Physician Enterprise The Importance of Charge Capture, Business Intelligence and Being a Data Driven Organization Executive Summary Physician-hospital alignment is a key strategy for most hospitals across the country. Many hospitals are utilizing employment models to develop greater quality and economic alignment and to meet regulatory compliance. In many parts of the country, current trends indicate that in the next couple of years, more than 50 percent of all physicians could be employed by hospitals within a given community. This growing trend has created many benefits for hospitals, including market growth, quality focus and new clinical care models. However, it has also burdened hospitals with significant physician practice operating losses, which have put tremendous pressure on the overall health system s bottom line. Many hospitals have structured their employed physician strategy using a separate physician enterprise entity with distinct leadership, governance, IT systems, budgets and operations. Many physician enterprises are employing 50 to 250-plus physicians, with operating budgets equal to those of many small hospitals. These entities need to be structured and operated as a business, with experienced professional leadership, a structured strategic plan, tools to analyze/monitor/ track key performance indicators and the ability to quickly intervene when negative trends are observed. The long-term success of the relatively new physician enterprise organizations is still unclear, but early experiences indicate that entities that use Business Intelligence tools and are data-driven are more focused and successful. This brief will examine key healthcare market drivers and the significant impact they will have on hospital-sponsored physician enterprise. It will also discuss critical factors that will have to be addressed in order to position physician enterprises for clinical, operational and financial success. These will include professional leadership, need for business intelligence and analytical tools, creating a data-driven culture, developing an organized revenue cycle management process and partnering with niche healthcare companies that can bring best-in-industry solutions and benchmarking capabilities. A brief healthcare industry overview will be provided followed by a deeper dive into the critical issues and solutions that hospital-sponsored physician enterprises may wish to evaluate and implement. Challenges of Hospital Sponsored Physician Enterprises Hospitals and health systems are amassing large physician enterprises at a tremendous cost and often without a strategic plan, data analytics or automated systems to effectively and efficiently manage physician practices. There are a number of key issues driving the physician enterprise cost curve up and creating an unsustainable model of care: Copyright 2012 Ingenious Med ingeniousmed.com
Physicians being employed as a defensive move to ensure patient referrals. Lack of organized infrastructure and professional leadership. Costly disparate IT systems, often lacking appropriate interfaces. Lack of actionable strategic and operational plans. Having inadequate data to drive clinical, operational and financial performance. Relying on data that may be weeks or even months old, versus managing practices in a real-time fashion. Lack of a revenue cycle management plan, diligence around the process and professional expertise. Inadequate proactive compliance oversight, with many organizations managing compliance through retroactive audits. Hospital margins that are becoming more compressed and will not be sufficient to cover the growing losses with many physician enterprises. Hospital-sponsored physician enterprises should evaluate their current structure, expertise and performance with respect to the key issues discussed above, and develop and implement plans to position their organization for greater focus, accountability and success. Upcoming healthcare reform will create new challenges and accelerate the impact and need for change. Healthcare Environment Impact on the Physician Enterprise The healthcare industry is facing tremendous challenges, which are being accelerated by healthcare reform. As of May 2012 the U.S. national debt was more than $15 trillion and healthcare expenditures are currently about 18 percent of GDP, a figure that many experts predict will continue to rise in the future. The impact and uncertainty around healthcare reform is creating great confusion and delays and ultimately adding cost to an already stressed industry. The current healthcare model is unsustainable and will require fundamental changes in order to affect greater efficiencies and drive the overall healthcare cost curve down. Addressing healthcare reform in a perfect world would be a challenge in itself, but it will truly test the current industry, which is dealing with broader issues, including: Healthcare Reform - Driving the development of new models of care, increased reporting requirements and the creation of new economic incentives for all providers. Reimbursement Changes Increasing shift from volume to outcomes-based reimbursement; declines with state and federal funding; creation of bundled payments; implementation of ICD 10. Increase in regulations and compliance Scrutiny of physician-hospital relationships; HIPAA; information exchange between providers. Declining admissions and shift to outpatient and home-based care. Copyright 2012 Ingenious Med ingeniousmed.com Physician Enterprise 2
Impact of Technology Significant cost of technology to meet meaningful use, telemedicine advancements and technology allowing more home-based care. Data driven decision-making and business analytics are not inherent in most physician enterprises. Physician-hospital alignment strategies are limited in options, very costly and often reactive. The current and future healthcare environment continues to be unclear, resulting in many organizations proactively positioning themselves for multiple scenarios, with others taking a wait and see position. Regardless of the approach, it is clear that major changes will be required to meet the environmental and regulatory changes currently engulfing the healthcare industry. One area that will need immediate attention is the evaluation and realignment of the revenue cycle management process within the physician enterprise. Challenges Presented by Revenue Cycle Management in Physician Enterprises The successful physician enterprise will require investment in IT, professional management, operational system development and real-time analytics in order to create a high quality and financially sustainable physician alignment strategy. The days of managing physician practices as a department within the hospital organization are long gone. One critical success driver is ensuring a highly efficient and effective revenue cycle management system. There are a number of critical issues that have created barriers for many organizations in developing high performing revenue cycle management capabilities within their physician enterprise, including: Reliance on a single solution to address the entire RCM process. One IT system cannot meet all the technical and operational needs of a physician practice at an A level. There are a number of niche bolt-on healthcare solutions that are best of class in addressing specific components of revenue cycle management. RCM staff often lack adequate training and physician practice management expertise, resulting in lower performance and high turnover of RCM frontline staff. Lack of business intelligence tools that analyze, plan, monitor and report in order to drive clinical, operational and financial performance. Most organizations rely on data that lags behind by weeks or even months, resulting in an inability to quickly adjust practice operations that, in turn, results in greater inefficiencies and poorer financial performance. Poorly designed processes that often lead to information gaps, data conflicts, errors and, ultimately, compliance issues. Too much focus on back-end validation and follow-ups versus greater efforts on quality upfront data collection at the point of care through a robust charge capture system. Too many manual steps involving multiple individuals that lead to delays, lack of accountability and increase in errors. Poor alignment of work and incentives throughout the entire revenue cycle management process, leading to poor communication, lack of alignment and overall lower performance. Copyright 2012 Ingenious Med ingeniousmed.com Physician Enterprise 3
Physician enterprises must assess their current personnel, operating systems and organization of work to ensure that there is alignment of objectives and incentives. The lack of timely and quality data can lead to unfocused and inadequate business analytics, resulting in poorer operational, quality and financial performance. In addition, current reimbursement incentive (PQRS) will not be achieved, exposing the organization to regulatory compliance. Execution Management Becoming a Data-Driven Organization Timely, quality and accurate data is the lifeline for the physician enterprise to ensure high-performing practice management. Physician enterprises must become data-driven organizations in order to maximize their clinical, financial and operational performance and to navigate through a complex and highly regulated healthcare system. Executing this management and data-driven philosophy will require operational and cultural changes and will be a challenge for many traditional organizations. These changes are driven by the following business imperatives: Need for business intelligence and analytic tools to measure performance and benchmark against best practices. Need for an actionable strategic and operational plans to create short- and long-term roadmaps for the organization. Quality and timeliness of data are extremely important. Most data available within physician enterprises usually lags by a couple of weeks or even months, resulting in an inability to quickly adjust operations to address poor performance. Organizations need actionable data that tells providers what is going on in the practice/hospital today as opposed to reacting to data from weeks past. Physician enterprises need the ability to analyze/drill down on data at the granular level (practice level, physician level, procedural level) in order to drive quality and operational performance. Quality metrics and key performance indicators (i.e., charge capture rates, LOS, readmission rates, cost of care, PQRS, compliance monitoring and others) should be created to monitor, track trends and take actions to improve key operational and quality processes. Variations in practices within large physician practices can lead to increased inefficiency, higher cost and often poorer quality. Benchmarking and best practice sharing within a physician enterprise and compared against national indicators is extremely valuable and can help drive an organization to the next level. Transparency is essential as the entire care team needs to be aware and involved in driving the physician enterprise strategic and operational plans. Execution management and accountability at both the practice level and individual level are criti- Copyright 2012 Ingenious Med ingeniousmed.com Physician Enterprise 4
cal. Even the best clinical, strategic and operational plans will not be successful if there is not organizational alignment and accountability at all levels of the physician enterprise. In today s healthcare environment, physician practices must use data to drive out inefficiencies and reduce the current high cost associated with hospital sponsored physician enterprises. Key Success Factors for Physician Enterprises Although many physician practice management and healthcare executives do not see the light at the end of the tunnel as it relates to navigating through these turbulent times, there are those that have developed strategic and operational plans, invested in experienced leadership and in critical information technology and partnered with niche organizations that can bring the necessary expertise, focus and success needed to address critical business processes. Key success factors that will drive the physician enterprise to a solid foundation and to perform at the upper quartile of clinical, operational and financial performance include: Actionable strategic and operational plans critical for providing a roadmap for the organization, physicians and the entire care team in order to ensure short- and long-term focus and success. Automating physician workflow at the time of care to assist physicians in the areas of quality, coding, compliance, documentation and communication across the care team, all of which contribute to lowering the cost of care through improving quality and efficiency. A focused revenue cycle management operational plan will drive the overall performance of the physician enterprise. Empower, educate and enable the providers who are seeing patients with the ability to accurately capture charges as well as the appropriate documentation to back up the charges that are captured. Management reports driven by real-time data are critical to managing through Key Performance Indicators and best practice sharing and to driving overall performance. Data alone will not drive success. Converting data into useful information is the ultimate objective through management reporting. Partnering with niche organizations to ensure maximum results across the entire revenue cycle management (RCM) process should be considered. Bringing in experienced professionals and technology to drive specific elements of the RCM process is a strategy that has proven to be very valuable from the aspects of cost, quality and overall performance. An example of this strategy is meeting PQRS criteria to assist physicians in capturing their payfor-performance metrics by providing technology that captures critical data at the time of care. Many organizations believe it is critical to implement electronic charge capture in order to establish standards within their physician practices prior to the implementation of ICD 10. Compliance is becoming a greater concern for all healthcare institutions and with RAC Copyright 2012 Ingenious Med ingeniousmed.com Physician Enterprise 5
audits now being performed on physicians as well as hospitals, it is imperative that employed physicians code appropriately. It is critical to invest in technology that ensures physicians document properly in the patient s health record and charge at the appropriate level. Business Intelligence and analytics are required to establish actionable plans, monitor results and take appropriate corrective actions throughout the entire physician enterprise. Examples include using reports that can be viewed on a real-time basis to review coding at the physician level and compare against industry standard metrics to identify individuals who appear to either be over- or under-coding. This allows an organization to identify problems and train employees accordingly as opposed to attempting to make corrections under the pressure of an audit. Technology provides the ability for real-time communications at all levels of the physicia enterprise, which is essential in driving daily operations and clinical care. The underlining success for physician enterprise is in becoming a data-driven organization and focusing on overall execution management of the clinical, operational and financial strategies and plans. Technology allows for heightened levels of focus and accountability that contributes to the success of an organization. With a greater focus on execution management and real-time accountability, physician enterprises will need to address the cultural realities that will impact the organization. There are many niche healthcare companies that can assist physician enterprises reaching reaching their objectives by bringing technology, expertise and focus to critical elements of both the clinical and business operations. These niche companies will be a critical factor in successfully addressing the healthcare reform. Summary With millions of dollars of revenue and expenses at risk plus an increase in regulations, hospital-sponsored physician enterprises cannot afford to manage without the expertise, tools and professionals necessary to develop and execute an effective strategic plan, business analytics, actionable tactics, key performance indicators and management reporting. Data and business intelligence must be shared and embraced by the entire organization. This level of transparency and accountability will lead to a higher performing and more successful physician enterprise. Business intelligence tools can give a physician enterprise a wealth of information in real time, as recently as the last charge captured on such things as length of stay, physician RVU s, distribution of charges, census statistics and more. All of this actionable data can tell the organizations what is going on in the practice and hospital today, as opposed to reacting to data from days, weeks or months past. Long gone are the days of managing employed physicians as a group of doctors within a department of the hospital. Today s economic and regulatory environments have created a need for a separate structure for the hospital-sponsored physician enterprise that is led by individuals with the appropriate business acumen and experience, and driven by quality data and a focused business plan. Copyright 2012 Ingenious Med ingeniousmed.com Physician Enterprise 6
About Ingenious Med, Inc. Founded in 1999 by a group of practicing physicians, Ingenious Med is an award-winning platform that automates the activities of physicians. Ingenious Med automates the revenue and charge capture processes for nearly 20,000 users in the nation s leading healthcare facilities. Ingenious Med s impower platform is the nation s largest charge capture and physician performance solution in the healthcare industry today. The new imagine solution is a robust business analytics platform designed to maximize information for administrators and practice managers. The cloud-based, charge capture and analytics platforms provide real-time data that helps hospital systems and physician groups improve physician productivity and efficiency, enhance quality of care, maximize revenue, increase billing accuracy and ensure compliance. More Information Visit www.ingeniousmed.com or call 678.486.4205 Copyright 2012 Ingenious Med ingeniousmed.com Physician Enterprise 7