The normally bumpy road that is physician recruitment and retention can become pothole-riddled when the local economy turns sour. Now imagine your hospital is about 80 miles from Detroit. As the economy—and the auto industry—struggles, the healthcare environment is rapidly changing for Michigan hospitals, health systems, and physicians. However, Jackson's Allegiance Health has continued to employ successful physician recruitment, relations, and retention tactics even as the numbers of unemployed and, subsequently, the uninsured continue to climb.
"I've noticed the doctors are much more sensitive to their income," says Jerry Grannan, executive director of physician integration at Allegiance. "In our employed models, we try to emphasize the security aspects of it, like the automatic savings for retirement that we have. But we haven't seen big problems yet in docs reacting to the economy besides that."
But new recruits have different concerns than employed physicians. To counter primary care physicians' misperception that the growing number of uninsured means less business, Michael Houttekier, physician recruiter at Allegiance, stresses to potential primary care physician recruits that the area has an access-to-care problem and needs more doctors.
"Normally, when you present it like that to physicians, they see the longevity of themselves being a practitioner here, which ultimately overshadows the particular economic situation that we're currently in," Houttekier says.
Recruiting to retain
Allegiance's success boils down to a level-headed approach to recruitment and retention. Houttekier once hired a doctor from California who stayed only one year before returning home. He never made that mistake again. Now, he makes sure each recruit has a Michigan tie.
"You try to keep your strategies in line to recruit to retain, not recruit to just recruit," Houttekier says. "When you do that, you don't just get that warm body fill."
If new physicians have a preexisting Michigan connection, not only will they better integrate into the community, but they'll have a more accurate idea of what to expect.
"They come to the state knowing what they're getting into," Grannan says. "You can't come to Michigan and say, 'Oh my gosh, I didn't realize the economy was struggling.' They're coming for other reasons—proximity to family and all that. They know what they're getting into. And if they went into it strictly for economic reasons, they wouldn't come to the state, period."
Emphasizing new media
When filling a new position, Houttekier, who manages all physician advertising campaigns, doesn't believe in the blanket approach to marketing. He places ads in niche publications and Web sites, depending on the specialty he's hiring for, and has been dabbling in Facebook. He says any successful recruitment campaign must take advantage of new media, because younger and older doctors alike are computer savvy.
"Doing it electronically has spun off into Facebook. I think it will end up spinning off into MySpace to recruit physicians from there," Houttekier says. "I think it's the biggest media that we have at our fingertips, and it makes it relatively easy versus sending out a postcard to all the people." Houttekier uses postcards and other print materials (see the postcard featured at right and on p. 4) when appropriate, but tries to supplement them with online efforts. For example, an online streaming video of the health system's main facility is in the works.
"When we send out an e-mail blast or any type of literature in print, they can go on and log into the streaming video so they can actually see an advertising campaign for our facility," Houttekier says. "We have a brand-new heart center, a brand-new ED—things like that tend to increase someone's interest to say, 'Wow, this is a system on the move, and this is a place I'd really be interested to look at.' It kind of broadens your opportunities by doing something like that, plus it saves paper."
Keeping tabs on recruits
Once a new physician is hired, the responsibility moves from Houttekier to the physician liaison. Allegiance implemented an intensive follow-up process for new hires after some, such as the aforementioned California physician, left prematurely. A few years ago, the recruiter and liaison positions merged, but soon separated again once it proved to be too much work for one person.
"Our liaison goes out and keeps tabs on our new recruits for three years … to identify issues or concerns in real time—more than figuring out that there is a problem when they announce their resignation," Grannan says.
The liaison can take physician concerns directly to the CEO, if needed. Some of the most common issues are integration of physicians' spouses and children into the community and physicians' relationships with other doctors and staff members.
By recruiting using highly targeted ads, stressing the positives over the negatives, implementing selective hiring, and keeping track of new hires, the three-person Allegiance recruiting and retention team has created a system that remains strong even in today's uncertain economic environment. In the past four years, it has successfully recruited 54 physicians. Only six have left.
"The economy will end up turning around, so you have to look at the long-term in how you sell an opportunity," Houttekier says. "Try to focus on the future."
Lake Wales (FL) Medical Center patients are now more likely to be placed in a private room because of the hospital’s new wing with single occupancy rooms. The 32 rooms will be open to the public on Wednesday for an open house that also celebrates the hospital’s 80th anniversary.
Creating a strong brand message isn't enough in today's competitive market. Brands must be generous and provide an added value in the life of its audience, whether that value is related to entertainment, social, or beliefs. Consumers won't purchase a product merely because they recognize the label, they must have positive feelings associated with it.
Understanding and properly managing Prescription Drug Events (PDEs) is vital to a Medicare Part D plan's financial success, as good PDE data allows for accurate reconciliation with the Centers for Medicare and Medicaid Services (CMS), and ultimately, revenue optimization for the plan. A Pharmacy Benefits Manager (PBM) that is aligned with a plan sponsor can provide the tools and guidance necessary—along with solid business processes—to improve PDE management and optimize plan reimbursement.
PDE Background
As of November 2008, the industry average PDE unresolved reject rate for the 2008 plan year was 1.3% across Part D plans, resulting in more than 11 million unreimbursed claims, many of which could have been reconciled. By following best practices, and working closely with an expert in the industry, a plan can significantly improve PDE accuracy and reduce the reject rate percentage.
The PDE is central to CMS reimbursement and year-end prescription drug plan financial reconciliations. Through the PDE, CMS calculates cost-sharing subsidies for qualifying low-income individuals (low income subsidies), federal reinsurance subsidies, and risk sharing (through the risk corridor structure). A PDE rejection rate above CMS' threshold can trigger an audit or other regulatory action.
Because CMS relies on accepted PDE data to determine payments to plans, effective processing is a cornerstone of financial success for Medicare Part D plans. Well-managed PDE programs optimize the plan's CMS reimbursement for incurred claims. On the other hand, in cases of unreconciled PDEs, the plan pays the claim, but the rejected PDE will not be factored into any reimbursement from CMS.
Consider this:
Effectively processing PDEs can result in significant returns—for every dollar of PDE reject avoided, a plan can increase reimbursement by $0.40 to $0.80.
For a health plan with 100,000 Part D members, this could translate into $680,000-$1.5 million annually.
Strategies to increase PDE accuracy, avoid rework, and optimize CMS reimbursement
1. Take command of critical timeframes. Because reconciliation covers an 18-month window, a plan needs to keep three plan years open simultaneously to reconcile rejected PDEs from a prior plan year, the immediate past year, and the current plan year. Delayed PDE processing may result in last minute resubmissions and missed CMS deadlines. To avoid these issues, timely management of PDE rejects is essential.
2. Monitor open enrollment activity. Plans need to be aware of their enrolled members in relation to members processed/accepted by CMS. In Medco Health Solutions' experience, more than 90% of all PDE rejects are related to enrollment issues, making PDE a lagging indicator of other "upstream" processes. Focusing on PDE-related success drivers—in this case quality of enrollment data reconciliation with CMS—at the very outset of the plan year will be beneficial over the ensuing 12-18 months.
3. Incorporate pre-edits into PDE generation. In many cases, PDE issues may be a result of basic information processing or data quality gaps. For example, a blank health insurance claim number (HICN) on the PDE will result in a 603 reject code that could have been addressed prior to submitting to CMS. Plans using vendors for PDE processing should make sure those business partners incorporate the necessary pre-edits.
4. Identify root causes for rejected PDEs. Rather than resubmitting rejected PDEs, first have reporting mechanisms in place that will analyze PDE rejects so you can address their root cause and communicate that information to senior management. Vendors supporting a plan's PDE process should offer this service, along with the expertise to advise on an appropriate course of action.
5. Create automated PDE tracking that references the PDE data repository. It's not uncommon for plans to submit PDE records multiple times in the ordinary course of business, whether due to adjustments or other events. Ideally, your PDE processing system should create and apply a unique "fingerprint"to each of these PDE iterations, so they can be traced back to the original version. Successful implementation of a system such as this will increase accuracy and reduce the likelihood of reporting false claims. The process should include integration of point-of-sale accumulators to provide real-time true out-of-pocket (TrOOP) and drug spend reporting.
6. Apply ongoing process improvements. Since the PDE process overlaps into the next plan year, try to apply any knowledge or issue resolution to all PDEs your plan is addressing. These "lessons learned" will save significant effort in subsequent plan years.
7. Benchmark against external resources. Compare your plan's PDE performance to external resources, such as the industry-weighted average reports available through CMS' Health Plan Management System (HPMS) system. If you're using a pharmacy benefit manager (PBM), inquire about benchmarking against peer plan sponsors.
8. Know the reject codes. There are more than 130 reject codes that represent errors, which range from incorrect member data to drug codes that are not valid Part D drugs. Tracking rejects monthly, developing control charts, and utilizing CMS reports, such as MMR (Monthly Membership Report) and TRR (Transaction Reply Record), can help proactively identify issues upfront, improve claims payment accuracy, and reduce PDE rejections.
9. Monitor further changes to risk-corridors. Risk corridors are specified risk percentages above and below the target amount submitted in a plan's bid. They decrease a plan's exposure where allowed costs exceed plan payments for the basic Part D benefit. For 2008, CMS widened the risk corridor through plan year 2011 (rising from 2.5% to 5%). By doing so, CMS expects plans to more accurately plan for their claims experience.
CMS is considering a change to the risk corridor structure after 2011. Should CMS decide to eliminate the risk corridors completely, plans will no longer be able to rely on this "safety net" for bad claims experience, meaning the other subsidies and repayment mechanisms gain in importance—all of which depend upon accurate PDE processing.
10. Establish a PDE expert team with end-to-end accountability. The most effective PDE processing takes a two-pronged approach: leveraging the expertise and guidance of an expert, such as a PBM, and engaging an internal, cross-functional team that will work together to resolve PDE issues and improve ongoing operations.
The internal, cross functional team should include members from all impacted areas, including technology, eligibility, finance, and pharmacy. For example, a designated PDE team would spearhead PDE processing and data analytics, and the PDE business owners would likely function as the team lead. Enrollment specialists would research and correct any issues associated with eligibility rejects, while pharmacy operations might close any NDC reject issues. Each group must not only interface with peers within the organization, but also with any outside vendors that are involved in the process. This group would also provide updates to senior management and maintain a focus on critical issue resolution and resulting financial impacts to the bottom line.
Ensuring that you have appropriate PDE acceptance rates is integral to optimizing a plan's CMS reimbursement. Take time to review your PDE processing capabilities in light of your organization's acceptance rate and benchmark verses external resources. Consider working with an organization that has built efficient and accurate PDE processing. Plans that are looking for partners to help them process PDEs should consider a vendor's experience and knowledge of Medicare Part D Prescription Drug Plan operations.
Chris Merenda is senior director of Health Plans for the Retiree Solutions group, Medco Health Solutions, Inc., and Thomas T. Reinckens is executive director of Medicare PDE Enrollment and Reconciliation: Retiree Solutions, Medco Health Solutions, Inc. Merenda is responsible for Medicare Part D products and services for health plan clients and has been involved with the Medicare Part D Program since the spring of 2005. Reinckens is responsible for developing and overseeing the enrollment and reconciliation processes for Medco's various Medicare Part D offerings. His team directly oversees reconciliation of the Medicare benefit for prescription drug events, enrollment processing, and financial reconciliation.
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When it comes to the Red Flags Rule, the Federal Trade Commission's mandate that creditors establish an identity theft prevention program, an expert says facilities should not sound the sirens.
"Our plan is to train staff to look for red flags and to bring it to the privacy officer's attention," Chris Simons, RHIA, director of UM & HIMS and the privacy officer of Spring Harbor Hospital in Westbrook, ME, tells HealthLeaders Media.
"We certainly don't want registration staff confronting patients or getting in the way of providing medical care when patients need it."
Spring Harbor is ahead of the game. It established its Red Flags Rule program before the FTC's original May 1 deadline. Last week, the regulators pushed compliance back to August 1.
"This is good training any time, so I am fine that we are ahead of the curve," Simons says.
The rule forces any organization considered to be a "creditor" to implement programs to identify, detect, and respond to patterns, practices, or specific activities that could indicate identity theft. "Creditors," the FTC says, are agencies that regularly extend or renew credit–or arrange for others to do so–and includes all entities that regularly permit deferred payments for goods or services. Simons and Spring Harbor followed the FTC guidelines to a tee. It wrote a policy that included potential red flags, established protocol when a red flag surfaces, and presented the program to its board of directors for approval.
It also rolled out a PowerPoint training presentation that included:
Admissions staff
Registration staff
Patient accounts staff
HIM
Clinicians
IS staff
In the training, the hospital identified potential red flags, such as:
Patient presents documents for identification that appear to be altered or forged
Patient's photo, identifying characteristics (e.g. ethnicity, sex, age) or signature does not appear to match what is on file
Social Security number or other identifier (e.g. insurance policy number or date of birth) is inconsistent with external information sources
Address/phone number or other demographic information is inconsistent with other sources of information
Medical records show treatment inconsistent with current presentation
Spring Harbor's Red Flags policy also identifies the privacy officer as the point of contact for any staff member who spots a red flag. The privacy officer then notifies the patient if the case was indeed determined as identity theft and acts accordingly to protect the victim.
Spring Harbor's policy also asks registration staff members to request picture IDs or at least two other forms of patient ID.
The key for your facility, just like it as Spring Harbor, is to identify discrepancies and refer to your policy when it happens.
"We focused on this from a patient safety point of view," Simons says. Simons says most facilities should have already had checks in place like these. It's just that now, the FTC has made enforcement formal through a regulation, which is similar to HIPAA through the HITECH Act.
"This is very timely," Simons says. "Every time you turn around, there's a breach."
Insurance companies have offered to end the practice of charging higher premiums to women than to men for the same coverage. Karen M. Ignagni, president of America's Health Insurance Plans, made the offer in testifying before the Senate Finance Committee. It was the latest concession by insurers as Congress drafts legislation to overhaul the $2.5 trillion healthcare industry. In November, insurers said they would accept all customers, regardless of illness or disability, if Congress required all Americans to have coverage. In March, insurers offered to stop charging higher premiums to sick people.