Accelerating Comanagement in Cardiac Care

Engagement of physicians is critical to carrying out accountable care models, with physicians having more clinical and operational influence than in the past, according to Stuart Baker, MD, president and COO of Navvis & Co., a national healthcare management consultancy. In return, a hospital gains from quality, safety, cost efficiency, and patient satisfaction improvements, he says.

"Various operational committees carry out the strategies devised and submit them to the division and have them approved by the board," Graham says. "We run the division and generate the strategy and operational plan. We have accountability to the Allina board and a dotted line to the president of ANW."

In a division, "we do use a balanced scorecard that is focused on [cardiovascular issues] but also seeks to align incentives throughout the system around care, service, financial health, people, and growth," he says. 

Hospital officials scrutinize the scorecard in evaluation of hospital work and policy, says Christine Bent, COO of MHI. "We have a strategic planning retreat annually where we put together our annual goals and targets which are captured in our scorecard. This has been a very successful tool for us to help achieve our goals, keep us on track, and align our incentives at the group, hospital, and system level."

Success Key No.4:  Proper structure

Comanagement arrangements depend largely on leadership and planning to establish a proper structure for hospitals to meet legal requirements.

"There is a potential landmine of issues that you have to weave successfully through; but properly structured, you can meet applicable legal requirements," says Michael Blau, a healthcare attorney with Foley & Lardner in Boston.

Baker, of Navvis & Co., says comanagement plans also count on proper structure, and compensation that cannot exceed fair market values. "The culture, relationship, and dynamics of an organization have to be worked out."
In separate interviews, Blau and Baker caution that data must be established to thwart any conflict of interest concerns in Stark Law and anti-kickback requirements. Other issues include civil monetary penalties, false claims, and tax exemption requirements.

According to Baker, the comanagement model differs from conventional hospital-physician joint ventures because the hospital maintains ownership of the clinical service lines, and the subsequent revenue streams. Physicians gain more clinical and operational influence and have greater compensation for strategic planning, budgeting and oversight of plans, he says.

Comanagement contracts will not meet personal service and management contracts' safe harbors if aggregate compensation is not established in advance, says Blau, who is chair of the law firm's healthcare venture practice.

"If you are going to create performance standards for physicians, you improve quality by reducing infection rates, for example, but you can't 'cherry-pick' and pick patients that are less likely to get infections and meet quality performance standards."

To avoid any potential conflicts with state or federal regulations,
Blau suggests:

• Having medical director agreements
  accounted for, and not paying medical
  directors under other agreements.
• Ensuring active participation and
  time management by active physicians.
• Obtaining independent fair market
  appraisal of payment relationships.
• Hiring a clinical monitor, preferably
  independent and outside the
  organization.
• Conducting strict evaluation of state
  and federal laws, from the perspective
  of the Centers for Medicare &
  Medicaid Services and Office of
  Inspector General perspective. There
  must be fair market value.

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