Crossroads Between Physician Productivity & Burnout


Deconstructing the Construction of a New Facility

The success of building a new clinical location is dependent on many factors and people working collaboratively and in sync.  Some tips for a successful outcome include:

Time – One can never start planning too early.  Prior to construction and during construction, take time to understand and document wants vs. needs vs. must haves.  You can narrow and prioritize the list at a later date.  Changes to the design during construction can result in additional costs.

People – Consult the users of the space.  This includes all stakeholders including providers, front desk, billing, clinical staff, ancillary services and your administrative team.  Observe the work in the current space and verify all of the key workflows.  Ensure barriers to productivity are resolved.  As you design the new space, consider opportunities to enhance efficiency, patient and staff and physician satisfaction.

Communication – Consider building “touchdown space” in the clinical area and optimize your flow.  Many designs now have co-located shared space with providers and support staff, which is known to improve communication and teamwork.

Voice of the Patient – The voice of the patient is key when constructing and problem solving; not to mention when creating a patient centered environment.  Interview patients to obtain their input.  Consider surveys, on-site interviews, focus groups and outreach calls to gather information.

Practice – Test out the new workflows and create a mock-up of the exam room.  Map out your table, stools, cabinets, sharps boxes, locations for disposable supplies such as gloves, door, curtain, etc. Simulate how the team members and patients will move within the space.  A fun and effective exercise in the initial planning stage is to put together a cross functional team to create the ideal layout using post-its!  This helps to surface workflows but can also point out differences in opinion among the team.

Team Meetings – Consider if you will need space for teaching or team meetings.  With the implementation of value-based care, a shared administrative space may prove to be essential for your PCMH.  Don’t forget about staff meetings or educational programming, which is required by licensure or recommended by leadership.  If you are a teaching program, consider the needs of students, fellows, residents and instructors.

Technology – Consider your current level of technology.  Will the construction include new features of your current software or upgrades or a completely new system?  This is a good time to review your Electronic Health Record (EHR) and Practice Management System (PM) or Radiology PACS, and identify change opportunities to allow time to plan.  For example, my current client is using it as a vehicle to redesign and optimize their clinical capabilities.  Instead of assigning each student a designated workspace (i.e., Exam rooms 1 and 2), they are using the rooms as resources, which will allow for other users to utilize the exam room when the Monday and Wednesday provider is on vacation.  This change will allow a 36% opportunity to increase production.

Construction is exciting, but identifying a lead project manager can be essential to a successful outcome.

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant

CMS Quality Payment Program – APM Path- part 3 of a 3 part Series on MACRA

What is an Alternative Payment Model (APM)?

In part two of this specific blog series on MACRA, I emphasized the CMS QPP decision tree and covered the MIPS path.  In part three, we will discuss the APM path.

Alternative Payment Models (APMs) are new approaches to paying for care through Medicare that incentivize quality and value.  The CMS Innovation Center develops new payment and service delivery models.  Additionally, Congress has defined—both through the Affordable Care Act and other legislation—a number of demonstrations that CMS conducts.

APM entities must meet one of two thresholds each year for their physicians to be considered qualified participants: the Payment Amount threshold or the Patient Count threshold

Using the Payment Amount threshold, APM entities must receive a minimum percentage of Medicare Part B payments through the APM each performance year, with the percentage rising through 2022.




  • A payment approach that provides added incentives to clinicians to provide high-quality and cost-efficient care.
  • Can apply to a specific condition, care episode or population.
  • May offer significant opportunities for eligible clinicians who are not ready to participate in Advanced APMs.


Advanced Alternative Payment Models (AAPMs)

Advanced APMs are a subset of APMs and enable practices to earn more rewards for taking on some risk related to patients’ outcomes and cost of care

Under the Quality Payment Program, clinicians who participate to a sufficient degree in Advanced APMs are excluded from MIPS and earn a 5% lump sum incentive payment based on their Part B professional services for a given year, and also receive greater rewards for taking on some risk related to patient outcomes.

Advanced APMs must meet the following three requirements:

  1. At least 50% of the clinicians in each APM Entity use certified EHR technology to document and communicate clinical care information with patients and other healthcare professionals.
  2. Bases payments on quality measures that are comparable to those used in the MIPS quality performance category.
  3. Be a Medical Home Model expanded under CMS Innovation Center authority or:
    1. Meet a revenue-based standard of financial risk that averages at least 8% of revenues at-risk for participating APMs
    2. Meet a benchmark-based standard of financial risk in which the maximum possible loss must be at least 3% of the spending target

In 2017, the following models are Advanced APMs:

  • Comprehensive ESRD Care (CEC) – Two-sided Risk Arrangements
  • Comprehensive Primary Care Plus (CPC+)
  • Next Generation ACO Model
  • Shared Savings Program – Track 2
  • Shared Savings Program – Track 3
  • Oncology Care Model (OCM) – Two-sided Risk Arrangement

In future performance years, we anticipate that the following models will be Advanced APMs:

  • Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1- CEHRT)
  • New Voluntary Bundled Payment Model
  • Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT)
  • Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)
  • ACO Track 1+

Under the AAPM path, clinicians will receive an annual 5% lump-sum bonus between 2019 and 2024, with a 0.75% increase to their Medicare physician fee schedule beginning in 2026.  While the AAPM track does not carry the penalty risks present in the MIPS track, APM entities must have a risk-based payment model for clinicians to qualify for AAPM.

While Advanced APMs have a fixed bonus incentive of 5% through 2024, it is important to understand that the Quality Payment Program does not change the design of any particular APM.  Instead, it creates extra incentives for a sufficient degree of participation in Advanced APMs.

How Do Eligible Clinicians Become a Qualifying APM Participant (QP)?

APM entities must meet one of two thresholds each year for their physicians to be considered qualified participants.  CMS will calculate a percentage “Threshold Score” for each Advanced APM Entity using two methods:

  1. The Payment Amount threshold and the Patient Count threshold.
  2. Using the Payment Amount threshold, APM entities must receive a minimum percentage of Medicare Part B payments through the APM each performance year, with the percentage rising through 2022.

Using the Patient Count Method, APM entities must see a minimum percentage of Medicare patients through the APM each performance year, with the percentage rising through 2022.

  • Methods are based on Medicare Part B professional services and beneficiaries attributed to Advanced APM.
  • CMS will use the method that results in a more favorable QP determination for each Advanced APM Entity.
  • The Threshold Score for each method is compared to the corresponding QP threshold table and CMS takes the better result.
  • The QP Performance Period for each payment year will be from January 1—August 31 of the calendar year that is two years prior to the payment year.

Beginning in 2021, this threshold percentage may be reached through a combination of Medicare and other non-Medicare payer arrangements, such as private payers and Medicaid.









What is a Partial Qualifying APM?

Clinicians are considered Partial Qualifying APM participants if their APM entities participate in an Advanced APM, but meet a slightly lower threshold outlined by CMS.

Clinicians participating in the Partial Qualifying APM track will not receive AAPM’s 5% incentive payment, but they can opt into the MIPS path if they can meet its reporting requirements.

In Summary

The shift from the Sustainable Growth Rate formula’s “fee-for-service” payment model to MACRA’s value-based payment model should ultimately help to preserve Medicare funds in the long-term while incentivizing ongoing initiatives that could make a positive impact on population health in the U.S.  The Advanced APM track and the QP status may be desirable for many MIPS eligible providers.  Due to the inherent financial risks involved in any AAPM, an organization should evaluate these programs with care and consideration.



Senior Consultant -Culbert Healthcare Solutions

Admissions/Registration: Helping to Improve Accounts Receivable

One of the most important ways to improve A/R is the admissions/registration areas of any healthcare organization.

Many facilities band-aid issues within the admission/registration areas by correcting errors in billings, which is not effective nor is it cost efficient.  It is estimated that it costs healthcare facilities $15 per visit to track and collect co-payments and deductibles after the fact.  For many healthcare organizations, such as physician offices, this practice could result in a zero net revenue gain.  Additionally, it costs healthcare facilities approximately $15 – $25 per visit for billing staff to correct registration errors and approximately $15 per statement sent to patients for co-pays, deductibles and co-insurances that could have been collected upfront.

So what steps can a healthcare facility take to remove the admissions/registration area band -aids and ultimately improve their A/R?

Step 1:  Management should be open to change

Most admission/registration managers have vast experience in their field and want nothing but a well-run department.  However, for many managers the stress of running a high-volume department that can potentially be open 24 hours a day does not allow them the luxury of thinking outside the box.  Staff may not be willing to discuss issues with management, some applications do not provide error reports to managers, and some applications do not record who made the error(s) so they cannot be addressed with that individual.  For improvement and changes within the admission/registration areas, management must be open to change, permit their staff to assist in recognizing issues and require their application(s) or MIS department to provide error reports.

Step 2:  Assign an impartial third party

The first step in this process is to assign the task of meeting with the admission/registration areas to an impartial third party.  This is the most important step in this process as admissions/registration needs to feel comfortable in discussing all issues they face daily without fear of retribution or criticism.  The impartial third party should not only meet with management of these areas, but with 75% of the staff covering all shifts.

 Step Three:  Logging issues

This is not the time to address or correct issues that are discovered.  Although issues presented need to be clear and concise, they should not be demonstrated or dissected as this is purely a fact finding process.  All issues discussed are to be logged no matter how insufficient they may appear.

Step Four:  Organization

Issues need to be organized into categories such as process, system, staffing, training and education.  Once this is accomplished a meeting should be held with management to determine what issues are the priorities and can be addressed immediately versus issues that may take time to resolve (such as lack of staff).

Step Five:  Resolving issues

Process issues:  It is imperative that management and staff be open to resolving processing issues.  A process should not be kept in place because it has “always been done this way” but because it enhances the admission/registration process.  An impartial third party can assist management in looking at the processes, determining if they are assisting or hindering the workflow and changing what does not work.

System issues:  Are the admission/registration pathways specific to your site or are they generic?  Does the application provide “help” screens or pathways that are easy to maneuver and are they specific to your site?  Are required billing fields designated as “must enter” and won’t allow staff to bypass?  Is your IT staff knowledgeable of your environment and application?  Is your application vendor directly involved with improving your application pathways?  Can your staff search for a patient’s prior admission/visits within the application?

Staffing:  Are the errors the result of under or overstaffing?  Both can be issues for admission/registration areas as too much work per staff member can cause a hurried approach whereas too many staff can cause disruptions in daily work.  When are most of your admissions/registrations?  Can your facility add or deduct staff according to daily needs?  Are pre-admissions/registration the practice of your department so that most of the information can be input prior to the patient’s visit?

Training:  Has your staff been properly trained in the workflows of the department and admission/registration pathways within the application?  Does staff understand what fields are required and why?  Does your staff update prior admission/registration information or just process the data?

Education:  Correction of errors must be done by the admission staff and not billing.  This is very important because they need to understand what constitutes an error and why.  Some applications only record the last person who worked on the admission/registration versus who made the error.  This limitation should not stop management from requiring error correction.  Although the last person who touched the admission/registration may not have made the error it is the responsibility of anyone who touches the admission/registration to ensure all information is correct.

Holding registration responsible for errors is a proven tool that will assist staff in knowing what an error is, assist management in recognizing what staff training needs are and allows billing to concentrate on their job responsibilities.  As registration is made aware of their errors, it is imperative to teach them how to perform registrations and keep them from repeating the same errors over and over.  Correction of their own errors will assist in staff in adhering to policy, train them in proper registration processes, and will ultimately decrease billing errors and free up billing to perform their job responsibilities.

Do You Have a “Culture of Safety” in your Ambulatory Setting?

Safety is no longer a problem just for executives. Much is said at conferences by health organizations and is in the literature about having a “culture of safety.”  This term embodies the application of safety and quality as a primary and overarching goal in the medical practice.  Safety becomes part of the daily work in which leaders and staff proactively solve problems, reduce risk and improve care.  Organizations turn to the safety tools from the “culture of safety” movement.  Using these and other tools, team members of all levels communicate about safety, ask questions and learn without the barriers of title, status or a fear of retribution. In this setting, leaders, physicians and staff are equally empowered to make changes during the course of their work.

One might be surprised to learn that there is a greater risk for harm in a routine office visit than some inpatient admissions. With the number of outpatient encounters significantly growing the risk becomes even more pronounced.  This blog provides guidance to leadership regarding strategies to reduce risk in the medical office by having clearly defined care guidelines and using the tools and tones of the culture of safety.

As you begin thinking about your environment, consider the overall approach to staff training. Review your on-boarding process and consider how you introduce safety principles in your culture.  Practices need to outline expectations early to avoid issues at a later date. Too many offices make the mistake of not having designated staff trainers which leads to inconsistency.  Ensuring physician and staff training is adequate, reduces the likelihood of performance improvement issues, stress from being understaffed, improves quality, as well as staff and provider satisfaction.

Next, consider the value of pre-visit work. Staff should learn a standardized pre-visit preparation process to identify gaps in care.  This will help staff to close all gaps during the office visit.  Ensure staff and providers know and understand the expected testing, the referral circle (internal vs. external) and the process for ordering required studies.  The employee probation period should provide support, coaching and instruction in the employee’s clinical setting.  Augment this training with online and classroom training.  Leaders can review paid claims and use business intelligence tools to analyze the cost and services provided, conduct audits and intervene when care is provided outside of the protocol.

Diagnostic errors can include missed care opportunities, delays in care, or more seriously, an incorrect diagnosis. Patient care should be consistent with evidence-based care guidelines.  A variety of approaches such as, decision support tools, order sets, electronic tasking, pop up messages, care coordination staff and evidence-based protocols, can reduce errors. Certified medical assistants can alert a provider to sign off on a pending order created by them, help to monitor the test that has been performed and the result delivered to the patient.   Encourage staff to use the culture of safety tools to ask clarifying questions to validate the follow-up plan when there is a deviation from the protocol.

Once diagnostic testing is ordered, it is important to provide clear information to the patient regarding the delivery of the result. The follow-up plan should be consistent as expressed by providers, staff and even the ancillary service.  Patients should either have a scheduled follow-up appointment to review the findings, be told they will receive a call or they should expect a letter within a number of pre-defined days.  It’s important to avoid saying to the patient, “if you don’t hear from us, then everything is okay.”

This type of discharge planning can result in miscommunication and delays in care.  Staff could use the culture of safety technique of “STAR” technique (Stop, Think, Act and Pause) to confirm they understand the follow-up plan for each patient and confirm it is consistent with office protocol.

Staff not updating the family history section in the patient record during the history taking can contribute to an important detail being missed. Staff learn differently and training materials may need to be in multiple languages or in various formats such as a written article, a checklist, or a routing slip. Encourage staff to utilize the culture of safety technique of validation and verification to ensure they understand what is required for each patient.

Communication errors may occur if an electronic system is not being used effectively to communicate or if active listening is not occurring, such as when a staff member is rushed or when a practice is chronically understaffed. Best practice includes future appointments being noted on the routing slip or a workflow which includes electronic orders being entered prior to the patient reaching check-out.  Consider if “pod” check-outs would help to ensure the discharge plan is reviewed/activated in the exam room, thus reducing hand-offs.

Errors or delays can inadvertently occur if a specific diagnosis is lacking or an incorrect diagnosis is entered. Using the culture of safety tool, such as practicing with a questioning attitude, staff can help to eliminate/reduce these errors.

With value-based care, the emphasis is on improving quality, safety and patient satisfaction. Practice leadership should continuously review their internal workflows and processes to shine a light on potential quality and safety issues from a variety of perspectives.  Consider holding a daily huddle with your team or identifying a safety coach in the practice to increase recognition, decrease harm to patients and employees while improving care.

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant

Consultants as Mentors?

Working in any industry, you encounter people with various backgrounds and degrees with little or no knowledge of the business. You run into the young graduate who just entered the workforce, the established employee who is set to retire or the ambitious employee who is thirsty for more knowledge. In a hustle and flow environment, where do you find time to encourage your employees to master their skills, prepare them for management level or assist in adapting to a new environment when the industry changes around them?

Consultants continuously walk into organizations where change is in the midst, an established business is not working as efficiently as it could, or an open position needs an interim replacement. We observe as an outside party and want to help to create efficiency, structure and indicate where we identify the gaps, but we also know we are there for a specific task.  During engagements, it isn’t uncommon to form relationships with the company staff – listening to their concerns, providing limited feedback if necessary and amusing the ones that just want to complain, even when there isn’t anything to complain about.  Many times, we are perceived as a wealth of knowledge – a golden ticket to show them what they want to learn or to help do some of the work no one else has time for.  When we as consultants have the time to share that knowledge and mentor the existing client staff, success is exponential.

In a recent article with Fortune.Com, CEO and Co-founder of AirBNB, Brian Chesky, explains “you’re the average of the five people you surround yourself with. So the question is, how mature are the people you surround yourself with?  If you surround yourself with the right people, you can grow up pretty quickly.”  Imagine making a decision based on just your thoughts rather than thoughts that are inspired by interactions with insightful individuals or groups.  That could heavily impact a place of business, how you interact with staff, and your own psyche.

Consultants that have the skill of mentoring or coaching are able to provide more of a service to the client rather than just the task at hand. This type of consultant will flourish, as they build a rapport with the client which could allow future interaction together, providing knowledge transfer, understanding the client outside of the assigned task, and creates an abundance of new relationships.  Mentoring is a silent skill – some people have it and others don’t, which is perfectly fine.  Consultants are there to provide a service and this is just an added bonus during a client engagement.



Jim Lachner joins Culbert as Regional Executive -Advisory Services

Culbert Healthcare Solutions is pleased to welcome Jim Lachner as the newest member of our business development team. Jim will serve as Regional Executive – Advisory Services, where he will be responsible for supporting clients located on the west coast.

For the past 30 years, Jim has delivered software and service solutions to medical groups, hospitals, integrated delivery networks, and academic medical centers. Prior to joining Culbert, he held senior sales executive roles at Cerner, First Consulting Group and KPMG.


Joel Szymanski Joins Culbert as Regional Executive -Advisory Services

Culbert Healthcare Solutions is pleased to welcome Joel Szymanski as the newest member of our business development team. Joel will serve as Regional Executive – Advisory Services, where he will be responsible for supporting clients throughout the Midwest.

For the past 12 years, Joel has delivered software and service solutions to medical groups, hospitals, integrated delivery networks, and academic medical centers. Prior to joining Culbert, he held senior sales executive roles at Nuance and Allscripts.




Consulting -Life Balance

Have you ever tried to be a road warrior and maintain mental, emotional, spiritual and physical health at home? Typically, it’s challenging because you usually give all you have at the client site and rarely have anything left to give once you arrive home. So, what can be done to maintain a healthy ‘you’ while meeting the needs of family/friends, your firm and the client? Many people try to get their ‘me’ time in on the weekends while at home, but there is only so much you can do with 48 hours (for some 72). Saturdays seem to fly by and Sunday greets you with the bittersweet awareness that you wanted to sleep in, however, you forgot to pack last night. Hopefully these tips will support help you to achieve some resemblance of consulting/life balance.

 Take a look at some helpful suggestions below:

  • Bring home with you on the road! For as much as we live in an age of technology, we sometimes forget to actually ‘use’ the technology in our hands to stay connected with family and friends. A scheduled 10 to 15 minute video call can do wonders for you and those who love you. It will keep you up-to-date with what is going on in their lives and maintains that much needed connection. This can greatly support your emotional and mental health. If you have a spiritual practice, you don’t have to wait for the week to end. Practice what makes sense during your work week, whether that’s reading, meditation, music, etc.

Speaking of bringing home with you, if you are an avid reader, bring your book(s). Do you knit, crochet, etc.? Bring it with you! Play a lot of online games? Many games can be played using your smart phone or other electronic device (not your work laptop please!). Bring whatever makes the most sense with you on the road. You can decompress while on the road – you do not have to wait until you get home.

  • Don’t lose sight of the things you enjoy. While on the road, make sure you don’t leave your passion and fun behind you (at home)! Many areas have similar activities you would engage in at home, right in their own backyard. I’ve experienced some pretty enjoyable painting, fitness, bowling, spa, and other fun activities while traveling. Working out (not in the hotel) has kept me focused and motivated on many assignments!
  • Interested in volunteering? There are many local and not too distant programs and charity locations in most towns or cities. Working long hours at the client site can sometimes be inevitable, but scheduling time for fun, relaxation, or volunteering can help in decreasing your stress level, sense of isolation, and lack of fulfillment.
  • Get chores done before the weekend. Don’t be hesitant to find a local dry cleaner, nail spa, hair salon or other self-care establishment in the town or city of your client. This can decrease the amount of time you (or your family members) have to spend on those weekend errands. You’ll have more time to do those really precious things you can’t do on the road, including absolutely nothing!

Consultant/life balance is achievable, but it requires flexibility, openness and a few moments to decide where you want to engage in your other activities. You’ll be ready to live more and give more to yourself and those around you once at home, all while meeting or exceeding the expectations of your client and firm. Everyone wins with work and life balance!

Melissa L Roberts, Culbert Consultant and Life Coach



Connecting the Dots- The Value of SSOT Crosswalk Documents

Many healthcare organizations adopt a “best of breed” philosophy regarding their information systems. In many cases, they want the best practice management system for professional billing, plus the best EHR for clinical documentation, plus  the best hospital PM/PA system for technical and facility billing, etc.  Sometimes, they would rather implement one system that can do it all but due to financial constraints or contractual agreements, they are obligated to maintain their multi-system/multi-vendor environment.

In such complex integrated environments, it is imperative to maintain Single Source of Truth (SSOT) crosswalk documents to help the organization’s IT, finance, and operations teams connect the applications together. When integrating new practices or departments into the enterprise, it is especially crucial that the implementation teams understand how not to tangle those connections.

In a recent project, an organization attempted to transition newly acquired physician practices from legacy RCM and clinical systems onto their enterprise solution, which consisted of a diverse environment of practice management, clinical, hospital financial, and ancillary systems. Despite those enterprise systems being in place for several years, it was a surprise to learn that the organization had never taken the time to specifically document how all of their departments and locations in the source practice management system mapped to corresponding values in the downstream systems.  The provider entries in the various systems had also not been reconciled, which sometimes caused interface failures.

As the project manager representing the practice management system initiating the visit/encounter process, I offered to create a catalog of master mapping (crosswalk) documents which would be used to design the application builds and connect each department, location, and provider in system A to the corresponding values in system B, system C, etc.

Once the various IT teams agreed upon the exact values that represented the “dots to be connected” in each system, project sponsors endorsed the mapping documents as the Single Source of Truth (SSOT) to be referenced for all implementation activities. The SSOT documents were then utilized by all teams to correlate application build mapping variables between the multiple RCM, EHR, and ancillary systems.

Armed with the knowledge of how the key data elements for each system reconciled to each other, the implementation teams could formulate detailed future state workflows, business requirements, technical cutover plans, and integrated testing scripts. Whenever interfaced transactions failed during integration testing, most issues could be easily traced back to values that were not in sync with the SSOT documents.

Maintaining current and accurate crosswalks and SSOT documents may seem like a no-brainer in an environment with multiple disparate systems that must communicate with each other. However, it can be tedious and time-consuming work and when time and resources are both limited, many organizations overlook its importance.  Many hours of redesign, rebuilding, and re-testing could be avoided if time was spent wisely by first identifying critical integration points and connecting the dots.