"Contrary to what some may believe, with increased staffing come much larger gains in revenue after operating cost, as well as productivity," says MGMA CEO.
As the saying goes, businesses often have to spend money to make money—at least when it comes to investing in nonphysician practitioners (NPPs) and key support staff, according to a recent survey from the Medical Group Management Association (MGMA).
Overall, practice operating expenses increased at almost the same rate as revenue between 2015 and 2016, according to the 2017 MGMA DataDive Cost and Revenue Survey. However, practices that came out with increased revenues owed it largely to increased NPPS and support staff.
According to the analysis, the practices with a higher NPP-to-physician ratio (0.41 or more NPPs per full-time equivalent [FTE] physician) earn more in revenue after operating cost than practices with fewer NPPs (0.20 or fewer NPPs per FTE physician), regardless of specialty.
"Our annual Cost Survey continues to show the importance of NPPs and support staff in physician practices and hospitals, as well as other factors that impact practices’ bottom line" said Halee Fischer-Wright, MD, MMM, FAAP, CMPE, president and chief executive officer at MGMA.
"Contrary to what some may believe, with increased staffing come much larger gains in revenue after operating cost, as well as productivity," she added.
Across all specialties, the analysis revealed a difference of one to three more support staff per FTE physician in physician-owned practices compared to hospital-owned.
Hospital-owned practices have more opportunity to consolidate business office functions and centralize services for multiple practices, therefore requiring fewer overall support staff on-site than physician-owned practices, noted the researchers.
Nonetheless, certain expenses continued to rise for all groups. From 2015 to 2016, drug supply expenses increased by more than 10% per FTE physician.
Meanwhile, physician-owned practices spent anywhere between nearly $2,000 to $4,000 more per FTE physician on IT operating expenses than they did the prior year, resulting in an expense of approximately $14,000-19,000 in IT operating expenses per physician each year, depending on the specialty.
The Cleveland Clinic is known for prioritizing patient experience, particularly around relationship-centered communication. Experts explain how this philosophy makes not just moral but financial sense.
Hospitals and providers are more aware than ever that communication and empathy can make all the difference in how a person feels about a hospital stay or medical encounter.
But with competing priorities such as patient safety, quality, and other elements that visibly impact the bottom line, the 'why' for investing in patient experience can be a tough sell. Experts from the Cleveland Clinic note the following ways doing the right thing translates to dollars.
Payers Are Keeping Score
The Centers for Medicare & Medicaid Services began tying Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores to hospital reimbursement in 2012.
While the penalties for sub-par performances have increased slowly, the dollars now are substantial. As of this year, HCAHPS scores determine up to 2% of a hospital or health system's Medicare payments.
"The risk for not giving patients a good experience financially now becomes very high, so hospitals or practices that don't stand behind the fact that we need to take care of our patients both behaviorally and clinically stand to lose a significant amount of money," says Lori Kondas, MBA, senior director for the office of patient experience at the Cleveland Clinic.
There are several other ways patient experience indirectly, but cumulatively influences the bottom line, adds Joshua Miller, DO, the Cleveland Clinic's vice president for regional family health center operations.
The industry's shift toward value-based care is only one.
"We'll sit down with our doctors and say, 'We really care about this.' We'll talk about narrow networks, how [payers] will drop physicians and things of that nature potentially on scores, so we need to start paying attention to it now or we're going to pay later because of it, either from a malpractice suit or other financial consequence," Miller says.
Consumerism Is King
Meanwhile, the healthcare industry must also accept being in the midst of the age of consumerism, adds Kondas.
"It really is patient experience overall that drives people toward where they choose. With that increasing amount of transparency, patients can see what others think about you," she says.
"It's sort of like TripAdvisor. You can go anywhere and learn about a healthcare system—and not just about what the quality of care was, but how [consumers] were treated."
Empathy Boosts Efficiency
"The evidence suggests that you can actually save time by making a single empathic statement," says Chief Experience Officer Adrienne Boissy, MD, MA.
"The rationale behind that is that if someone is coming to me emotionally charged and I ignore those cues and continue on my own agenda, those cues will either continue to surface and escalate," she says. "Or the patient will stop talking because you've demonstrated that you're not willing to 'see' the emotional human in front of you."
Addressing the cue the first time takes less time, she says.
A patient who is angry about a long wait before an appointment, for example, is more likely to be distracted by that frustration and less engaged in talking over medical concerns with the provider, potentially snowballing into poor adherence, which may in turn contribute to a preventable hospitalization, to name just one plausible scenario, notes Miller.
Since 2011, Cleveland Clinic caregivers have learned how to handle these situations with a course in relationship-centered communication. "We tell the doctors it's almost like an MBA for communication," Miller says. "It's to give them more tools in their tool belt," he adds.
The widely promoted idea that stopping antibiotics too soon creates antibiotic resistance and could breed deadly superbugs is wrong and should be replaced, researchers say.
The age-old admonition for patients to “complete the course” of antibiotics prescriptions is not backed by evidence and should be replaced, according to an analysis published in The BMJ.
Sparking controversy, the authors challenge the message—backed by the World Health Organization and U.S. Centers for Disease Control and Prevention--to “always complete the full prescription, even if you feel better, because stopping treatment early promotes the growth of drug-resistant bacteria.”
To the contrary, patients are put at unnecessary risk from antibiotic resistance when treatment is given for longer than necessary, not when it is stopped early, according to Professor Martin Llewelyn at Brighton and Sussex Medical School and colleagues.
“Historically, antibiotic courses were set by precedent, driven by fear of undertreatment, with less concern about overuse. For many indications, recommended durations have decreased as evidence of similar clinical outcomes with shorter courses has been generated,” they wrote.
“For most indications, studies to identify the minimum effective treatment duration simply have not been performed,” noted the article.
What researchers do know today is that many variables affect a person’s response to antibiotics, including the pathogen being treated and previous exposure to antibiotics.
While hospitals have updated practices to monitor patients for biomarkers and stop antibiotics when no longer needed, more research is needed to arrive at appropriate new instructions for patients to follow at home, such as “stop when you feel better.”
One of the reasons the “complete the course” mantra has held so well is that it’s simple and easy to carry out, noted the researchers.
In order to change public thinking, the medical profession must buy into the idea that the old advice is wrong and engage in more patient-centered decision-making around antibiotics. One leverage point in discussing the idea with patients is that “completing the course” runs counter to most people’s belief that they should take as little medication as necessary.
“Concerted and consistent efforts have successfully educated the public that antibiotics do not treat viral infections,” the authors noted.
Executives at the forefront of achieving the Triple Aim discuss barriers to meaningful innovation in an era of shrinking reimbursement and system disequilibrium.
If there's one thing organizations share when it comes to population health, it's that there's plenty of opportunity to refine their strategy.
The top takeaways from this year's HealthLeaders Media Population Health Exchange, a gathering of more than 40 invited senior health executives in Colorado Springs, CO, surrounded lessons learned in overcoming four key widespread difficulties.
Return on investment
The entrepreneurial energy in many organizations is strong, which is great for fostering bottom-up innovation—but the resulting unstructured efforts can be problematic for demonstrating hard ROI, according to Neil Carpenter, vice president of strategic planning, research and transformation for LifeBridge Health in Baltimore.
For example, "physician's research and administrative time is not well tracked for but is a very costly investment for the organization," he said.
"So the care solution that's created by a faculty member may require lots of unfunded time and even administrative support; but you don't see those costs buried in the budget, and you don't know if there's a real ROI on the solution."
As a result, LifeBridge is working to improve its focus on a shorter list of initiatives that are strategically critical to the organization.
"We're trying to get the leadership team to be more hands-on in the pilot phase to make sure it's set up in a way that we can get real cost and outcomes data out of it," Carpenter said. "And if there's hard ROI, we scale those [projects]."
Legal and regulatory opposition
Compliance is complicated, and health system counsel often prefers to err on the side of caution—costing not only frustration but also untold dollars if a project is stalled or halted altogether.
That said, it is possible to make attorneys and compliance specialists partners in facilitating change. "Involve them at the ground level," said Megan Harkey, MHA, director of operations and finance for Houston Methodist Coordinated Care in Houston. "And ask, 'How do we get there?' You want not just a yes or no, but how to get to yes."
"If you have too many pilots and no one managing the air space, the planes crash," said Julie Bietsch, vice president of population health management for Dignity Health in Phoenix, AZ.
Therefore, Dignity makes an effort to diversify its pilot projects into various markets. Then, "once you've gotten past the bugs, you've got to move fast towards implementation," she said.
And while some site-specific customization may occur, the onus should be on entities to prove why variation is necessary.
Fear of failure
However, the nature of pilot projects is that a proportion of them are expected to fail.
To make progress, it's critical that leadership creates a culture that embraces calculated risk and an environment of change, said Parinda Khatri, PhD, chief clinical officer for Cherokee Health Systems in Knoxville, TN.
"In reality, it's much more expensive not to take risk," she said. "You don't get in trouble at CHS for failing. You get in trouble for not trying."
The Strong for Surgery Program is linked to a two-thirds decrease in the rate of smoking in patients undergoing cervical and lumbar spine procedures, according to research from the University of Washington.
A presurgical health-optimization program known as Strong for Surgery has shown dramatic results in getting patients to quit smoking before elective back surgery, according to research presented this week at the American College of Surgeons (ACS) 2017 Quality and Safety Conference.
“People who smoke are two to three times more likely to have a failure of the spine surgical fusion, endure continued pain and dysfunction, and have a reoperation that can cost as much as $100,000,” said lead study author David Flum, MD, MPH, FACS, professor of surgery and associate chair for research at the University of Washington, Seattle.
The intervention, launched by the University of Washington in 2012 and promoted by the ACS since 2016, uses a similar concept to the widely used operating-room checklist, but takes place in the preoperative setting.
To help patients become healthier before surgery, surgeons use the Strong for Surgery smoking checklist to determine patients’ smoking status. The program includes tools to direct patients who smoke to cessation programs and treatment.
For the new study examining the effectiveness of Strong for Surgery, researchers looked at data involving nearly 24,000 patients who underwent cervical or lumbar spine fusion procedures at 18 hospitals across Washington State between 2011 and 2016.
The analysis showed that the proportion of patients who smoked in 2011, before the quality-improvement intervention was introduced, was 36% compared with 12% in 2016.
In addition, smoking cessation counseling surged from 6.14% in 2012 to 42% in 2016.
“In addition to the Strong for Surgery checklist, getting surgeons directly involved in the messaging around cigarette cessation is very powerful, whereas public health interventions are about generic messaging directed at everyone,” Flum said.
“In general, surgery is a very teachable event, so it’s a prime opportunity for patients to take stock of their health, and we find that patients are more apt to listen,” he added.
By connecting overdose patients with non-clinician 'recovery coaches' quickly, hospitals have a better chance of promoting long-term recovery.
For hospitals and health systems, truly treating substance abuse disorders means doing more than pumping stomachs, administering fluids, or giving emergency opioid-reversal drugs.
Such treatments, while life-saving, address only the surface of addiction.
One of the opportune settings to convert rescue into recovery is the emergency department, says Kyle Martin, MD, medical director of emergency services at St. Mary's Hospital in Madison, Wisconsin, part of SSM Health, a nonprofit health system that includes 20 hospitals and more than 60 outpatient care sites.
The ED is where many patients suffering from addictions interface with the healthcare system, he notes.
"A lot of them don't have primary care physicians, and aren't accessing care in any other way than through the ED, so that's really the only place we're going to be able to touch their lives," Martin says.
Optimize the Moment of Crisis
Outreach during the moment of crisis can make all the difference. "I'd imagine people have seen some adverse effects of their addictions, but it's a powerful moment to wake up in the ED and have a physician explain that you were basically dead."
Martin's ED in Madison, which receives about 38,000 visits per year, saw more than 180 cases of opioid overdoses in 2015—or about one every other day.
In the hopes of bringing overdose rates down, St. Mary's has launched a program modeled after the Rhode Island–based Providence Center's AnchorED, which deploys "recovery coaches" to the ED to counsel patients treated for opioid overdose and introduce them to resources for addiction recovery.
The coaches, all of whom have overcome their own addictions and received special training in counseling, also follow up with patients after meeting in the ED to help them stay engaged in the process.
Similar programs exist or are in development at hospitals in New York, Pennsylvania, New Hampshire, and Massachusetts.
Martin says he hopes to see his hospital's pilot succeed and expand throughout SSM Health and beyond.
"We in the ED can get into this cycle in which someone comes in and they have overdosed; we reverse them and watch them for a while, but don't actually know how to break the cycle. That's what this program hopefully will be able to accomplish."
Identify Funding Opportunities
The St. Mary's recovery coach program would not be possible without the organization's partnership with Safe Communities Madison and Dane County, a $7,500 grant from the Wisconsin Medical Society Foundation, and $15,000 from Dane County, Martin says.
He recommends that healthcare systems reach out to their outpatient addiction communities to learn about organizations that may be able to help.
"Often, I think the outpatient and inpatient worlds are kind of operating in isolation, or in parallel. The key is making a bridge through an organization like Safe Communities so you can get people who have real-world experience in the community and are really plugged in," he says.
With the passage of the 21st Century Cures Act in December 2016, which includes $1 billion in state grants over two years to address opioid abuse and addiction, such opportunities may expand.
Watch for Recidivism
While a degree of relapse is inevitable, lower recidivism rates are a key indicator of success.
"The most powerful question will be whether we're able to get [patients] to their own homes and maintain a recovery program so they don't have to come back to the ED," Martin says.
While a handful of specialists saw pay increases of 7% or more, compensation stayed fairly flat overall, according to American Medical Group Association consultants.
More than three-quarters (77%) of physician specialists enjoyed increased compensation in 2016, but the overall weighted average increase of 2.9% was slightly lower than the 3.1% bump specialists experienced in 2015, according to a report from AMGA Consulting.
In addition, the AMGA 2017 Medical Group Compensation and Productivity Survey, representing data for 140 physician specialties and 28 other provider specialties, revealed the specialties experiencing the largest increases were as follows:
Nonetheless, surgical specialties saw an average increase of 2%, down from 3.6% in 2015. Meanwhile, primary care specialists saw a smaller dip, earning an average increase of 3.2% in 2016 compared to 3.6% in 2015.
“We are seeing signs of a perfect storm gathering as costs continue to rise, productivity is flat, and collections are flat, with 51% of specialties this year reporting a decrease in median net collections,” said Tom Dobosenski, CPA, president of AMGA Consulting.
“These trends are driving enhanced efficiency and consolidation, but the cost curve will only bend so much. With 61% of groups responding that some of their physicians’ compensation was based on the achievement of value-based measures, the move to value-based incentives is happening, albeit at a slower pace than anticipated. However, value-based incentives do not lessen the economic pressures on medical groups, as they do not necessarily mean reductions in compensation.”
To avoid ending up with a flimsy strategy, consider the philosophy used by Dignity Health’s population health department.
Julie Bietsch, vice president of population health management for Dignity Health in Phoenix, has a diverse background as a registered nurse as well as a longtime executive in the payer world. But to explain her health system’s philosophy toward population health, she points to a construction analogy.
“When we first launched our population health strategy, we used the analogy that we’re building a house,” said Bietsch last week during the HealthLeaders Media Population Health Exchange, a gathering of more than 40 invited senior health executives in Colorado Springs, CO.
“The first thing you have to know is what kind of house you want to build. We wanted to build a house that was affordable for patients, was of high quality, and met their needs and added value to them,” she said.
To do so, the team created the following elements:
“Our foundation was our network—our physicians,” she said. This phase also refers to the time to determine the size and shape of one’s foundation or network.
Adding walls means selecting the right clinical pathways and platforms to share consistency across your clinical model. It must also be focused on the ambulatory market, she said.
Doors enable referrals, Bietsch explained. “What goes inside and outside of your house through the referral process?”
You have a better chance of managing quality of care and cost efficiency if patients stay within your network.
The windows are your analytics. “How do you look into your house and outside of your house using analytics?”
The roof is made up of payers and patients and a plan for marketing to them.
Marketing can vary drastically among Medicaid, Medicare, Medicare Advantage, Medicare Shared Savings Plans, commercial plans, and direct-to-consumer products. “So we had to decide who we were going to sell this house to,” she said.
Decorating must be the final step, Bietsch said.
“If we don’t have walls up, we don’t have windows up, and a vendor is trying to sell me an innovative patient engagement tool—and I don’t have a network and I don’t have a clinical program—I’m not ready to decorate my house yet,” she said.
“So if I buy a new tool, it’s basically going to sit on a shelf because I can’t integrate it with my clinical solutions and our network of providers will not use it.”
However, it’s important to get buy-in for your plans early on.
“If you don’t sell and have people invest in your house in the beginning, they’re going to build their alternative house,” she says. “And their house is going to be made of sticks—and cost the buyer more in the end.”
Formal advanced business education isn't essential for clinicians to succeed in the C-suite. But certain personality traits do matter.
It's one thing to scan a physician's CV and learn what business credentials he or she would bring to a leadership role. It's another to assess whether a person's character traits are right for the job.
"Sometimes, unfortunately, it's a bit of trial and error," says Cynthia Hundorfean, MBA, president and CEO of Allegheny Health Network, a Pittsburgh-based integrated health system with seven hospitals and numerous outpatient sites across Erie and western Pennsylvania.
"But you have to be very good at selecting leaders who you think have the personalities, as well as the qualifications, to be able to lead efforts that are beyond their basic skill set," she says.
More Than Intelligence
It is a process of both art and science.
"Every doctor is intelligent," says Lynn Massingale, MD, cofounder and chairman of Knoxville-based TeamHealth, which offers outsourced clinical care across a variety of specialties to approximately 3,400 acute and postacute facilities and physician groups nationwide. "At the same time, they don't all have the right personalities or interpersonal skills for leadership."
At TeamHealth, clinicians identified for leadership positions undergo evaluations—such as DiSC profiling, a personality and behavior assessment tool—that help illuminate traits of one's potential leadership style.
"We actually use some tools for testing prospective physician and business leaders, but we look for high emotional IQ, empathy, ability to build consensus, etc., as starting points," says Massingale.
"Then we take those prospective physician leaders and help them understand what their strengths and weaknesses are, show them the areas they need to work on to be better leaders, and over a number of courses, augment their skills in conflict resolution and communication, to fill in the gaps."
The Right Stuff
But personality traits in and of themselves aren't necessarily good or bad for leadership. One person might tend to behave more analytically, for example, while another communicates best on an emotional level. These are qualities to consider when matching the right person to the right team or opportunity.
Some qualities that are consistently linked to success, in Hundorfean's opinion, are a candidate's willingness to be self-aware, reflective, and coachable.
"To be a strong physician leader, you need to be a good physician. I also look for people with warmth and energy," says Hundorfean.
"But most of all, I look for leaders who are direct. I like people who say what they mean, and don't waste time," she says. "When you're dealing with patients, physicians have to be direct with them, and I want our physician leaders to do the same when they are talking to me, or to employees."
Ability to Engage
Promising leaders also understand their own assets.
For example, Mark Rubino, MD, MMM, became president of AHN's Forbes Hospital in 2016, and holds specific standards for himself in carrying out the goals of the promotion.
"If we're going to move the organization forward, it comes down to the engagement of frontline staff," Rubino says.
"It can get a little overwhelming in regard to the amount of tasks that are necessary to perform this job, but I get very uncomfortable if part of my day isn't spent walking those floors, interacting with the nurses, doctors, and other caregivers. I learn more from that than I do almost anything else," he says.
Investigators at Johns Hopkins found that 92% of handwritten prescriptions failed to meet ideal practice standards, contained errors, or failed to comply with federal opioid prescription rules.
Electronic prescriptions for opioids aren’t just safer when it comes to legibility.
Because physicians complete them using standard templates, e-prescriptions are also far more likely to comply with Drug Enforcement Agency (DEA) standards and industry best practices, such as date, pill quantity, and inclusion of at least two patient identifiers, according to a study published in the Journal of Opioid Management.
The study involved 510 prescriptions filled at a Johns Hopkins Medicine outpatient pharmacy, and aimed to contrast prescribing and processing errors that occurred in electronic versus handwritten opioid prescriptions at the time of discharge. Nearly half (47%) of the prescriptions studied were written by hand, while the rest were created by the electronic health system.
Overall, 42% of prescriptions contained some error, researchers found.
While both the handwritten prescriptions and electronic prescriptions failed to meet the DEA’s standard at the same rate (41%), according to the researchers, all prescriptions that violated best practices were handwritten.
Among prescriptions written by hand, 89% deviated from “best practice” guidelines or were missing at least two forms of patient identification information.
None of the electronic prescriptions—created using a template aligned with best practices—showed these errors.
“Mistakes can be made at any point in the prescribing, transcribing, processing, distribution, use and monitoring of opioids, but research has rarely focused as we have on prescribing at the time of hospital discharge or on written prescriptions prescribed for adults,” said Mark Bicket, MD, assistant professor of anesthesiology and critical care medicine, and the paper’s lead author.
While safety measures taken at the pharmacy make it unlikely that patients will get the wrong dosage or drug due to the prescribing errors described, problems at any stage compromise overall patient safety Bicket noted.
“What we hope our results do is get more practitioners to adopt electronic prescribing systems because we have a duty to practice in a way that has the lowest chance of harm to our patients,” Bicket said.