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The top-five lists, as they are called, are designed to encourage conversations between physicians and patients about low-value medical care. Physicians are increasingly ready to have those conversations, says Mitchell Schwartz, MD, chief medical officer & president, Anne Arundel Medical Center. “The way to thrive is to save money that is being wasted and that doesn’t add value to the patient,” he says.
Choosing Wisely has its roots in a project initiated by the National Physicians Alliance. Stephen Smith, MD, a family physician who came up with the idea, worked with three primary care specialties on the first top-five lists. The publication of those lists created such a splash that the idea quickly spread.
Lowell Schnipper, MD, an oncologist at Beth Israel Deaconess Medical Center, says physicians know that emerging payment systems will require them to practice high-value care, and the top-five lists help them do just that. “I think this is the vanguard of what is going to be a sea change in the way physicians practice,” he says.
What feedback are you getting from physicians and others as they learn about the Choosing Wisely campaign and the top-five lists?
Schnipper: I chair the American Society of Clinical Oncology’s Cost of Cancer Care Task Force, which developed that society’s top-five list. Initially, patient advocacy groups asked me some very pointed questions about several of the items on our top-five list. Cancer is terrifying to patients, and the advocates were worried that we might be abrogating patients’ very last possible chance for a cure. So it took some explanation, but I think the patient advocacy groups now have a clear understanding of the goals of trying to provide intelligent care that is evidence-based. Ultimately, care rooted in high-quality evidence will provide our patients with the best and safest care available.
As for oncologists, they have come up to me at committee meetings and events and congratulated us on the top-five list. They say that it has helped them immensely in their office practices because the five items that we selected for the list have been shown in the medical literature to be unnecessary. I think the oncologists feel that providing authoritative support like this helps them to communicate with patients about something that is otherwise very challenging from an emotional and factual level.
The positive reaction has been sufficient to stimulate us to pick another five tests and treatments, which will make it a top-10 list. That work will begin next year.
What are the barriers to physicians making high-value medical care decisions?
Schwartz: When a patient comes to the emergency department with a headache and expects to get an MRI, it’s very challenging to say “No,” even though we understand that the tests may be superfluous. There is a cultural expectation that, “I’m here for a test and a prescription.”
We feel that, slowly but surely, with patient education and exposure—such as is happening with the Choosing Wisely campaign—this cultural expectation will be modified.
Smith: The Choosing Wisely approach is financially disadvantageous to physicians. A woman I know told me that she had an EKG every year as part of her annual exam even though she is a low-risk patient. So when she said, “No, I don’t want an EKG,” her internist said to her, “I agree with you that we really don’t need to do this, but because there are so many things that we’re losing money on, my practice has decided that this is something we can make money on.”
I think most doctors want to do the right thing, and the Choosing Wisely campaign gives them the authoritative support for doing that.
The most powerful barrier is the acculturation of doctors. We train our medical students and residents to abhor uncertainty and to leave no stone unturned. When I was in medical training, we would go on rounds, and the attending physicians would start asking questions: “Did you do this? Did you get that test?” The attendings would always find a test that was not ordered, and then they would humiliate the offender. And we would say to ourselves, “I’m never going to let that happen again. I’m going to make sure I order every possible test.”
It’s a whole new way of thinking for physicians to raise the issue of whether we are going to exhaust our resources, financial and otherwise, by wasting money on things that are very, very low probability—and may actually be harmful to patients. I think we’re at a tipping point right now in terms of culture changes, but this really is a culture war.
How can hospital executives engage physicians to consider resource use?
Schwartz: Having a meeting where resource utilization is discussed can occur only after a long effort of education and trust building. If that education and trust building has not happened, then the typical response to this discussion is a hunkering down of, “I know what I need to do for my patients, and you’re just interested in money.”
On the other hand, if there is true physician leadership and the pronoun “we” is used frequently—in terms of everybody is responsible for patient care—then you can really have a good discussion about this. As long as hospital leaders put the patient’s welfare at the top of their priority list, doctors are more than willing to have a lot of discussions regarding the cost-effectiveness of care. Having a group of doctors sit around a table and discuss the nuances of best care and best practices is typically a very engaging dialog that easily works itself out into a set of guidelines.
Once you get to that discussion point with doctors, they get to define the best practices. Executives should elevate the physicians into leadership roles to make those decisions.
What can hospital executives do to encourage physicians to adopt the Choosing Wisely top-five lists for their specialties?
Schnipper: They can use their electronic health records to monitor whether physicians are complying with best practices. There’s nothing that doctors respond to better than being shown data that they are responsible for.
In addition, hospital administrators should encourage educational programming that is focused on the quality of care through evidence-based medicine. Where appropriate, physicians should be encouraged to develop care pathways that define the proper evaluation and therapeutic interventions for specific clinical problems. Studies in clinical oncology have demonstrated that patients can be optimally treated for, as an example, advanced non-small cell lung cancer by adhering to pre-defined clinical pathways for that particular problem—while reducing expenses by 35 percent.
Smith: First of all, publicly endorse the top-five lists and the Choosing Wisely campaign.
Number two: Tout the Choosing Wisely approach to all hospital employees. Tell them, “When you go get your physical this year, if you don’t have any risk factors, you should not be getting an EKG and you should not be getting a lot of chemistry tests—that’s not good medical care.”
We have to make sure that people understand that this is the right medicine. This is not rationing—and patients are actually putting themselves at risk for medical misadventures by doing things that are not indicated by evidence. The hospital CEO ought to be up there in front, saying “When I get my physical, I want only the things that are right for me, and I don’t want all these unnecessary and wasteful practices.”
Also, hospitals can sponsor grand rounds to educate physicians about the Choosing Wisely campaign. There are a lot of us who know about this, so get a local physician to give a talk and slide show.
What I would not do is set insurance benefit designs around the top-five lists. We are really trying to focus this in terms of a professional conversation between doctors and patients—and not have payers come in prematurely and say, “We’re not going to pay for this.” I think there would be a risk of a backlash if there was aggressive benefit design based on these recommendations.
How do you coach physicians to have conversations with patients that lead to high-value decision making?
Schwartz: We do not get into the “this is how much it’s going to cost” discussion. In the emergency department, we basically take a patient’s full history, conduct the appropriate testing, and review the results with the patient. We say to the patient, “At this point, there’s no indication of risk, and we feel comfortable sending you home. You can always be reevaluated over time by your physician, and we don’t think at this juncture an MRI is required.”
In a busy emergency department, when you as a physician walk into the room, the patients don’t know you or what your experience is. It is your job—in three minutes—to introduce yourself, gain their respect, and help them understand that you are there to help them. If you can do that, you can have an enlightened discussion. There are ways to help the patient make the right decision through a two-way discussion, as opposed to saying, “Look, I’m the doctor, do what I tell you.”
The National Physician Alliance has a top-five demonstration project in three primary care practices under way. Any lessons learned so far?
Smith: The lesson learned is that it is easy to comply with the top-five lists for primary care and that one shouldn’t have great trepidation about adopting them. Many of our field testers were concerned that they were going to get a lot of push back from patients, but it just doesn’t happen. Patients trust their doctors. Physicians should approach these conversations knowing this is the right thing to do, and communicate that they are always open for a conversation because patients may have unique circumstances that need to be considered. It is rewarding to know that you’re doing the right thing—so have the courage to do it.
The other thing we have learned is that five is a good number as opposed to 15 or 50. This is a very manageable list, and providers can easily keep them in mind. Our hope is that, by practicing this way, we are going to begin to change the hearts and minds of the doctors so they start thinking of themselves as good stewards who always ask the question, “Why am I doing this? Is it the right thing? Am I being mindful of the costs of care and the harms and risks of care?”
That doesn’t mean not doing what the patient needs. But there is no ethical obligation to do things that are wasteful or actually harmful to the patient.
Change Healthcare: Accelerating Revenue Cycle Transformation
Jason Williams, vice president for strategy and business analytics, Change Healthcare, discusses the importance of technology and technology-enabled services in reinventing the revenue cycle.
Ensemble Health Partners: Driving Revenue Cycle Innovation
Judson Ivy, president of Ensemble Health Partners, discusses the value of revenue cycle outsourcing and the importance of selecting the right partner.
Grant Thornton: Facilitating EAM
Priority Advantage: Helping Organizations Optimize Their Medicare Advantage Plans
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Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
10 Ways to Reduce Patient Statement Volume (and Reduce Costs)
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
Reduce Patient Balances Sent to Collection Agencies: Approaching New Problems with New Approaches
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
The Future of Online Patient Billing Portals
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Payment Portals Can Improve Self-Pay Collections and Support Meaningful Use
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Large Health System Drives 10% UP (Patient Payments) and 10% DOWN (Billing-related Costs)
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
ICD-10: Managing Performance
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Clarity Drives Collections
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Revenue Cycle Payment Clarity
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Streamlining the Patient Billing Process
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Wallace Thomson Hospital Automates to Maximize Limited Resources
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7 Steps for Building and Funding Sustainability Projects
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Key Capital Considerations for Mergers and Acquisitions
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
Key Capital Considerations for Mergers and Acquisitions
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
Trend Watch: Providers adapt as value-based care moves from hype to reality
Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.
Yuma Regional Medical Center case study
Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities.
Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.
Reforming with a New 50-Bed Acute Care Facility
Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.
5-Minute Briefing on Revenue Integrity Through HIM WhitePaper Hospitals FS
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5-Minute Briefing on Accelerating Cash Flow Through HIM WhitePaper Hospitals FS
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5-Minute Briefing on Reducing the Cost of RCM WhitePaper Hospitals FS
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Providers Focus Too Much On Revenue Cycle Management
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Lucille Packard Children’s Hospital Stanford Case Study
How Lucile Packard Children’s Hospital Stanford increased payments received within 45 days by 20% and reduced paper submission claims by 70% by using ZirMed solutions.
Using Predictive Modeling To Detect Meaningful Correlations Across Claims Denials Data
The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.
ZOLL and Emergency Mobile Health Care Case Study
Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.
Maximizing Medicare Reimbursements White Paper
Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.
Denials Deconstructed: Getting Your Claims Paid
Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.
Automation and Operational Improvement Drive Sustainable Results
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Revenue Cycle Management Resolves Migration Implementation Issues
Many healthcare organizations are pursuing next-generation health information systems solutions. Learn more about Navigant's work with University of Michigan Health System.
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Building A Common Vision with Employed Physicians
HSG helped the physicians and executives of St. Claire Regional in Morehead, Kentucky, define their shared vision for how the group would evolve over the next decade. As well as, develop the strategic and operational priorities which refocused and accelerated the group’s evolution.
Practice Performance Improvement
The client was a nine-hospital health system with 14 clinics serving communities in a multi-state market with very limited access to care, poor economic conditions, high unemployment, and a heavy Medicare/Medicaid/uninsured payer mix. In most of these communities, the system was the sole source of care.
Though the clinics were of substantial size (they employed 98 physicians) and comprised of multiple specialists, the physicians functioned as individuals and the practices lacked any real group culture.
Clinical Integration Without Spending a Fortune
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Contrary to popular belief, we have clients who have generated substantial shared savings and a significant ROI over time, without massive investments. Yes, some financial capital is required for resources the CIN providers can’t bring to the table themselves. But the size of that investment can be miniscule relative to the value it produces: improved outcomes and documentation for payers.
Adding Value to Physician Compensation
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This report focuses on the three big questions HSG receives about adding value to physician compensation; Why are organizations redesigning their provider compensation plans? What elements and parameters must be part of successful compensation plans? How are organizations implementing compensation changes?
Effective Revenue Cycle Management in Your Network
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The efficiency of a medical practice’s billing operations has critical impact on the financial performance. In many cases, patient billings are the primary revenue source that pays staff salaries, provider compensation and overhead operating cost. Inefficiencies or inaccurate billing will contribute to operating losses.
Succeeding in Value-Based Care
This publication identifies and outlines the necessary characteristics of a fully-functioning clinically integrated network (CIN). What it doesn’t do is detail how hospitals and providers can participate in the value-based care environment during the development process.
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Therapy: Benefits at All Levels of Care
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Cost Accounting: the Key to Cost Management and Profitability
Managing the cost of patient care is the top strategic priority of most hospital CFOs today. As healthcare shifts to more data-driven decision making, having clear visibility into key volume, cost and profitability measures across clinical service lines is becoming increasingly important for both long-range and tactical planning activities. In turn, the cost accounting function in healthcare provider organizations is becoming an increasingly important and strategic function. This whitepaper includes five strategies for efficient and accurate cost accounting and service line analytics and keys to overcoming the associated challenges.