Drowning in Sea Change

Jun 20, 2014 at 08:33 am by Staff

MGMA Tackles Tough Issues to Help Practices Stay Afloat

Value-based reimbursements, ICD-10 reboot, meaningful use, clinical integration physician alignment, transparency, PQRS, 5010 implementation, e-prescribing, staffing and training, compliance, audits … oh yes … and caring for patients

There’s no question the American healthcare system is in the midst of sea change as foundational rules are rewritten and a new infrastructure for care delivery is being put in place. While providers, practice managers and administrators are supportive of many of the concepts, it doesn’t make the transition any easier.

With wave after wave of change washing over practices, it’s certainly ‘sink or swim’ time. For those trying to navigate the rough waters, the Medical Group Management Association’s extensive resources, advocacy and insights on critical issues help shore up practice managers as they fight to keep afloat.

Laura Palmer, FACMPE, a senior industry analyst and subject matter expert for MGMA, said practices across the country are facing unprecedented change. While much of it is tied to the Affordable Care Act, a move to restructure the delivery and payment system was underway even before the landmark legislation was set in motion but has since been greatly accelerated. Today’s practice managers are being asked to alter ‘business as usual’ on most every front.

Benefits & Eligibility

Referencing the ACA impact, Palmer said it’s about much more than just expanding coverage. “It’s really a change in how insurance plans work,” she noted. Keeping up with who covers what, where, with whom and at what point has become increasingly complex as staff members drill down through eligibility requirements and benefits to figure out the bottom line for patients.

While access might be expanding as more people join the insurance rolls, Palmer noted there has actually been a trend of narrowing networks. Not every physician or service provider is on every plan level under a payer. Adding to the confusion, not every family member is on the same plan.

“We’re starting to see more differentiation, and it’s more difficult for the patient and provider, who needs to know where to send someone for referrals,” she noted.

Whereas traditionally a lab company would have been on every plan under a payer, that’s not necessarily true today. A platinum plan might have more options than a gold or silver plan. “It’s a lot more complicated,” Palmer said. “You can’t depend on what you knew in the past to be true.”

Therefore, she continued, it’s critical to regularly check coverage parameters and limits. Verifying benefits annually used to be pretty common. However, Palmer said that no longer works. “Best practices say we really need to check eligibility and benefits every single visit for every single patient,” she said.

Although patient benefits tied to large employers or government entities still aren’t likely to change more than once a year, the same isn’t necessarily true for smaller employers. And, Palmer pointed out, people change jobs much more frequently now so even if a company’s plan hasn’t changed, the patient’s job status might have.

Appropriate Staffing

True access to care doesn’t mean simply having the coverage in place to allow a patient see a provider. The second part of the equation is having providers available to meet appointment demands within a reasonable time frame.

“The days of a doctor’s office being closed for two hours over lunch are long gone,” Palmer said. In fact, she noted, many practices are looking at evening and/or weekend hours, group care settings and adding non-physician extenders to meet demand.

From a reimbursement standpoint, practices must see enough patients to keep the doors open. From a quality standpoint, which now ties to reimbursements, it’s critical to meet best practice parameters. Palmer noted evidence-based standards might call for a patient with a specific complaint to be seen within 48 hours. Practices have to figure out how to do that or risk the consequences … both of missing quality benchmarks and of lowered patient satisfaction scores, which also will soon tie into reimbursement rates.

“You don’t want patients to go to the Emergency Room because they couldn’t get an appointment,” Palmer said. She added, “Practices need to make sure they have adequate staff coverage and a triaging system in place to ensure patients are getting the right care in the right environment in the right time frame.”

Making New Friends

“Practices that in the past might have been competitors in a particular community are now having to play nice with each other,” Palmer pointed out of new coverage rules and clinical integration models.

Tied to the narrowing network trend, providers are finding payers and plans increasingly dictate referral patterns. Palmer said new payment models, such as the formation of accountable care organizations, also are forcing more collaborations encouraged by both the financial setup and patient need.

She added that while this kind of collaboration across care settings is generally viewed as a good move for quality patient care, it is different than traditional practice silos and will take time for providers to adjust to creating more community-based care than has been available in the past.

Adjusting to New Payment Models

Although the vast majority of reimbursements remain in the fee-for-service world, the switch to a value-based system is already underway. “The practical aspect of how we deliver care is already changing,” Palmer said.

Practices have begun investing in changing technology and staffing models before reimbursements have caught up to the new way of doing business. Case managers, nutritionists and non-physician providers are being added … even when those services aren’t clearly reimbursable across most payers … because of the value they add to patient care.

Currently, Palmer noted, only about 3-5 percent of a practice’s reimbursements are tied to quality metrics. While those numbers have remained pretty steady for the past few years as reported to MGMA, Palmer said she was eager to see if there is a change indicated in this year’s data. Anecdotally, she said MGMA staff members have heard from more practices that contracts are being negotiated with quality metrics in mind.

Despite payments lagging a bit behind, Palmer said practices have really embraced the concept of value-based care. “It’s the right thing to do,” she stated. “I think physicians and practices know to really manage care, the best way is to look at total patient care.”


Recognizing that not every provider in every setting is on the same page about the latest ICD-10 delay (with a new implementation date of Oct. 1, 2015 as confirmed by CMS in May), Palmer said it cropped up as the number one concern for 2014 in MGMA’s annual Medical Practice Today survey.

Chief among worries are cash flow concerns, vendor issues, testing, and adequate staff training. Palmer noted, “The delay in implementation is going to allow for more testing, and that’s got to be good for everyone.” She added, she thinks it will give vendors the needed extra time to resolve software issues and practices time to get the technology and training in place.

However, Palmer acknowledged there would be some practices that once again put ICD-10 on the back burner only to panic again next year instead of using this time to really prepare.

Practice Setup

“Integration and alignment issues are still a big topic of conversation,” Palmer said.

What is the most effective practice model? Should practices merge? Sell to a hospital? Specialize or become multi-discipline? The ‘correct’ answer, she said, truly varies depending on circumstances and location.

“Healthcare is local,” Palmer pointed out. “What would work in Maine won’t necessarily work in Arizona.”

The MGMA Lifeline

MGMA’s resources can serve as a lifeline to practice managers who are treading water as fast as they can. Palmer stressed the organization’s role is not to make decisions for practice managers but to put them in a position to proactively make thoughtful choices based on their own unique set of circumstances.

The goal, she said, is to “bring people vetted information – good information from reliable sources – so practice managers can make informed decisions.” She continued, “There isn’t one right answer. The joke around here is if you’ve seen one practice … you’ve seen one practice.”

Although new delivery models are building local alliances, there is certainly still a competitive relationship among practices in a given geographic area. Palmer said a key benefit of MGMA is that it provides a safe environment for peer networking to allow the exchange of information across regions. Where a practice manager might not ask the competing cardiology practice down the street how they are handling benchmarking or succession planning, MGMA membership provides a forum where that manager could talk to cardiology practices outside the market catchment area to find out how they are addressing those issues.

Finally, she noted, MGMA offers the tools to allow managers to excel in their careers. “We provide professional development so we grow the next generation of practice managers,” Palmer stated.

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