Accounting for Your Success
The final rule for the Centers for Medicare and Medicaid Services’ (CMS) Accountable Care Organization initiative (aka the Shared Savings Pro-gram) is incredibly complex. Much of the practical, day-to-day details of implementing accountable care at the practice level are still unclear (“murky-but-moving” is how some have described the process).
The Train Is Moving
Still, hospitals and physicians are moving ahead to form collaborations. In fact, 58 percent of primary care physicians expect to eventually join an accountable care organization (ACO), with 44 percent expected to make the move within the next three years, according to the results of a recent survey in Medical Economics.
In particular, many of these collaborations are crystallizing around hospital systems, faculty practices and Independent Practice Associations (IPAs). The rationale is certainly compelling: Allying with fellow physicians and others in an ACO might be a good way to preserve — or even increase — income, especially as the traditional fee-for-service system comes under increasing attack.
Rewards and Requirements
At its most basic, the Medicare Shared Savings Program will allow four types of entities to create ACOs:
1. Physicians in a group practice arrangement
2. Physicians in independent practice associations
3. Hospitals that employ physicians
4. Partnerships or joint venture arrangements between hospitals and physicians
Approved entities must agree to participate for three years. They also must be accountable for the quality, cost and overall care of Medicare beneficiaries assigned to them; have sufficient numbers of primary care physicians to meet the patients’ needs; and have defined processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care.
Pick Your Partner Well
There are plenty of questions to ask before offering your services to an ACO. Yet, the best advice may simply be to look for organizations that exhibit some basic characteristics of success, such as:
• A willingness to invest in health information technology. A robust IT infrastructure is critical for managing patient information across multiple sites of care. This will require electronic health records and health information exchange to manage care and share information in real time.
• A commitment to measurement and reporting. An ACO must monitor quality and cost and then report that data to the payer, whether this is an employer, patient or health plan. The ACO must have defined processes to set quality benchmarks and measure performance indicators.
• An acceptance of alternative payment methods. Ultimately, payment methodologies should be designed to bring about “value-based” payments, in which physicians and other providers receive traditional fee-for-service payments, with physicians getting a share of any savings generated.
• A focus on evidence-based medicine. ACOs are required to have defined processes for promoting evidence-based medicine (which can include clinical guidelines and decision support tools) utilizing current, credible and objective evidence about what tests and treatments work.
If You Decide to Join…
Joining an accountable care organization isn’t a step to be taken lightly. When a hospital or integrated delivery network asks you to join its ACO, make sure you get the answers to these five critical questions:
1. Who will lead? CMS rules call for active, inclusive management of any ACO. At least 75 percent control of an ACO’s governing body must be held by ACO participants, including at least one Medicare ACO system patient. So look for an organization committed to an effective, representative system of governance. Likewise, consider where you fit into it all – for example, what are your own capabilities and desires for leadership?
2. How will savings be shared? The ACO concept is all about shared savings. If, for example, primary care physicians as a category are to receive a portion of the payments, then any agreement should spell out how allocations will be made to each provider (e.g., through utilization and outcome measurement).
Conversely, there should be a mechanism in the agreement that penalizes over-utilization. For example, doctors who are overprescribing and overusing services shouldn’t receive the same portion of the shared savings.
3. Are the right providers in place? To ensure success, the ACO must cover the entire continuum of care – primary care, acute care and post-acute care services. Certainly, specialty physicians will be required, but the onus will be on primary care providers. ACOs must be able to care for a minimum of 5,000 Medicare beneficiaries, which means they must have enough primary care physicians to serve the patient population. Best estimates translate this to approximately 5-20 primary care physicians.
4. What’s the risk model? The ACO can enter into a one-sided or two-sided shared savings agreement. Under a one-sided risk model, an ACO that creates savings of at least 2 percent would get 50 percent of the money above that threshold, but it would have no penalty if it spent more in the first and second year. Under the two-sided model, an ACO could receive 60 percent of the money above the threshold but would also be penalized if it led to higher costs. By the third year of the program, all ACOs would become responsible for losses.
5. Is there a way out? CMS rules dictate that an ACO must commit to the Medicare Shared Savings Program for at least three years. But it is not clear how long individual providers must commit. Here, you may want to hedge your bets and make any commitment short-term (e.g., the initial three years).
However, if participation requires a considerable up-front investment, you may want to commit to a longer relationship. Regardless, you’ll want to at least have thought out an exit plan – and any repercussions for leaving.
As questions inevitably arise about the appropriateness of the ACO model for your practice, we hope you’ll turn to our experienced professionals for guidance.
1. Get meaningful about EHR. If you don’t have one already, obtain a meaningful use-certified electronic health records (EHR) system and start using it in meaningful ways.
2. Start measuring performance. Start tracking your performance on Healthcare Effectiveness Data and Information Set scores, customer satisfaction, etc.
3. Crunch the numbers. Compare your practice data (e.g., utilization) against metrics from the American Health Care Association, federal government data sites, managed care organizations, independent practice associations and hospitals you use.
4. Bone up on Medicare compliance. Take compliance very seriously. Work with managed care specialists and experts in Medicare regulations to get on track
5. Create synergies. Look for opportunities to work with specialists in your area to create a team approach to patient care.
6. Study the market. Study successful providers in your market – and learn from them.
7. Focus on quality. Last of all, focus on practicing good medicine and providing excellent service to your patients.
During an economic downturn, all of the elements necessary for workplace fraud to occur are amplified. Financial difficulties at home may motivate an otherwise honest employee to steal. At the same time, strained budgets may result in staff cutbacks and less oversight and segregation of financial duties.
Understanding the Fraud Triangle
It’s critical to understand the three elements that experts agree are necessary for fraud to occur – the so-called “fraud triangle”:
1) Motivation. Typically referred to as “unbearable financial pressure,” this is, of course, different for different people. For example: “I’d really like to have that convertible,” or “I’m way over my head in debt and can’t bear the humiliation of declaring bankruptcy.”
2) Rationalization. This is the thought process that makes fraud acceptable in the perpetrator’s mind. For example: “I’m not stealing – I’m just borrowing the money and I’ll pay it back,” or “I’m just taking what they owe me … everybody does it.”
3) Opportunity. This is the occurrence of a situation the thief feels he or she can exploit without getting caught. For example, without proper internal controls, cash from patient copays (an increasingly substantial amount at many practices) is easy for a motivated perpetrator to pocket.
Mitigate the Risk
The good news is that the “opportunity” leg is the one point on the fraud triangle that you actually can manage. With solid internal controls – the checks and balances you incorporate into your everyday practice management – you can eliminate many of the opportunities for fraud to occur. Consider these steps:
• Segregate financial duties. For example, ensure that staffers who enter cash are not the same ones creating the deposit tickets. And use processes that provide an audit trail so you can track who is doing what, see when they are doing it, and retrace the process from invoice or receipt entry through approval, posting and payment. This could be paper logs/ledgers or a software solution.
• Monitor regularly. Establish certain predefined financial parameters for your practice and regularly monitor that you are within them. For example, if you track your copay collection percentage, use a system that allows you to constantly monitor that ratio. Randomly conduct spot-checks every few days and compare your schedule with your day sheet to verify that all the treatment delivered was posted. Routinely scan adjustments to ensure there was a valid reason for making them.
• Review bank statements. Another no-cost control measure is for management to closely review bank statements and accounts payable and receivable.
• Require signatures on large checks. Consider requiring a physician owner’s signature on checks written over a certain amount.
• Engage staff. The majority of fraud is uncovered via a tip from someone who’s seen something suspicious. The Association of Certified Fraud Examiners (ACFE) reports that organizations with anti-fraud training for employees and managers experience lower fraud losses. Likewise, consider instituting a “fraud hotline.” Whether handled internally or outsourced, a confidential means for employees to report suspected fraud can be a wise investment.
• Consider insurance. Employee dishonesty insurance, also known as an employee fidelity bond, protects you if an employee embezzles or steals something from your office. Ask your insurance provider whether you can purchase a “blanket bond,” which will cover everyone in the office and will preclude you from having to update the names on the policy every time someone new comes aboard.
Conduct an Internal Controls Study
Establish a baseline for your practice’s fraud prevention efforts with a thorough internal controls study – either conducted in-house or with the help of a third party specializing in fraud prevention or detection.
Our firm is experienced in fraud prevention and internal control studies. Call us to discuss the needs or your business or organization.
Busy healthcare providers face an avalanche of daily distractions – nearly five disruptions an hour, according to a 2011 study in the Journal of Medical Internet Research.
Consider these tips for balancing the bombardment:
• Dial down smart-phone distractions. As more and more doctors rely on mobile devices – for both clinical and personal uses – the potential for distractions is rising. Fine-tune your device’s notification settings to distinguish work-related from nonclinical communications so that professional matters (incoming test results, pharmacy requests, etc.) are prioritized ahead of others.
• Screen electronically. You’re probably already letting voicemail catch all non-emergency phone calls, but how about creating an auto-responder for email/voicemail? Use this to let others know when you will be available.
• Manage the crush of pharmacy reps. Consider using scheduling software such as RepConnect (http://rep connect.com), which alerts reps to register online and self-schedule their office visits based on your parameters.
• Bundle up. With non-urgent issues, have your staff “bundle up” matters and approach you with several things at once at a designated time. When they have non-emergency access to you only at a pre-determined time, your staff will learn to save non-urgent issues until then.
• Use the fax. Faxed communications (between pharmacies, hospitals, home care agencies, etc.) minimize telephone interruptions and phone tag. Ask your staff to place faxes on top of the next patient’s chart so you can address them between patients.
• Create “No interruption” zones. Use colored tape, tile or a small rug to clearly indicate designated area where interruptions are not allowed. And then use this area to perform critical tasks (charting, order entry, dispensing, etc.)