Questions for CV Leaders That Still Need to Be Answered

Thursday, October 27, 2016 | Larry Sobal

My first blog post of 2016 talked about 16 Key Questions for Your Heart Program in the New Year. A lot has changed since then: we now have the MACRA final rule in place (slated to begin on January 1), a pending announcement on which 98 (out of a possible 294) Metropolitan Statistics Areas (MSAs) will be selected for bundled payments of AMI and CABG in 2017, and Section 218(b) of the Protecting Access to Medicare Act of 2014 amendment directing CMS to establish a program to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging services, which will impact cardiac-related nuclear, MRI and CT studies. Oh yes, I forgot to add that we are still waiting on the final rule from CMS related to Section 603 of the Bipartisan Budget Act of 2015 ("Section 603"), which excludes many off-campus services from being paid as hospital services under the hospital outpatient prospective payment system ("OPPS") as of January 1, 2017.

When you add in declining reimbursements for hospitals, reduced margins and continued shift of volumes from an inpatient to outpatient setting, the need for effective Governance, Strategy, and Leadership is more critical than ever. That is why I want to revisit those 16 questions from January to see which ones are still relevant in terms of the current environment.

Organizational Questions:

1. Is your organizational model functioning effectively in terms of setting clear vision and strategy?
2. Is your governance process physician led?
3. Do you have a leadership dyad that leverages a physician and administrative leader so that together this team functions as an effective partnership?
4. Do you have a formal succession plan to ensure future leadership is being developed and is ready to step in and serve?

As my MedAxiom Consulting colleagues and I work with heart programs across the country, effective Governance continues to be the differentiator between those programs that are thriving and prepared for a tumultuous future versus those that are not.

Operational Questions:

5. Do you have a balanced and comprehensive set of information that tells you how well your operations are performing in terms of key processes, financial results, and service?
6. Is your clinic access a differentiating feature so that patients can get in to be seen on a timely basis, particularly urgent requests from your referral base or patients with acute symptoms?
7. Likewise for non-clinic CV operations, do your cath labs, CV OR’s, cardiac diagnostics, and inpatient units run like well-oiled machines with effective throughput balanced with flexibility to handle those unexpected surprises?
8. In an era of revenue scarcity, are your revenue cycle processes effectively making sure you are coding properly and being paid for all the work being performed (both in the clinic and hospital) with a minimal number of insurance denials?

Poor access, workflows and revenue cycle effectiveness continue to hamper many programs resulting in millions of dollars of missed opportunity.

Almost every consulting engagement we perform involves some aspect of assessing operational issues. Poor access, workflows and revenue cycle effectiveness continue to hamper many programs resulting in millions of dollars of missed opportunity. It’s one reason we suggest starting with a simple CV Opportunities Assessment. 

Clinical Questions:

9. Similar to #5 above, do you have the information you need to tell you how you are performing clinically, incorporating both your own internal data and the growing list of external sources such as registries, QRUR reports and other metrics?
10. Have you successfully discussed, adopted and implemented clinical guidelines and/or appropriate use criteria where there is external evidence (or local consensus) on the best methods of providing care or where you have gaps compared to external benchmarks?
11. Do individual clinicians (physicians and advanced practice providers) receive data regarding their clinical performance along with a structured process to discuss the data and understand/address outliers?
12. Do you survey the satisfaction of your patients and referring physicians to understand their perspective of your clinical performance?

One of the most difficult organizational competencies to acquire, and therefore still somewhat rare to find, is the ability to conduct meaningful clinical improvement work and then be able to spread and sustain those measureable improvements across a CV Service Line. But how else will you be able to be successful in MACRA and CV bundles and as more reimbursement incentives shift from fee-for-service to some Alternative Payment Model? 

Transformational Questions:

13. Do you have organizational experience and competency in using teams to assess and achieve lasting and measurable change in operational and clinical processes and outcomes?
14. As reimbursement begins to change from fee-for-service to one of the many value-based models, do you know your current performance and where you need to be in the future to be successful in these contracts?
15. Have you realigned your compensation and incentive plans so that they support the behaviors necessary to be successful in the future?
16. Have you built or do you have access to the analytics to synthesize population data to understand patient risk stratification and use predictive methods to guide care plans?

Not only has the health care industry become more complex, organizational structures and decision making have become more complex as well. Often we see siloed cultures where the hospitals, service lines, and medical groups are not communicating and therefore not aligned. This is especially problematic when physician compensation design is misaligned with organizational strategy or contractual incentives.

My conclusion is that these 16 key questions have become even more critical to the success of your CV program than they were in January. MedAxiom would love to help you find the answers to these questions and put your heart program in a position of success for 2017 and beyond. Let me know how we can help.

 

Illustration: Lee Sauer

---

 

Larry Sobal is Executive Vice President of Business Development at MedAxiom. He has a 35-year background as a senior executive in medical group leadership, hospital leadership and insurance. Larry consults, writes and presents on topics relevant to transforming physician practices and health systems.

 

 

 

---