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Readers Write: Carrot or Stick? Physician Compensation in Value-Based Cancer Care Delivery

April 27, 2017 Guest articles No Comments

Carrot or Stick? Physician Compensation in Value-based Cancer Care Delivery
By Lucy Langer, MD and Lalan Wilfong, MD

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A previous post on re-designing cancer care in the context of the Centers for Medicare and Medicaid Innovation’s (CMMI) Oncology Care Model focused on physician engagement in cancer care delivery redesign and how to create a framework to engage physicians in quality improvement and the delivery of better patient care. In this article, we will discuss considerations around physician compensation when trying to strike a balance between productivity and value in this new care model.

The OCM pilot, which began in July 2016, is an alternative payment model designed to test whether specific changes in the payment for cancer care delivery can result in better care, smarter spending, and healthier people. Under the OCM, physician practices are subject to both financial and performance accountability during episodes of care defined by active chemotherapy administration to cancer patients. Reimbursement in the OCM is fee-for-service, but also includes a per-beneficiary Monthly Enhanced Oncology Services payment. According to CMS, this $160 MEOS payment is intended to assist participating practices in effectively managing and coordinating care for oncology patients during episodes of care. The potential for a performance-based payment is designed to incentivize practices to lower the total cost of care and improve the quality of care for beneficiaries during treatment episodes.

Evolving Models

Physician engagement is an essential component for success in payment models like the OCM. Practices can change physician behavior through the compensation model. Most oncologists are compensated based on relative value unit-generation, and some contain a small, additional bonus or incentive for activities such as supporting leadership roles in the practice. But how will compensation models evolve in the era of value-based care delivery?

New compensation models ought to include:

  • Productivity measures.
  • Incentives to provide high-quality care and thresholds that are relevant to the practice.
  • Visibility and reporting once key quality metrics are included.
  • Physician buy-in and full engagement to support the quality initiative.

In the new era of value-based care, practices must determine how to recognize physicians for their contributions to the larger practice’s ability to meet quality and cost-containment targets. This means creating a financial incentive for balancing both personal productivity and practice accountability to improve the quality of care provided.

Real-World Experiences

The US Oncology Network brings together more than 1,400 independent physicians from more than 45 physician-owned practices and over 400 sites of care across the United States, including primarily medical oncologists, radiation oncologists, surgeons, and urologists. We are both part of a committee within the network that has come together to think through and provide guidance as we transition to value-based care. Collectively, this committee has put resources in place to help 14 affiliated practices successfully enroll more than 19,000 Medicare patients (to date) in the OCM. In addition to the OCM, many practices affiliated with our network are participating in similar APMs.

As a result of this level of participation and the potential impact of these programs on each practice’s financials, key questions regarding physician compensation have emerged. For instance, with more than 420 physicians, Texas Oncology is focusing efforts to use a small proportion of compensation to incentivize clinical guideline- or pathways-based treatment protocols. With the implementation of a clinical decision support tool and tying 2 percent of salary to pathways performance, we have seen pathway adherence increase from 78 percent to 90 percent over a one year time frame*. On the other hand, Compass Oncology, with over 40 practitioners, is pursuing a different model and moving towards implementation of a novel total compensation model that shifts away from RVUs to a “Balanced Scorecard.” The Balanced Scorecard emphasizes three key elements – practice growth, fiscal responsibility, and quality metrics – that identify where physician behaviors can align with practice goals, patient needs, and payer contracts.

Productivity remains an important contributor to the health of a practice, and eliminating productivity from physician compensation entirely would be unwise. By pairing productivity with value and quality goals set at the practice level, we believe that physicians will be more likely to alter behaviors towards a more team-based approach.

The transition to true patient-centric care is the essence of new payment models aimed at reducing waste, enhancing patient services, and optimizing patient outcomes. An engaged physician brings value to the practice by providing leadership as a member of a larger team focused on meeting the patient needs. While the doctor-patient relationship remains central to this care, additional services are recommended to meet the needs of the patient. These include social work and financial counseling to decrease the barriers to receiving care, survivorship and palliative care to address patient symptoms and advance care planning, and triage nursing and advanced practice providers to provide clinical services between physician visits. Physicians should be incentivized and compensated for facilitating effective teams and providing mentorship, education, and leadership to drive practice transformation and success in value-based payment policies.

Metrics, Metrics, Metrics

Practices that participate in the OCM and similar models will be held to reportable metrics that emphasize value. Payments will be made based on performance compared to historical data for our own practices as well as the performance of other practices in the model. Baseline value metric data is available to us through CMMI, and tracking performance to these value metrics is an important element when considering physician incentives.

We believe that by incentivizing performance via novel payment models to address quality metrics and improvements in patient care, we must also ensure this approach fully aligns with our practice culture, values, and goals. Metrics that are widely held to be important in oncology as indicators of ‘best practice’ and high-level care, such as days on hospice, performance to established pathways and guidelines, and patient satisfaction, are under consideration for inclusion in the model.

Carrot or Stick?

Ultimately, in considering how to incentivize and motivate physicians through enhanced compensation models, each practice will have to wrestle with some fundamental questions: Is it better to use a carrot or a stick? How can the practice ensure ‘buy in’ to any major changes in compensation? What are the underlying values and strategic goals that you are trying to achieve? How do we balance productivity and value-based care? While we do not purport to have THE answer to physician compensation in the era of value-based care, it is clear that for our practices, legacy RVU models may not truly reflect physician activities that contribute to success with non-fee-for-service contracts. Each practice will have to customize any compensation formula to fit the practice culture, demographics, and payer contract mix.

Lucy Langer, MD is president of Compass Oncology in Portland. Lalan Wilfong, MD is medical director of quality programs at Texas Oncology in Dallas. Both practices are in The US Oncology Network.


References

1J Clin Oncol 34, 2016 (suppl 7S; abstr 187)


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Readers Write: Making Cost Estimates Part of the Patient Financial Conversation

March 30, 2017 Guest articles No Comments

Making Cost Estimates Part of the Patient Financial Conversation
By Jim Denny

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Imagine bringing your car in for repair and asking for an estimate, only to be told the mechanic couldn’t provide one. You probably wouldn’t leave your car with this body shop; instead, you’d take it down the road to the mechanic that could give you an upfront price. While most consumers wouldn’t get their cars fixed without fully knowing the cost, healthcare organizations still expect patients to agree to treatment without a full understanding of the cost involved. In some cases, this leads people who have serious health issues to delay treatment for fear of how much they will have to spend. The lack of transparency, coupled with the perceived payment inflexibility, causes patients to feel like they can’t control their healthcare expenses.

The reality is many healthcare organizations are not providing cost information to patients, even if they have it readily available. In a recent national survey, 75 percent of provider respondents stated they can share cost estimates; however, less than 25 percent of patient respondents say they requested one at their last visit, and only 16 percent received one without asking for it. These figures indicate that patients may not always be aware that cost estimates are available to them, and that providers may not always offer this information proactively. This represents a missed opportunity to strengthen communication, limit confusion, and set clear payment expectations.

Why the Disconnect?

One of the reasons that organizations may not offer estimates (even if they are capable of generating them) is a concern about reliability. Healthcare organizations often believe that providing potentially incorrect information could be worse than not providing any information at all. However, survey results indicate that patients have a different view, with most expressing that they would appreciate the information even if it is not 100-percent accurate. In fact, nearly two-thirds of respondents would find any estimate, or one that falls within 10 percent or more of their actual costs, to be extremely helpful. This reinforces the point that a less-than-exact figure is still considered valuable. Organizations should not allow this fear of inaccuracy to hold them back, and should look at operationalizing estimates, providing one before a patient asks for it.

Making Estimates Part of the Routine

To enable these discussions, organizations must make sure that the process of generating and sharing an estimate is embedded into operational workflow. If this effort is too cumbersome or takes staff off task, then they are more likely to skip over it — and given the lack of patient awareness that estimates are available, the patient may not know to ask for the approximation if it’s not offered, leading to even less estimates provided to patients.

To seamlessly weave cost estimation into financial discussions, organizations should consider using technology that streamlines the process, making it as easy for staff as pushing a button during registration or during other front-office activities. Not only should the estimate reflect the total cost of care, but it should also involve a real-time eligibility check that determines unmet deductibles, co-pay, and co-insurance amounts, so the organization can provide the patient with as close an approximation as possible of what the patient will owe. The cost estimation technology should be part of a comprehensive revenue cycle solution that allows staff to see the complete picture of the patient’s account, helping them to knowledgeably answer questions if they arise, while further streamlining the billing process for both front- and back-office staff.

Organizations should also train their staff on what the cost estimate conversation should entail and how it fits into the larger financial discussion. Staff should learn about how to encourage patients to carefully review the estimate and ask follow-up questions. Note that these conversations can be difficult and complex, so proper education may involve scripts and role-playing exercises to ensure that each staff member is comfortable with his or her role in communicating information, and is aware of the impact he or she can have on patient satisfaction.

A Key Step in Improving Transparency

Being proactive about cost estimates is not only the right thing to do from a patient experience perspective, but it also may increase the likelihood of payment because the patient has received upfront information that allows him or her to plan for the expense. The more organizations can incorporate cost estimates into early financial conversations, the more clarity they will provide to patients, ultimately enhancing the transparency of the encounter, and increasing the patient’s trust and satisfaction with the organization.

Jim Denny is founder, president, and CEO of Navicure in Duluth, GA.


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Readers Write: Six (Inexpensive) Steps to Better Cybersecurity for Your Practice

March 28, 2017 Guest articles No Comments

Six (Inexpensive) Steps to Better Cybersecurity for Your Practice
By Lance Hayden

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Physicians have a lot on their plates. Running a practice means combining the daily requirements of managing a complex business with commitments to patient care and treatment. Factor in the often daunting regulatory and technology environments of healthcare, and one can understand why practices may sometimes feel a bit overwhelmed. It’s no big surprise when physicians worry about how to address cybersecurity concerns on top of everything else.

Recent media coverage has put a spotlight on healthcare security. From large security breaches where medical records were stolen, to frightening ransomware scenarios where entire organizations find themselves in a hostage situation with their systems and data, healthcare providers increasingly find themselves wondering, “Could we be next?”

A typical medical practice also faces budget constraints and limited resources to take on new IT security projects. Many doctors feel they lack the knowledge and skills necessary to fully understand security concerns, much less mount an adequate defense against sophisticated hackers and cyber criminals.

Without the confidence to know they are putting effort and resources into the right areas, too many practices fall back on a wait-and-see strategy, or focus only on the “checkbox security” of minimum compliance standards that can pass an audit but may prove inadequate for defending against determined cyber threats. Unfortunately, apathy can set the stage for an attack, which can be followed by chaos and loss if a practice does gets hit with a security incident.

The good news is that it doesn’t have to be this way. Although many physicians worry that security can only be achieved through expensive technologies or consultants, the fact is that the majority of security incidents are not the result of super hackers working technological magic.

Implement a Healthier IT Lifestyle

Security researchers have found that most attacks are preventable; they take advantage of known vulnerabilities that would have been easy to fix if the affected company had made a better effort. In this way, IT security is a lot like preventive medicine. No physician would be surprised if a patient with unhealthy day-to-day habits eventually developed a more serious condition, and the same applies to cybersecurity.

In this spirit, physicians can “heal themselves” of many cybersecurity problems by simply implementing a healthier IT lifestyle within their practices. None of the six steps below takes a lot of money, or a great deal of IT or security skill. But when they become part of a practice’s business habits, they can go a long way towards keeping a physician’s systems, data, and patients safer and happier.

1. Know What You Are Protecting. Do you keep track of your information and IT systems as well as you manage your pharmaceuticals or medical equipment? Information and IT systems are just as important to the success of your practice. You should take the time to inventory them, know where they are located, and understand your legal, regulatory, and business responsibilities for keeping them secure.

2. Keep Good Backups. In some cases, like ransomware, having a good, current backup can mean the difference between an inconvenience and a catastrophe. Make sure all of your important information is backed up, protected offsite, and regularly tested. If you don’t have the resources inside the practice, contract with a vendor to make sure you are prepared in an emergency.

3. Practice Strong Authentication. Even after decades of knowing better, weak and easy-to-guess passwords are still one of the most common ways that attackers get in. Today, it’s very easy to pick strong passwords you won’t forget by using a password manager. And make sure to turn on two-factor authentication wherever possible; this requires users to enter a code from a phone or another device as well as a password when logging in.

4. Lock Down Your Technology. Don’t make your IT systems an easy target. Keep them current by regularly downloading and installing vendor patches and updates. Avoid running open WiFi networks inside your practice. Turn on WiFi Protected Access 2 (WPA2) in your wireless routers, with strong passwords. Don’t let guests connect to the same networks that the practice uses for business.

5. Develop an Incident Response Plan. The worst possible time to be figuring out how to handle a security breach is in the middle of one. An emergency room wouldn’t wait until the ambulance was pulling in to prepare, and you shouldn’t put off planning for a security incident. Develop a protocol for security breaches, including who’s in charge, who gets called, and what steps get taken and in what order.

6. Make People Your First Line of Defense. Effective cybersecurity requires people, processes, and technology to work. And a “human firewall” can be one of your most powerful defenses against attackers. Devote time to writing good security policies and guidelines, and hold everyone accountable for following them. Policies without training are not very useful, though, so make the effort to ensure everyone understands them and knows what they require. Then, test your users against phishing attacks and other common attack vectors so that everyone is prepared in advance.

Implementing these six habits in your practice can go a long way towards protecting yourself from attack, and none of these activities require major budget expenditures. As with medicine, prevention is the best medicine when it comes to cybersecurity.


Additional Resources

Information and resources are easy to find these days if you want to know more. Check out these public websites specifically set up for small businesses as a starting place:

Lance Hayden is the chief privacy and security officer of EPatientFinder in Austin, TX.


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Readers Write: Winning the Cutthroat Competition for Health Tech Talent

March 23, 2017 Guest articles No Comments

Winning the Cutthroat Competition for Health Tech Talent
By Rachel Neill

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In the past 10 years, we’ve gone from a massive recession to an amazingly low national unemployment rate of 4.6 percent. It’s hard to believe that not long ago, senior managers were scrambling to take on entry-level work just to stay afloat in their respective industries. However, in 2016, the Bureau of Labor Statistics released reports that healthcare, and professional and business services added over 900,000 jobs in the preceding 12 months. Competition for talent in the health tech industry has become cutthroat, in part because of the rapid pace of industry growth. Established companies with significant market share have historically been able to lock up the best and brightest workers by virtue of buying power alone, but those days are over for now. Top talent is fleeing traditional powerhouse companies and jumping to nimble, well-funded competitors.

Employers have to think beyond traditional hiring processes and employee incentives if they want to stay competitive. Elaborate job descriptions and standard salary and benefits paradigms fall short. In order to attract and retain the best workers, especially those much-maligned-yet-undeniably-desirable Millenials, companies can make simple, yet significant, changes to adapt to the evolving needs and desires of the people they employ. Consider the insights below as you begin to rethink how your organization attracts and retains the best talent.

Keep an Open Mind … and a Short Job Description!

I hate job descriptions (Note to HR: Are they really a necessary evil?). Job posters may think they’re doing potential hires a favor by making an exhaustive list of qualifications, duties, and descriptors, but they’re probably not. There always seems to be a big disconnect between the actual hiring manager and the HR department, and a smart-sounding, long job description written out for legal or other well-intentioned purposes that often – and unfortunately -  eliminates some potentially good fits before they’re even in the door.

Hewlett-Packard’s internal report findings show that men apply for jobs when they are 60-percent qualified on paper, but women don’t until they feel 100-percent confident or have checked off every item on the description. That isn’t good; it means that a lot of talented people, women in particular, don’t even have a chance to succeed in many positions. The longer and more verbose a description, the less likely you are to get a diverse candidate pool. Job descriptions don’t lend themselves to transferability, either. For example, Epic implementers make great project managers across multiple industries based on the training and hands-on experience they get while traveling and working at multiple healthcare systems. They can define the scope of a project, put together a detailed plan, manage a budget, and get executive buy-in. None of those skills is unique to health tech, or any other industry for that matter.

What can you do that is actionable? Keep job descriptions short and simple. Don’t be overly specific unless a skill can’t be learned or there isn’t a substitute skill out there. Think about complementary skill sets someone might have and incorporate examples into your job posting. Finally, make the application process simple and encourage current employees to refer people they think have the chops.

Employee Perks and Benefits Matter

You may have heard about Netflix’s unlimited paid parental leave or France’s new law that aims at making it illegal to require employees to answer after-hours email. (Supporters of the law have compared humans and technology to dogs and leashes). More and more employees are seeking work-life balance and flexible employment. You may not have the budget for unlimited parental leave, but there are plenty of other programs you can put in place.

Develop an employee perk page. Don’t worry, It’s free. Work with local and national companies to negotiate discounts – this can be on anything from gym memberships to clothing. Think creatively, but don’t overload employees with perks they might not use. If you aren’t sure, ASK. Most people would appreciate lower-cost access to health and fitness programs, but not everybody wants 10-percent off at the local drapes emporium.

Re-think your vacation policy. Maintaining an open vacation policy and becoming a results-based work organization doesn’t mean your employees will never show up to work. Actually, compensation and benefits research indicate that employees with flexible vacation policies don’t take any more time off than those with formal PTO programs in place. However, it gives an employee autonomy and the ability to stay healthy and take care of life as it happens. Tying paid time off into a results-based plan means that you can limit the program for any outliers who may not be meeting standards or that are taking advantage of the program.

Remote work. These days, technology allows us to fulfill many of our professional responsibilities from just about anywhere. Offering employees the option to work from home can help employers recapture time that may have been lost because an employee felt that they needed to take PTO.  If your employees can get their jobs done from another location, then why not let them have some flexibility?

Workers Want to Make an Impact

Today’s employees today, especially Millennials, are looking at the impact their position will have beyond the four walls of their office. They want to know that the work they are doing is meaningful, often in ways wholly unrelated to the job itself. Many are making a difference with data, or attacking and solving big problems in healthcare. Firms attracting top talent like Healthfinch, Catalyze, Redox, and CareMerge are sifting through and connecting the massive amounts of data to improve patient outcomes. Consider making this meaningful impact a highly visible part of the much-dreaded job description I mentioned above.

In the end, Professor of Management and Human Resources Peter Capelli leaves us with some parting wisdom: “If there’s nothing distinctive you can offer to set your organization apart, and you don’t want to pay enough to buy the talent you prefer, then, just like any other shopper, you’ll have to start compromising on what you want.”

Rachel Neill is CEO of Carex Consulting Group in Madison, WI.


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Readers Write: Disrupting the Traditional Physician Practice

March 21, 2017 Guest articles No Comments

Disrupting the Traditional Physician Practice
By Waqaas Al-Siddiq

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The emerging field of connected healthcare is rapidly becoming a reality and has the potential to overturn a healthcare system deeply rooted in pen, paper, and people. This leaves healthcare workers wondering what their future role will be. Big data at the individual level will introduce terabytes of biological, anatomical, physiological, and environmental information that a human will simply be unable to process. This data-deluged future will require synergy between man and machine, which will ultimately transform life science into data science. It will also markedly improve healthcare and health outcomes.

Remote patient monitoring is the use of wireless, remote technology to manage patients at a distance. This includes not only apps on smartphones and tablets, but smart sensing technologies coupled with artificial intelligence. They have low-power connectivity, streamlined user interfaces, data processing, and the capacity to store and analyze data for medical use. This, and other kinds of connected care, promises to make diagnosis, treatment, and prevention widely accessible at a fraction of current costs. Even today, wearable devices are available that can diagnose heart conditions; asthma monitoring sensors that detect poor air quality and adherence to medication; and glucose monitors that send the data of diabetics straight to their smartphones. By improving patient adherence and preventing unnecessary physician visits, connected care technologies like AI-enhanced RPM promise to reduce costs and improve lives.

A facet of healthcare that is particularly poised to benefit from AI-enhanced RPM is chronic care management. CCM is the most expensive branch of care, soaking up 86 percent of America’s healthcare dollars. Typically, a physician will prescribe medicines, suggest lifestyle changes, and schedule follow-up visits, which leaves much of the ongoing “management” of the disease to the individual.

In their summer 2015 Equity Research publication entitled “The Digital Revolution comes to US Healthcare”, Goldman, Sachs & Co. name two specific ways that RPM can improve chronic care management:

  1. By digesting and presenting data in a customizable and comprehensible way, RPM applications will enable physicians to act immediately. This will also help the patient to immediately understand their health status and counter any negative progression.
  2. By continuously monitoring a patient’s vital signs, AI-enhanced RPM can catch or even predict acute care events and initiate action that will save the patient.

Currently, cardiologists use Holter monitors to capture a patient’s heart’s activity over a 48-hour period. The data is brought back to the physician, who then renders a report based on that past activity. Conversely, RPM would capture and relay activity in real-time to doctors, catching any immediate dangers as well as conditions that take longer periods of time to diagnose. The AI would then analyze the data for variances, comparing it to other patient data, and amalgamating a personalized data set. This will not only improve health outcomes, but more effectively leverage a physician’s time by eliminating the need to compile reports and personalized treatment plans. This will free their schedule so that they can interact with more patients, and focus on the complex cases that require human intervention.

Jack Kreindler, MD founder of London’s Center for Health and Human Performance, sees great potential for RPM enhanced with AI. He envisions being able to move beyond the simplistic rules of current monitoring to “use these technologies to eliminate all avoidable hospitalization and in the process, solve the trillion-dollar problem of chronic disease, which is crippling our economies.”

Properly employing healthcare technology can result in better patient outcomes, improve convenience, and potentially lower healthcare costs, but there is still concern about the doctor’s future active role in patient care. The shift in the healthcare reimbursement paradigm from fee-for-service to value-based care is only the first step towards the implementation of connected healthcare, which began with the desire to keep patients out of hospitals beds. Now that the motivations of both patients and physicians are aligned, technology is positioned to facilitate and empower this new collaboration. Implementing highly sophisticated tools like AI-enhanced RPM would allow physicians to engage patients and offer better treatment that is also more comprehensive.

AI-enhanced technology is poised to disrupt the current healthcare paradigm. It will support the physician’s traditional role in healthcare while also empowering patients, and inviting collaboration and knowledge, which will result in a better partnership for overall health.

Waqaas Al-Siddiq is founder and CEO of Biotricity in Redwood City, CA.


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