The Verden Group

Patient-Centered Specialty Practice for Specialists

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While still in its infancy, word about the National Committee on Quality Assurance’s (NCQA) medical home program for specialists is spreading fast. The program was released last March and appears to be gaining considerable momentum. We receive inquiries daily from practices asking how we can assist them with meeting the program’s standards; from gastroenterologists, oncologists, nephrologists, orthopedists, even ophthalmologists.

Unlike the primary-care Patient-Centered Medical Home (PCMH) program that has taken several years to become firmly established, it appears that specialists are “early adopters” of this new similar program — Patient-Centered Specialty Practice (PCSP) — designed especially for them.

About the PCSP program

The Patient-Centered Specialty Practice Recognition Program “recognizes specialty practices that have successfully coordinated care with their primary-care colleagues and each other, and that meet the goals of providing timely access to care and continuous quality improvement,” according to the NCQA website. What this really means is this — specialists undertaking the program must comply with a rigorous framework designed to ensure that testing, referrals, and patient care are all highly coordinated and that communication between specialists, primary-care physicians, and facilities is efficient, timely, and meaningful. As you can imagine, it takes a lot of time and effort for practices to meet these standards. Transitioning to the new framework takes at least six months and often much more than that, particularly if you are a large practice with multiple locations (plan on at least a 12-month project in those cases).

Early adopters

So why would specialists seem so eager to sign up for the expense, hard work, and change that achieving recognition would bring them? Based on our clients’ perspectives it appears to come down to three things:

1. It’s a great way to differentiate from other practices.

There is considerable competition in some markets and specialists are looking for ways to provide better care to attract more patients, more referrals, and better-paying contracts. Primary care practices that have achieved PCMH status are looking for specialists that help them to better coordinate patient care; making specialists that achieve PCSP recognition effective “partners” in that care.

2. Value-based purchasing is here.

Payment for services is quickly moving away from being encounter based and toward being outcome based. Specialists are seeking a model in which to better understand how to comply with CMS programs, how to meet commercial insurers’ performance programs (such as bundled episodes of care, shared cost savings, and performance payments), and are getting ready for working with accountable care organization (ACO) models. The PCSP model offers them a way to more readily and easily comply with meeting quality measurements, helps them to better manage population health data tracking, and allows them more control over how these programs need to work within their practices.

3. Better patient care and outcomes.

Many of our clients are seeking ways to focus on their most prevalent conditions and procedures in order to provide better care and outcomes. Meaningful use compliant EHRs have helped with tracking, reporting, and population management, but many physicians are seeking a more clinical focus. PCSP provides a way to do exactly that by allowing providers to focus on specific conditions and establish improvement cycles to work toward better outcomes.

Should you sign up?

While many insurance companies across the country recognize and pay for PCMH programs, the PCSP program is still very new. So far, 310 specialists across the country have achieved PCSP recognition and many more are in process. But as this represents only a small number of specialists so far, insurers have not yet had demand to develop PCSP payment models. However, the PCSP program offers insurers a great way to reward quality across networks, without having to build out individual programs for each specialty. I therefore expect to see PCSP-based payments begin to roll out by 2015. Specialists may do well to position themselves to take advantage of these expected future contracts as soon as they begin by starting their PCSP projects without delay.

- See more at: http://www.physicianspractice.com/patients/patient-centered-specialty-practice-specialists?GUID=58DA6F8E-3929-40C3-843B-AB8CBE77A0EA&rememberme=1&ts=26062014#sthash.zBBpgsBp.dpuf

NYS Insurance Price Wars

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One of the puzzling questions about the Health Insurance Exchanges (a key component of the Patient Protection and Affordable Care Act) is, “How can the same products have such variations in premium pricing?” Differentials of between $200 and $500 a month are noted for the same metallically labeled products.  Why the difference? Answer: the insurance carrier.

The lowest prices have been associated with the newest entrants into the NY market, Heath Republic and OSCAR. The established payers, such as Empire and, in particular, United Healthcare, were priced at the high end.

Since all products are essentially the same in terms of benefits, the difference would be in the costs of the network that supports the payer’s product and the pricing philosophy of the company.

OSCAR and Health Republic are using the MagnaCare network (not known for better rates to physicians and other providers), while Empire uses a stripped down network, excluding at a minimum all academic medical centers and their associated physicians. United uses the Oxford Liberty Network making it the largest network supporting products on the exchange.  Some of the physicians, like UPN members, have rates with a very positive differential from the street rates. These higher rates translate into a larger network and higher premium.

However, corporate strategy may also be at work in the pricing of exchange products. United, , concerned that they could attract adverse selection by their wider network, took a very conservative approach. OSCAR and Health Republic moved to a more aggressive approach, resulting in some accusations that they were offering unsustainable rates to buy their way into the market. Aetna stayed off the exchange, and thought they would escape adverse selection by doing so, but was found affordable by those not needing income subsidies to purchase health benefits, and attracted by the wide Aetna network.

Another element of the pricing strategy was to consider the federal “adjustment”, or the price for expected utilization and costs.  As an enticement to participate, Payers who took the “risk” of being on the exchange have been promised economic bailout during the first 3 years. Some payers priced these plans expecting that they will get federal support for medical losses in this initial period, as well as a severity of illness adjustor, worth more than the premiums.

Severity of illness medical record requests can be expected to increase, as diagnosis coding — and its importance in payment to the payers — will play a more important roll.  Right now, only Medicare for the Medicare Advantage Plans has a severity of illness adjustment factor.

How this plays out will be seen in the rate filing for 2015 and 2016, as payers price for growth, or for financial stability. In any case, as financial viability is squeezed, payers will squeeze providers.

- Robert Goff, Senior Advisor, The Verden Group

The Verden Group is delighted to welcome Paul Vanchiere (MBA) and Sumita Saxena, Esq., to our consulting team.

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With over 15 years of healthcare management experience, Paul Vanchiere joins The Verden Group to provide our clients with financial and operational practice consulting; Sumita Saxena, admitted to the California State Bar in 2000, brings her legal focus to the Group in the capacity of business consulting services.

“The addition of specialized consultants Paul and Sumita means our service offerings are more comprehensive than ever,” says Susanne Madden, CEO and founder of the Verden Group. “Their combined expertise ensures our clients have the benefit of expert business advice and practice management tools. Sumita’s focus ranges from guidance on employment laws, to negotiation and language interpretation for insurance contracts. Paul offers a unique financial analysis of Pediatric practices, including onsite assessment, that gives our clients the tools to meet every day challenges more efficiently at a price they can afford.”

To learn more about Paul Vanchiere and Sumita Saxena, and to read more about these new offerings from The Verden Group please click on the links below.

More on Paul Vanchiere:

www.theverdengroup.com/articles/verden-group-welcomes-paul-vanchiere-team/

More on the Complete Pediatric Practice Assessment:

www.theverdengroup.com/services/practice-management/

More on Sumita Saxena:

www.theverdengroup.com/articles/verden-group-brings-legal-context-guidance-business-matters/

 

 

 

 

 

The Verden Group welcomes Paul Vanchiere to our team.

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The Verden Group is pleased to welcome the founder of the Pediatric Management Institute, Paul Vanchiere (MBA) to our team. With over 15 years of healthcare management experience, Paul joins The Verden Group to provide our clients with financial and operational practice consulting.

Currently working exclusively with Pediatric practices, Paul’s past experience with cardiology and pathology practices, as well as physician practice acquisitions for the largest non-for-profit hospital in Texas, adds a unique depth to our client services. For the past five years, Paul has worked on financial and management issues for a physician group of over 200 general Pediatricians.

Paul_Vanchiere“Paul brings considerable experience to our group. As a speaker on a range of pediatric practice management issues and with a national portfolio of clients, his extensive knowledge of practice dynamics will play a pivotal role in our efforts to provide unparalleled service to our clients,” says Susanne Madden, founder of The Verden Group. “Paul’s seasoned practice management expertise allows us to provide our Pediatric clients with the tools to not only meet every day challenges, but to do so successfully as the healthcare environment continues its dizzying pace of change.”

Paul will focus on a unique service that provides a full financial analysis of Pediatric practices along with an onsite assessment for a nominal fixed price. According to Paul, “Pediatricians often have limited resources to invest in such engagements. I am extremely sensitive to their investment of time and resources in what we do for them. I strive everyday to provide tangible advice on how to manage their practice properly.”

Paul can be reached at paul@theverdengroup.com and more information about these services can be found here.

The Verden Group Brings a Legal Context to Guidance on Business Matters

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The Verden Group is very pleased to announce the addition of Sumita Saxena, Esq., to our consulting team. Admitted to the California State Bar in 2000, Sumita brings her legal focus to the Group in the capacity of business consulting services, specializing in matters such as practice agreements, guidance on employment laws, and negotiation and language interpretation for insurance contracts.

“The addition of Sumita to our team brings the level of services we provide up another notch,” says Susanne Madden, CEO and founder of the Verden Group. “We’re not a law firm. We work in a strictly non-legal, business-only capacity when advising clients but the fact is that legal issues are a part of doing business in healthcare today. Sumita’s expertise ensures our clients have the benefit of expert business advice on these matters and are guided appropriately as to when to seek legal counsel.”

With current experience as in-house counsel for a medical group, Sumita has the hands on expertise required to confidently advise Verden’s clients on the development of sound business operating procedures and practices from a legal perspective. Sumita also has extensive experience working on employment matters, workforce & performance management, and human resources management.

She is located in Redwood City, CA, and can be reached at sumi@theverdengroup.com

 

 

 

How You Can Successfully Participate in P4P Programs

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Pearl | April 30, 2014 | PerformancePayersPearlsPhysician Compensation

 

Participating in pay-for-performance (P4P) programs can work out well for both provider and payer. By “performing well” on certain clinical and administrative measures, savings are created that can be shared with both parties. That is, if providers can meet specific metrics that appear to produce some savings by, say, coordinating patient care better or ensuring that the population is receiving timely preventive care, then everyone wins and costs go down.

However, it can be a little perilous to participate in these programs if you don’t have a good understanding of your own data. Signing up to meet specific goals without first knowing where you currently stand or without being able to monitor progress as you go along a defined time period can mean falling short of expectations and losing out on additional revenues. So, it is vital that you must be able to run reports in your own system to either validate or dispute the data that the payer will be producing, in terms of how your providers have performed. Depending on your IT infrastructure, this may or may not be an easy task!

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Participating in New Healthcare Exchange Plans

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Pearl | February 19, 2014 |

It is early with regard to the healthcare exchange plans and yet practices across the country are already feeling the impact. It’s not just consumers who have experienced problems while attempting to sign up for the exchange plans on the healthcare.gov website; providers too are dealing with major headaches as they navigate through the first couple of months of this new system.

Looking for more information about the effects of healthcare reform on your medical practice? Join us May 2 & 3 in Newport Beach, Calif., for Practice Rx, a new conference for physicians and office administrators.

Let me explain. The insurance companies created something called “narrow networks” within their full network of providers. What that means is that only a subset of physicians within any given insurance company’s network “qualified” for participation in the exchange plans. The result is that while some physicians got rolled into these plans, others were excluded, even though they participate in some of the other products with that particular insurance company. For example, a physician could be participating with an HMO and a PPO-type product, but be excluded from the exchange product. This has created a dilemma for many practices. On the one hand, it means no new business coming in from new exchange members. On the other hand, it also means scrambling to hold onto existing patients that have switched to these new, lower-priced health insurance products.

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Medical Practice Super Groups, Are They for You?

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PHYSICIANS PRACTICE Pearl | November 20, 2013 |

- See more at: http://www.physicianspractice.com/practice-models/medical-practice-super-groups-are-they-you/page/0/1#sthash.McvWyqmn.dpuf

Practices today are facing challenges such as lower earnings, more complex regulations, higher costs, obligations to create higher-quality care and produce better outcomes, all while they see other colleagues merge or become acquired by local hospitals or healthcare systems. So at least once a week I get an inquiry from a physician asking, “Should I sell my practice?”

There is no single answer to that question. It depends on many factors, including whether or not the practice is in good financial shape and if it is well managed. I do consider those to be two of the strongest indicators for successfully remaining independent. However, the options shouldn’t be limited to either selling or remaining independent.

Practice-without-walls models

As an alternative, some practices are now coming together to form “practice-without-wall” groups or “super groups.” Some of these are single specialty and band together in order to achieve efficiencies of scale, to reduce costs, and to create collective competitive advantages. Others operate more like independent physician associations (IPAs) due to the fact that they are multi-specialty and may bill under multiple tax identification numbers.

I’m a big proponent of single-specialty super groups because this model allows for practices to come together under one unified business structure that can focus very effectively on building a quality single-specialty organization. That is, single-specialty super groups understand the challenges inherent in their particular specialty, and therefore are best equipped to tackle them and provide the most appropriate solutions.

So what does a super group actually do?

If built well, a super group offers individual practices the opportunity to retain some autonomy while reaping the benefits inherent in being part of a larger organization. The primary purpose of a super group is to centralize services and gain efficiencies of scale. Centralized services include billing, human resources, and accounts payable. Most contract and bill under a single tax identification number, and depending upon the size and quality of the group, will probably be able to negotiate better rates with insurance companies.

By centralizing things like payroll, billing, accounts payable, and claims management, you reduce the overhead that each practice has to lay out independently. But more than that, a larger-scale operation reaps the benefit of lower collective costs for things like malpractice insurance, medical supplies and vaccines, and health information technology, and provides the business resources best qualified to manage them.

What about practice autonomy?

You may be thinking that this sounds a lot like selling to a hospital. So what is the difference? To start, you won’t be just another employee. Super groups consist of shareholders. Certainly there will be collective rules that need to be adhered to, the same as there would be if you sold to a hospital, but most practices that join super groups get to keep their own staff, their patients continue to see the same providers, at the same locations, and arrangements between partners can remain the same depending upon the governance structure chosen.

What will change is usually the technology you use — super groups work best when all practices are on the same EHR, for example — and more and more frequently, the standard of “quality” to which you must perform.

Specifically, in order to achieve better insurance contracts, super groups need to demonstrate quality clinical outcomes and show that their members can achieve certain metrics and clinical targets. Payers are no longer interested in just size — even a small super group has negotiating power, provided it can demonstrate a compelling “value proposition” to the payer. That is, if the super group can provide superior services by managing care more effectively and successfully than its peers, then it can benefit from shared cost savings with a payer.

How to start a practice without walls

Are you friendly with associates in another practice? Do you share similar philosophies and clinical practices? Then it may be time to talk to one another. Seek out others who have formed super groups in other regions or in other specialties and ask them how they did it.

Forming a super group requires setting up a legal structure and working through development of an operating structure that all members can be happy about. With the proper support from lawyers, accountants, and consultants who have put together other super groups, you will be in good hands.

So before you sell, consider joining or starting a super group. It really is a great option!

- See more at: http://www.physicianspractice.com/pearl/medical-practice-super-groups-are-they-you#sthash.RxjpwjAM.dpuf

The Independent Pediatrician

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Our good friends over at PCC (Physicians Computer Company) in Vermont, very ambitiously set about to launch a new journal, aptly titled The Independent Pediatrician. They believe, much like we do at the Verden Group, that the day of the independent physician is not gone, rather, it just needs support from folks like us to help ensure that those brave docs thrive.

You can read the first issue here, free, on Issuu: http://issuu.com/independentpediatrician/docs/tipvol1

Enjoy!