - Site % AR Aging - Specialty % AR Aging: FY to to to to to to Total AR Aging $ 88,711 $ 33,426 $ 24,825 $ 24,211 $ 9,125 $ 8,019 $ 67,191 $ 255,509 AR Aging % 34.72% 13.08% 9.72% 9.48% 3.57% 3.14% 26.30% % AR Aging - Site % 41.24% 17.81% 10.12% 9.24% 6.32% 4.71% 10.55% % AR Aging - Specialty % 41.24% 17.81% 10.12% 9.24% 6.32% 4.71% 10.55% %

26 Dr. Smith 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% New Visits Health System - FY2011 Perfomance Indicators Specialty: Surgery - Vascular - Primary New Visits Total Est Visits Total FY2011 0% 14% 13% 74% 0% 100% FY2011 0% 3% 59% 39% 0% 100% FY2010 3% 56% 24% 16% 2% 100% FY2010 2% 19% 54% 25% 0% 100% Site Benchmark 0% 3% 12% 84% 1% 100% Site Benchmark 0% 22% 30% 48% 0% 100% Specialty Benchmark 0% 3% 12% 84% 1% 100% Specialty Benchmark 0% 22% 30% 48% 0% 100% National Bench 4% 14% 38% 34% 10% 100% National Bench 3% 28% 49% 18% 3% 100% 70% 60% 50% 40% 30% 20% 10% 0% Est Visits Office Consult Inpatient Consult 80% 120% 70% 60% 50% 40% 100% 80% 60% 30% 40% 20% 10% 0% % 0% -20% Office Consult Total Inpatient Consult Total FY2011 0% 20% 40% 20% 20% 100% FY2011 0% 0% 0% 0% 0% 0% FY2010 3% 26% 71% 0% 0% 100% FY2010 1% 15% 78% 3% 3% 100% Site Benchmark 17% 17% 33% 17% 17% 100% Site Benchmark 0% 0% 100% 0% 0% 100% Specialty Benchmark 17% 17% 33% 17% 17% 100% Specialty Benchmark 0% 0% 100% 0% 0% 100% National Bench 3% 11% 37% 39% 11% 100% National Bench 3% 13% 39% 34% 12% 100%

27 Health System - FY2011 Perfomance Indicators Dr. Smith Site: Location X Specialty: Surgery - Vascular - Primary 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Charge Lag Distribution - April - FY Office Other Office Other % 9% % 14% % 12% % 4% % 12% % 37% 61+ 0% 11% Charge Lag Trending - Rolling 12 Months Ended April FY May-10 Jun-10 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-11 Feb-11 Mar-11 Apr-11 Average Office Lag Average Other Lag May-10 Jun-10 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-11 Feb-11 Mar-11 Apr Month Avg Average Office Lag Average Other Lag

28 Physician Payer Mix Variance

29 Location Impact on Payer Mix

30 Heart Monitor for Physician Practices Future

31 KPIs to the right person

32 Charges and Payments

33 Payor Mix

34 Alerts: Let the doctors know what they need to know

35 Manage Meaningful Use

36 What have we learned? A plurality of physicians found the visit variance to target more useful than financial data Importance of regular review of scorecards Importance of transparency cannot be overstated Development of detailed plans with individual physicians (and on site staff) to meet goals

37 How do our Compensation Models align with Goals? Goals are evolving... What is the philosophy on incentive compensation? Limitations of current models

38 How are Goals and Metrics Evolving? Traditional focus on: Financial performance Productivity Changing to include: Quality Compliance with clinical protocols Outcomes (e.g. Chronic disease management, readmissions, etc.) Future ACO metrics Patient satisfaction Office Practice HCAPS Access Other?

39 How do our Compensation Models align with Goals? Relative Value Unit Based Models Pros Incentivizes productivity Minimizes billing and accounting conflicts Minimizes payer mix issues Cons Does not incentivize cost/efficiency optimization Still requires negotiation on unit value Potential to increase operating loses

40 How do our Compensation Models align with Goals? Revenue/Income Based Models Pros Incentivizes productivity Focus on bottom line performance Maintains physician focus on cost and efficiency Cons Billing/Collection and accounting challenges Potential issues around payer mix Issues with in-office ancillaries

41 How do Practice Management Models align with Goals? Not systems, but approaches to practice management... Question: What is the importance of physician input and control within practice pods in achieving goals? Balance between management oversight and physician control Degree of physician input on: Scheduling Staffing Physician recruitment

42 Future State... Models will need to create incentives for nonfinancial metrics Groups or pods of physicians must work together as teams, not individuals Incentives must be material to drive change Potential for increase in operating loss trend under health care reform Funding may be risk based and subject to patient compliance Evolution away from volume and facility driven revenue models If reform is successful admissions will decrease Will the same specialties be of value to the health system?

43 What have we learned.. Well defined strategic business plan tied to system strategy Disciplined management Consistent physician contracts Effective financial reporting and key indicators Effective operations group Compensation model that aligns with strategy Credibility and trust with Physicians

44 Questions?

45 Thomas J. Ferkovic Managing Partner SS&G Healthcare Ssandghc.com

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