What’s Keeping You Up at Night?

As if implementing the imperfect Affordable Care Act (ACA) and its demands on private and group practices (eg, training the front desk, collecting copays, determining deductibles, and identifying exchange patients) was not enough, many urologists—especially those not considering early retirement or leaving medicine altogether—are also examining the possibility of consolidating their practices via mergers or acquisitions. Faced with training staff for the transition to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision and avoiding heavy penalties for errors to partially fund the ACA, practices have to study and choose from an array of electronic medical records (EMRs) offerings and determine which is best for their respective practices.

As if this were still not enough, payer issues, designing and implementing inventory systems, benchmarking and identifying benchmarking sources, forming surgical specialty networks, and dealing with accountable care organization (ACO) penetration into the market are sure to steal some nights’ sleep from any conscientious practitioner. Who knew that practicing medicine would one day have required facility in accounting, office management, marketing, and insurance issues? Some of these topics were discussed at the 2013 Medical Group Management Association (MGMA) annual conference in San Diego, CA.

To Align or Not to Align
Some practices might be in the process of examining the possibility of aligning with another medical group and setting up a practice “without walls,” where physicians from one practice would be free to join physicians in another practice across town, while remaining in the same system; retaining fee schedules; sharing a common EMR program; and integrating finances, markets, and payer mixes. Practices without walls are becoming a healthcare delivery system preferred by a growing number of physicians. The model builds on the best features of a traditional group practice, retaining each physician’s autonomy and practice identity, while offering legal and financial protection for the professional staff. Problems might arise, however, if members do not share the same values and the same company culture.
A practice in Montana attempted to partner with a hospital while retaining some autonomy (ie, remaining independent, but being owned by the hospital system). The hospital eventually bought many of the surrounding practices. The fear was that all of this practice’s patients would ultimately be a part of the hospital system, giving the hospital the upper hand and obliterating further attempts for the practice to remain independent.

After their primary care cohort formed a large independent practice association, urologists and other specialistsin several practices in Nashville, TN,  were cast off to the side. The specialists joined forces and formed Health Innovation Specialists. The new partnership will collect and manage clinical data for practices ranging from orthopedic surgery and urology to obstetrics and neurosurgery. The group is investigating ways to move from a fee-for-service system to a value-based reimbursement system that will reward physicians who deliver high-quality care.

In the Dallas/Fort Worth, TX, metroplex, large systems are buying up independent physician practices at a prodigious rate. One of the most difficult aspects of this practice had been to keep employee turnover low. When buyouts first began over the past few years, the annual turnover was approximately 25% (AU: When? In 2012? 2013?), but increased communication with employees has decreased the turnover rate to 12%.
Many integrated practices that are being subsidized by hospitals, however, are already showing a loss in profits. In addition to trying to retain some degree of independence from the hospital, practices must also compete with other physician groups that are merging and attempting to control referrals in their market.

Through all of this, patient choice still plays a role in driving which practice will provide the healthcare. Although physicians in a group might refer patients to urologists in the same group, a patient who has had a bad experience with a particular practitioner can seek care from another practice. Aligning with a hospital can help if reimbursements have diminished and Medicare continues to cut into costs. Physicians might initially negotiate elevated relative value units during discussions and negotiations with hospitals, but their leverage will ultimately come from hospitals banking on having surgical procedures being performed at their facilities. As the patient population grows and costs increase, however, reimbursements will decrease.

Having the data, sharing the data, and showing the data can help determine who comes out on top. Collecting data is crucial to survival. If you are not collecting data now, as one participant at the MGMA meeting noted, you won’t have to bother, because in 5 years, you will probably not be in business.

One urologic surgical specialist  practice chose which ACOs to align with. The choice was determined by benchmarking based on internal quality measures. There are few census figures on prostate laboratories or vasectomy complications. Thus, it is important to capture data and use the data to show patients what you are doing and how well you are doing. Of course, doing this requires creating a system for collecting data. For example, it is important to create a database to illustrate the percentage of positive results of prostate biopsies. Instead of relying on numbers (eg, having 4-5 positive biopsies in a small practice or 20-30 in a larger practice), use percentages because that provides patients with a better picture of their results. Another attendee at the MGMA meeting seconded the need for benchmarking: “Unless you can measure it, you cannot fix it.” He recommended using Trellis Healthcare’s InfoDive, a web-based intelligence solution that allows a medical practice to analyze its internal data and compare them with those of other practices.

Communicating with Primary Care
Specialists fear that they are taking a back seat. This may be true, particularly because they are going full risk with patients through Medicare Advantage programs. Primary care physicians will seek specialists with whom they have good relationships and who provide high-quality care for their patients. This will ensure continued referrals. The key to this is to control costs and to communicate with primary care physicians about what is happening with their patients. The primary care physician wants assurance that a patient who comes in on a Friday afternoon with a kidney stone will not be put in the hospital with morphine and be left there until Monday. The ideal is to keep the patient out of the hospital, to keep costs low, and to continue keeping the patient on the road to recovery whenever possible.

Insurance Exchanges and Impact of the ACA
An insurance representative at the MGMA conference claimed that dealing with exchange patients is straightforward: “It’s just another contract.” The decision to stay in or out of the exchange is up to the urology practice managers. The first step might be to determine who in your region will bear the weight of the insurance exchanges. The larger companies are most likely to lose. The key is to start training employees now about collecting upfront. Members might be noted as “active” over the 90-day grace period, even though their premiums have not been paid. Certain patients might require ongoing treatment and recurring visits either for surgical interventions or therapy. Costs associated with these are often quite high. Determining whether to treat patients during this period is going to be problematic, and it opens a large concern for practices, particularly if treatment has already been provided within the 90-day window. Some therapies and treatments for radical postoperative surgeries are provided over a 90-day period. Numerous challenges abound at the moment, and many questions will remain unanswered.

The ACA requires plans to notify providers when members enter the grace period, but the ACA does not identify how plans must do this. If a healthcare plan provides electronic notifications or sends a postcard, it is not clear if either of these will qualify as a notification. Most plans will be high-deductible plans, so practices should attempt to collect what they can upfront for financial protection. During the first 30 days of the grace period, plans will continue to pay claims and can seek recoupment for any claims they have paid. They will also be obligated to pay the federal government back for any subsidies they have received for a member during this period; however, if a patient does not pay his or her premium, providers cannot pay the bill during the grace period. After the grace period, patients become self-pay. As one speaker at the MGMA meeting noted, there is nothing to prevent a patient from obtaining a plan and paying a premium for 1 month, living off the system for the next 3 months, losing that plan, moving to another plan, and playing the same game all over again. Conceivably, there is noth­ing to prevent a patient from paying 4 months of premiums for insurance in an entire year; consequently, this makes it all the more important to collect payments upfront.

Speak Now or Forever…
If practices have not had discussions with their groups about sending employees to the exchange, it is now getting late. Some employers may postpone making this decision for another year, but medical practices must make the decisions as soon as possible. Some urology practices are seeking to set up health savings accounts (HSAs) and are allowing their employees to pick and choose what they want. Whichever route a practice chooses, it should be aware that premiums will continue to increase by 20%, 25%, or 30% annually. One practitioner at the meeting noted that her staff would be eligible to participate in buying insurance on the exchange. The practice then required its staff to go to the ACA website and determine their rates based on their income. The staff learned what the out-of-pocket (OOP) costs were for each plan (bronze, silver, and gold), the cost for premiums, and the allowable subsidy. Employees then compared these benefits with their current group plan, specific to their family members, their children, and their costs. In all cases, the OOP costs for a catastrophic event with the exchange were roughly double the amount the group plan would have required.

Unfortunately, as reimbursement declines, expenses increase, and pressure from the government continues, current plans might not prove sustainable in another year. Employees often take benefits for granted. They do not understand the value and can absolutely benefit from such teachable moments.

Seeking Solutions
One practice joined a trust called the Multiple Employer Welfare Association to help control costs and premium increases. The practice noted a decrease in premiums associated with being part of the trust. Another group of urologists and radiation oncologists switched to a partially self-funded exclusive provider organization plan for benefits. The plan will offer a high deductible with an HSA component, where employees can make contributions.

Several participants urged piggybacking events onto large conferences. The American Urology Association encourages collaboration with smaller groups, such as the MGMA, the Financial Management Conference, and the Large Urology Group Practice Association, which is currently considering including small group practices. Collaboration at this time is essential to starting the grassroots movement rolling. Urology-specific education on how to get things done and on why getting them done is important is sorely needed. Collecting data and benchmarking must begin now if your practice will have a future.

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