Payment Reimbursement and Managed Care

Determining Options

Health systems and physician groups have a range of options. The tool below displays a range of approaches in terms of degree of integration as well as degree of change in terms of physician autonomy.   Tool: Physician – Health System Alignment Options  As health systems move from fee-for-service towards value-based payments, their physician relationships tend to move higher on the integration scale displayed in the alignment options tool above.  Both employment and clinically integrated networks are increasing rapidly in popularity. Bundled payments are also common, both through the Center for Medicare and Medicaid Innovation’s bundled payment program and with commercial insurers.  For many health systems, bundled payments are a key step along the journey.  As one academic center CFO noted, “This allows us to start looking at data and talking costs with our physicians for the first time.” Next Page               Home               Previous Page

HFMA November 13, 2014

Market Assessment

Both health systems and medical groups should assess and understand the local physician market to determine their best options. Ten questions for assessing a local physician market are:  What is the physician supply/demand balance in the market by specialty? What types of care are delivered within the market, and what is referred out of the market? Where do cases that leave the market go, and why? What are the referral patterns within the market? For example, do referrals go freely across system lines, or is “leakage” being reduced?  Are referrals influenced by narrow networks, clinically integrated networks, or some groups (for contractual reasons or other factors) not accepting some payer categories? Are some groups deemed to be of higher quality than others? What is the growth or decline in the patient population? How are patient demographics changing? How are physician groups likely to respond to the changes? Are physicians in some groups doing significantly better or worse financially than the market as a whole? How easy is it to recruit physicians to this market? Where does the market stand now in terms of these indicators:         •Medicare cost per member per month?         •Commercial costs per member per month?         •Physician group revenues per RVU, per specialty compared to national benchmarks?      

HFMA November 13, 2014

Medical Group Perspectives

A medical group’s perspectives on physician alignment and engagement opportunities can differ significantly based on the group’s demographics. Demographic categories include the group’s ownership status, type of group, performance and experience, and personality.  Common traits within these categories are shown in

HFMA November 13, 2014

Health System Perspectives

Most health systems’ key initiatives depend on the involvement of its physician groups (both employed and independent). This tool illustrates the steps in the journey toward population health management and health system sustainability can be made without direct physician involvement.

HFMA November 13, 2014

Assessing the Situation

A successful physician strategy is built upon an understanding of: Perspectives of the health system seeking to develop or refine its physician strategy Perspectives of the medical group and physician practices (both employed and independent) with which the health system seeks to engage Relevant market conditions As a starting point, it is important to understand the perspectives of both health systems and medical groups (employed and independent). Both perspectives are important, and although they share certain common goals, they are not the same. Tool: Examples of Common and Organization-Specific Goals

HFMA November 13, 2014

Seaside Medical Group Case Study

Issues addressed in this case study include: Moving a physician group from fee-for-service towards a value-based focus Addressing physician compensation changes in a medical group Forming a multi-organizational clinically integrated network (CIN) Sharing finances in a CIN Governing and managing a CIN

HFMA November 12, 2014

Mountain View Case Study

Issues addressed in this case study include:  Physician governance within a health system Integrating physician practice and other components of the management team Experiments in identifying population segments and tailoring approaching and resources to these segments Managing the cost/benefit ratio as

HFMA November 12, 2014

Case Studies

The two case studies offered in this toolkit address increasingly common situations in physician relations. Both are composite case studies based on the experiences of several actual systems and medical groups. In both instances, the organizations are moving aggressively toward accepting and managing more population health risk: Mountain Health System seeks to take its multispecialty physician group to a new level Seaside Medical Group facilitates a partnership and clinically integrated network involving several other organizations 

HFMA November 12, 2014

FY15 IPPS Final Rule Overview

This document highlights important updates to the 2015 payment rates to hospitals under the FY15 Inpatient Prospective Payment System final rule.

HFMA October 29, 2014

CY15 Medicare Physician Fee Schedule Proposed Rule Fact Sheet

This document summarizes the revised policies pertaining to payment policies under the Medicare physician fee schedule for calendar year 2015 (CY15). 

HFMA September 10, 2014
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