The Verden Group

The Potential of Patient-Centered Specialty Practice


PearlSeptember 02, 2015Practice ModelsHealthcare ReformPatientsPearlsPhysician Productivity


What is PCSP?

Patient-Centered Specialty Practice (PCSP) is a recognition program from the National Committee for Quality Assurance (NCQA) that went into effect in 2013. The PCSP program was designed in many ways to complement the success of NCQA’s Patient-Centered Medical Home (PCMH) program and expand its reach. The goal of the program is to encourage excellent care coordination by specialty practices in the outpatient setting, leading to less duplication of procedures and fewer hospitalizations.

Much like the PCMH program, the PCSP program focuses on proactive coordination of care, information sharing among clinicians involved in a patient’s care, and a centering of care around the patient (versus around the care setting).

According to the NCQA, “Specialists who achieve NCQA PCSP Recognition will show purchasers (consumers, health plans, employers and government agencies) that they have undergone a rigorous and independent review to assess their capabilities and commitment to excellence in sharing and using information to coordinate care.” What this means practically is that practices that undergo the process will be better placed to meet the challenges of the marketplace.

The value-based era

With the implementation of the Affordable Care Act, the shifting of costs to consumers, and the advent of large deductibles and consumer-based plans, we have moved swiftly into an era of purchasers looking to obtain “value” for their healthcare dollars. Synonymous with value is “quality” and patients are being both incentivized and penalized based on the healthcare provider choices that they make. For example, certain employers and payers will waive all cost sharing (copays, deductibles) for patients in certain networks that choose to receive their care from PCMH-recognized practices. Conversely, patients may face higher copays and cost sharing percentages for not going to PCMH practices where there is availability to do so.

Additionally, just about all physicians in many payer networks are being “graded” based on their ability to meet quality, efficiency, and cost metrics (check out United Healthcare’s Premium Designation Program, Aetna’s Aexcel Program, or Cigna’s Care Designation Program). These grades affect cost-sharing the same way that PCMH-based benefit design does; if a patient chooses to go to a physician who has a low score, that patient may have a greater financial cost share because of it.

However, while the PCSP Program has been in place for a couple of years now, payers have been slow to recognize this program to the same extent as they now recognize PCMH. It took approximately three to five years for most payers to recognize PCMH and I expect it will take the same for PCSP to be as widely recognized.

The potential of PCSP

While it may take some time to be as widely recognized, PCSP offers payers the same opportunity to neatly categorize and recognize “high performing, high quality” practices across specialties. It is expensive for payers to build out performance metrics for each and every specialty and frankly, for many specialties it can be hard to quantify “quality” at all. Therefore, PCSP offers payers a way to incentivize practices and reap a better return on their investments with PCMH-recognized practices. The continuum of care for patients can be better coordinated under similar models of care across both primary and specialty practices.

In addition, transitioning to a PCSP model can help practices better position themselves for working within future “accountable care” type models and clinically integrated organizations (for more on this, read the article “Physician Reimbursement Changes: 5 Ways to Gain Control“). The bad news is that once higher performing practices become the new standard of care, practices that have not addressed their “grades” and/or participated in quality programs will not only face consumers making choices to avoid them, but are also likely to be hit with fee schedule cuts too.

How to obtain more information

The PCSP program hinges around asking practices to focus on the following areas:

  • Develop and maintain referral agreements and care plans with primary care practices.
  • Communicate timely information that helps practices agree on a plan for coordinating care
  • Share care management for patient referrals.
  • Provide superior access to care, including electronically, when patients need it.
  • Track patients over time and across clinical encounters to assure the patient’s care needs are met.
  • Provide patient-centered care, which includes the patient (and the patient’s family or caregiver, if appropriate) in planning and goal setting.

If you are interested in exploring the PCSP program further, you can find more information here.

If you are already participating in an NCQA program (such as the Diabetes Recognition Program (DRP) or the Heart/Stroke Recognition Program (HSRP), you will receive credit toward your PCSP scores for that. Also since the program is aligned with meaningful use, if you are participating in that you will already have several points and material that can count toward your score too.

Bottom line

Quality-care programs are here to stay and practices can expect to see more and more initiatives rolling their way in 2016. NCQA’s PCSP Program offers both a framework for transitioning to better care coordination and clinical integration with other providers, and an opportunity down the line to potentially reap incentives from payer plans once those hit the market. As achieving PCSP can take a year or more depending upon your organization’s size, don’t wait until payers begin paying for it. Instead, get started now and reach out to payers with which you participate to ask them how they are supporting (or plan to support) practices that achieve PCSP Recognition today and in the future. The more payers hear from you on this, the more important it becomes for them to incentivize those practices that are achieving this level of care. At the very least, it may help to get a negotiation started where no incentive is currently available.

Building Effective Patient Education Programs


PearlApril 22, 2015Patient RelationsACOHealthcare ReformPatientsPearls

Patient education programs have been around for a long time, but typically these programs have been geared toward only the chronically ill and those that needed extensive management. In this era of the Patient-Centered Medical Home patients and insurers are looking more to physician practices to provide effective patient education in all aspects of their care. In fact, many insurance companies are actively measuring physicians’ performance on quality metrics. Current accountable care models factor in patient utilization of emergency rooms, hospital visits, and prescriptions, and attribute that cost to the patient’s primary-care doctor, which may also include specialties such as cardiology.

So what does this mean to your practice? With more accountability comes the need to manage patient populations more effectively to be able to hold the line on costs. If you are not doing a good job in actively engaging patients to “self manage” their own care, and utilizing lower-cost opportunities for managing your patients’ care, then you may soon find yourself failing to achieve a targeted level of care and cost utilization, and that will cost you money.

Creating and implementing effective programs

The most effective education programs are those that are customized to each patient. But don’t let that daunt you. You can define general care plans and then customize those on a patient-by-patient basis.

• First, determine what conditions to tackle. Get to know your patient population. What are the most complex and costly conditions that you manage? What conditions apply to the most patients across your practice? Hone in on those areas to begin with, set up and fine-tune a program or two, and then you can replicate successful programs across your entire patient base from there.

• Second, assess your patients’ needs. Determine what actual resources and help is needed by your particular patients. Do not hesitate to poll your patients by asking them directly what their specific needs and challenges for self-management may be. If you make assumptions about your patients’ needs, you may only meet the goals of a small part of your population, which can be counterproductive and result in poor compliance with the program. In addition to assessing needs, assess the challenges (such as lack of family support) and skills (Internet use, reading ability etc.) of your patients and build a program that can adequately meet them where they are coming from.

• Third, use what’s available. Don’t reinvent the wheel. There are lots of good materials, courses, and programs available. It’s OK to adopt a program you like; just make sure to thoroughly review all of the material and adjust the sections, ideas, concepts, and so forth to fit with your specific patients’ needs and your style of practicing medicine.

• Fourth, communicate effectively and set small targets. Let your patients know about these programs and educate them about what they are expected to do. Priorities should be clearly stated, mutually understood, and mutually agreed upon, and patients should be provided with information about what to do if they go “off the plan.” That will help to keep them empowered and engaged in their own care, and keep them communicating effectively with you and the office when there is a problem. Keep the goals small and manageable to begin with and don’t overload the patient with information. Tip sheets and goal targets should be the core of the program; then add in more information as the patient progresses. Keeping material simple, clear, and to the point will help with comprehension.

Setting one target per visit is a manageable way for patients to begin working a program. For example, set a new diabetes patient the goal of reducing his intake of sweets to three desserts per week, and provide a cheat sheet of desserts that are diabetes-friendly to choose from on the plan. At the next visit, you identify a new goal to add to the first one, and repeat. While it may take a while to turn a patient’s health around, research confirms that small, incremental changes are much more likely to be lasting changes, so think in terms of a marathon rather than a sprint to the finish line.

Lastly, make the plans, goals, materials, and office staff highly available to the patient. Post the educational material on your site, mail follow-up materials to patients, place outbound follow-up calls and/or e-mails to patients to check on how they are doing between visits. These touch points matter and can be the difference between a successful program and good patient engagement or wasted effort and time.

And don’t forget, as of January 2015, you can now bill a monthly, per patient code for chronic care coordination, CPT 99490. Just make sure to check the guidelines for this code to adhere to the description of services before you bill it.



Independent Integrated Networks: What You Need to Know


Pearl | July 01, 2015 | Practice ModelsPayersPearlsPerformancePhysician Compensation

Many physicians are by now familiar with such terms as “clinically integrated networks” (also known as CINs), but a slightly different model is beginning to emerge as independent practices resist being swallowed up by hospital systems, and physician organizations become more savvy. You can think of this model as a hybrid between the “super group” (or clinically integrated practice) model and the more familiar hospital-based offering whereby care coordination and data is managed centrally there. Rather, these independent integrated networks (IINs) are being driven by independent physician organizations, coalitions, and alliances between physicians themselves.

What is “clinical integration” anyway?

The Department of Justice and the FTC define clinical integration as an active and ongoing program to evaluate and modify practice patterns by the CIN’s physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality. Generally, the FTC considers a program to be clinically integrated if it performs the following:

1. Establishes mechanisms to monitor and control utilization of healthcare services that are designed to control costs and ensure quality of care;

2. Selectively chooses CIN physicians who are likely to further these efficiency objectives; and

3. Utilizes investment of significant capital, both monetary and human, in the necessary infrastructure and capability to realize the claimed efficiencies.

To legally create a clinically integrated network, CINs are typically formed under the following:

• As physician-hospital organizations: Typically a joint venture between a health system and its medical staffs, these seem to be most prevalent in the market right now.

• As a subsidiary of the health system: This is along the lines of an accountable care organization (ACO), where the health system is the sole corporate member of the subsidiary entity and member physicians sign separate legal agreements to participate.

• As independent practice associations (IPAs): Owned and operated by only physician partners, this is the basis for the model to which I refer.

“Independently integrated” practice networks are therefore IPAs that have figured out how to build consensus across membership to work together to improve care, control costs, share data, and invest in care coordination and health information technology to ensure that population data can be tracked and utilized and care metrics set and met.

What’s driving IPA interest?

Many smaller practices that want to remain independently owned are running into significant hurdles meeting new market and contracting demands, as well as having little leverage in the market to secure good contract terms with both insurers and hospitals that are building ACOs and limiting employee benefits to narrow networks. However, as part of a larger network of physicians, leverage improves, costs can be shared, and data managed centrally. Also, the technology to manage to metric-driven contracts is improving and the cost of implementing data mining across EHRs from multiple vendors is coming down substantially. Data solutions  that can work across multiple EHRs does away with the need to build costly data exchanges or attempt to migrate independent practices to a single platform (like our firm does for super groups).

In addition, IPAs that move toward being IINs often expand their centralized services to become similar to managed services organizations (MSOs). This provides much needed infrastructure for smaller practices that otherwise cannot achieve such cost efficiencies in the areas of securing best pricing for supplies, having in-house counsel available to members, and of course, IPAs help to secure the best terms and financial incentives for payer contracts.

What’s required to build an IIN?

Building an IIN at the IPA level requires a competent team of physicians who fully understand how integration works, and can set up an in-house care coordination team to actively assist members with managing patient care in the form of recalls, follow up, and reminders. These teams are typically financed by “per member, per month” stipends paid out by insurers. As many payer contracts are now “value based,” meaning that increases to rates are “earned” by achieving appropriate patient outcomes and sharing savings achieved through cost control and higher quality care, IPAs must manage to certain cost control and outcome targets.

Critical to successfully implementing an IIN is securing technology that allows for transparency, accountability, and data management. If you don’t understand how members are performing then you cannot effectively manage targets set to achieve value-based payments. And having member buy-in to the concepts and agreements is essential to achieving the clinical and financial goals inherent in such payer agreements.

Additionally, the best run IPAs have stringent membership requirements that ensure quality is built from the ground up. Criteria such as requiring all members to become recognized as NCQA Patient-Centered Medical Homes or specialty practices, requiring that certain evidenced-based guidelines be adhered to for providing care within different specialties, and managing specific conditions work really well in building a robust network. And fully utilizing members by way of committees to foster transparency and allow for creative input ensures ongoing improvement and organizational stability.

So if you are an independent physician, you may want to see what the IPAs in your area are up to, or consider forming a new IPA that is designed as an IIN from the beginning. Now is the time.

State Pediatric Medicaid and CHIP Medical Home Initiatives: At-a-Glance Table

statemapThe National Center for Medical Home Implementation (NCMHI), in partnership with the National Academy for State Health Policy (NASHP) has created a state at-a-glance table which provides an overview of pediatric medical home initiatives occuring through Medicaid and the Child Health Insurance Program (CHIP).

By learning about ongoing pediatric medical home initiatives in your state, pediatric clinicians, practices, state Title V agencies, American Academy of Pediatrics chapters, and others can gain insights on how to integrate their work and coordinate efforts across multiple systems.

Click here to view or download the state at-a-glance table.


Forming a Medical Practice ‘Super Group’


Pearl | September 03, 2014 | Practice ModelsManagers AdministratorsOperationsPearlsReferrals

We have seen an enormous consolidation in medical practices across the industry in the last three years. Many practices are being bought out by hospital systems in preparation for laying the groundwork for accountable care organizations and for building market share in the new value-based purchasing environment.

But rest assured, the independent practice is alive and well — there are practice models available that allow physicians to operate independently, while coming together as one entity to reap the benefits of cost efficiency. One way physicians can reinvent their practices, is to become a “super group.”

Looking for more ways to boost performance at your practice? Join experts Rosemarie Nelson, Lucien W. Roberts, Owen Dahl, and others as they help improve your medical practice and your bottom line atPractice Rx, a new conference for physicians and office administrators. Join us Sept. 19 & 20 in Philadelphia.

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Patient Portals Can Help You Meet Medical-home Criteria


Pearl | October 08, 2014 | Patient PortalsMeaningful UsePatient RelationsPearlsPractice Models

If you are thinking about implementing a patient portal, or already have one in place, you may not realize that this is a great tool to help you meet certain criteria necessary for achieving Patient-Centered Medical Home (PCMH) recognition.

Many portals offer the components required to meet part of the National Committee for Quality Assurance’s (NCQA) PCMH Standard for patient-centered electronic access. The purpose of doing so is to allow the practice to offer information and services to patients and their families via a secure electronic system whereby patients can view their medical record, access services, and communicate with the healthcare team electronically.

Providing electronic access to this information also enables practices to meet meaningful use requirements, so you get a double return on your portal investment if you are attempting to meet requirements for both the NCQA PCMH and meaningful use programs.

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New Practice Models Are Gaining Acceptance in Primary Care


August 20, 2014 | Great American Physician SurveyPatient RelationsPhysician CompensationPractice ModelsWork/Life Balance

Manhattan cardiologist Arthur Weisenseel has enjoyed a long and satisfying medical career; one that encompassed teaching at New York-based Mt. Sinai Hospital, running a successful cardiology practice with another physician, and stewarding his aging patients into a healthy old age. But, somewhere in the last five years to 10 years, his practice became problematic. Weisenseel says that despite working as hard as he could, he wasn’t able to consistently pay both practice expenses and himself. He says of that time, “I worked awful hard to get [there]. And to go home without reimbursement was becoming demoralizing.”

So, like a growing contingent of like-minded physicians, Weisenseel decided to explore other practice models. Encouraged by his patients and positive conversations with colleagues, he has now successfully converted his practice to a hybrid-concierge model, where patients can choose to pay an extra fee for concierge services or continue to reimburse him through traditional insurance plans like Medicare and third-party payers. Now he couldn’t be happier: Relieved of worries about financial and regulatory burdens, he says, “I come to work with joy and confidence.”

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Patient-Centered Specialty Practice for Specialists


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.

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NYS Insurance Price Wars


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.

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The Verden Group is delighted to welcome Paul Vanchiere, MBA, and Sumita Saxena, JD, 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:

More on the Complete Pediatric Practice Assessment:

More on Sumita Saxena: