The Drivers of Physician Alignment
By Brian McCartie, Vice President
Healthcare reform and reimbursement patterns for health services are driving physicians and hospitals together at an accelerated rate. It is a perfect storm where younger physicians, are looking to practice medicine and balance work life responsibilities in a secure and financially safe environment without the headaches of managing practice operations. Given requirements for adoption of Electronic Health Records and a focus on reducing the overall cost of healthcare, hospitals and physicians have little option but to align. The big question is can years of mistrust between physicians and hospital administrators be mitigated by "Healthcare reform".
Fifteen years ago hospitals hurried to acquire primary care practices in anticipation for the managed care advances and the gate keeper model of healthcare. Practices were purchased paying several times the revenue of the
practice and physicians were guaranteed salaries at pre-purchase levels. Small efficient practices were suddenly upgraded to hospital owned real estate to consolidate the practices resulting in higher rent and more expensive benefits for the physician's staff. The newly acquired physicians began their practice with few productivity incentives tied to their incomes. The result was a decrease in physician productivity. This trend continued through the early 1990's. Hospitals lost on average $100,000 per physician and they did what every board instructed (and every CEO dreaded) – they dismantled the medical group and divested from their employed physicians. The control of the practices was returned to the physicians and the hospitals continued to focus attention on their inpatient business.
For the next 8-10 years the Stark laws limited what the hospitals could do to assist their community physicians. The Stark laws had very specific rules regarding the support a hospital could provide the practices which impacted the availability of physician specialties and hospital services. If supply and demand were equal, providers would enter specialties where there was demand; migrating to communities where their services were needed. However, due to the discrepancies in reimbursement by specialty, medical students shied away from the lower paying primary care residencies in favor of higher paying subspecialties. Physicians concentrated on increasing their incomes by developing their own ancillaries in office and began to compete for traditional hospital services. The hospital viewed its role as the infrastructure of equipment and operating rooms to meet the needs of the community but did not expect competition from their own providers. Provider practices and hospitals were intra-dependent on each other but would remain autonomous businesses. This was the intention; however things were not that easy. Several factors on the hospital and physician side were driving both parties together at a ferocious pace into a new realm of provider/hospital interfaces.
Renewed interest in physician/hospital alignment is due to several factors:
  • Changing expectations Generational and gender shifts in the physician workforce are resulting in changing expectations for career goals and work schedules. Physicians are looking for schedules conducive to parenthood and family life; positions that offer professional growth, a life balance and security. Physicians are sub-specializing within their chosen field in an attempt to limit the scope of their practice, reduce their call burden and increase the life balance. The historic relationship with community primary care physicians and the hospitals became severed as hospital programs removed the need for the community primary care physician to join the hospital.
  • Increasing overheads and decreasing incomes: Expenses within private practice continue to rise at a rate beyond the annual increase (and threatened decrease) of Medicare. Malpractice coverage is problematic for specialties resulting in physicians limiting the types of care they provide. This trend forces the hospital to seek new methods of covering these services or limiting the services it offers in the community. The demands of implementing technology, costs of employing practice managers, medical insurance, benefits and rent all impact the viability of private practice. As revenue eroded, healthcare organizations found it easier to negotiate increases with the payers when they were representing both the hospital and the physicians in the community. Anticipation of a new payment system and the mandated adoption of Electronic Health Records to improve performance and outcomes convinced a high percentage of physicians that alignment is the only viable option.
Understanding the driving forces behind the changing healthcare industry and learning from past experiences is allowing for the creation of new health organizations with equal representation for the hospital and physician groups. Health systems are moving from a structure of grouped hospitals to Integrated Delivery Networks managed by individuals with group practice operational experience but lead by physicians. Hospitals will involve physicians in governance and decision-making while physicians prepare to relinquish complete autonomy. Creating trust between traditionally separate organizations is the direction of the future and requires leadership that is constant, strong and avoids reactionary responses to perceived needs of one group or the other.
The Coming New Year
News from Rob Culbert, President
The coming of the New Year brings with it the excitement of growth and getting involved in new opportunities in the ever-changing healthcare industry. In the coming year Culbert will expand in the following areas: Clinical Integration, Revenue Cycle, and the use of technology to achieve Meaningful Use and support new reimbursement systems such as Medical Home and Accountable Care Organizations.
Accountable Care Organizations are receiving a greater amount of attention but the relationship between quality and cost of healthcare is not a new consideration for Culbert consultants. With decades of experience in healthcare and their ability to combine practice management, clinical workflow and IT knowledge, we understand the importance of creating solutions that balance quality and cost. We take a holistic approach when examining and implementing healthcare solutions. For example, when implementing an EHR, the documentation of workflows and design decisions are made with consideration for mitigating risk to revenue cycle and provider productivity.
The New Year is also an opportunity for us to reaffirm our commitment to bringing character, competence, commitment and collaboration to every project. Character that reflects honesty and the desire to do what is right, competence resulting from decades of working in the healthcare industry, a commitment to helping others succeed and collaborating with our clients to help you achieve your achieve goals.
In 2011 we look forward to continue acting as trusted advisors to our clients as we work with you to address the challenges of the coming year.
Practice Management System Conversions: Implementation
Risks & Success Factors

By Brad Boyd, Vice President
More often than not, the selection of an Electronic Health Record (EHR) is driving medical groups to evaluate whether or not to replace their Practice Management System (PM) as part of their EHR initiative. In a core vendor environment where one vendor is providing a fully integrated EHR/PM solution, the integration provides powerful benefits including:
  • Workflow efficiencies between patient access, clinical and billing operations,
  • Linkage between Scheduling and Orders,
  • Reduced missing charges,
  • Reduced costs of interface maintenance,
  • Enhanced reporting of clinical and financial information, and
  • Enhanced vendor accountability.
When PM implementations are a component of a larger core EHR/PM vendor initiative, too often resources are disproportionately shifted to the EHR implementation. The ARRA stimulus opportunity is one valid reason why this occurs. A second cause is that organizations with an effective and efficient revenue cycle operation underestimate the complexities and risks of implementing new tools to support their fine tuned registration, scheduling and billing functions.
Based on our broad PM vendor implementation and conversion experience, we have identified 6 key PM implementation success factors which can easily be obtained by having resources with subject matter expertise with your new PM system involved at the earliest stages of your project:
  1. Most vendors have developed and branded implementation methodologies which were designed to streamline the implementation process. Often, these approaches include "out of the box" workflows and pre-delivered system build. These methodologies are often driven by a Best Practice approach and are effective in streamlining the implementation process. However, an organization must identify when it would be appropriate to modify workflows or system build to support the unique requirements of their business. Assuming that the canned implementation methodology will support the unique business needs of you organization will lead to unrealistic resource or timeline assumptions.
  2. System implementations are an ideal time to evaluate workflows, staffing size and structure, and performance metrics and benchmarks. A system implementation should be leveraged as a change agent. Overlaying a new application on top of existing workflows and staffing structure is not only a wasted opportunity to drive change, it also poses a major risk to cash flow. Progressive organizations take advantage of new technology implementations to transform their operations. Common examples include the implementation of centralized patient access centers which not only provide opportunities for reducing costs, but are also proven to increase patient satisfaction.
  3. Consolidating and standardizing Visit Types should be part of any PM conversion. This is an excellent opportunity to improve scheduling efficiencies, physician productivity, and performance reporting.
  4. There is significant variance in reporting capabilities of the major practice management vendors which serve the large group practice environment. Some vendors offer easy to use ad-hoc reporting tools which compliment their standard set of monthly reports. Other vendors provide complex reporting capabilities, however they require technical resources to be train in order to develop custom reports. Lastly. The volume of pre-configured reports varies by vendor, with some vendors requiring significant implementation resources to develop custom reports in parallel with their implementation to make sure managers have the information necessary to run their business. An organization should assess their reporting needs at the beginning of the implementation to make sure the necessary reports are available at go-live.
  5. Training is never an area to cut corners. Front desk or billing staff have often been doing their jobs the same way for years and old habits are hard to break. Not only is training on the new software important, training on new workflows, new policies and procedures, and the metrics used to determine staff productivity and performance are equally important.
  6. Post go-live optimization should be collaboration between IT, billing office and practice management. Workflows, the setup and use of the PM system to support efficient workflows, and performance should be monitored at defined intervals to identify opportunities for improvement.
Not only can the risks to cash flow associated with a PM system implementation be effectively mitigated, a physician group should leverage the project to improve practice operations and financial performance.
The Underestimated Super Users
By Thomas Ganzter, Consultant
So your organization has finally committed to implementing an Electronic Health Record ("EHR"). Whether you are making the leap into your organization's first EHR or replacing a legacy system, your Users are taking it as a direct assault on how they fundamentally complete their job today. While this is often a stressful time, the benefits of improved patient care, clinical workflow, physician productivity and revenue cycle are real, provided the EHR is designed to support your organization's unique needs. The EHR design process plays an instrumental role in setting the foundation to drive physician adoption.
The importance of a Physician Champion role in an EHR implementation is well understood. A role that is often underestimated, but equally critical to ensuring quality patient care and maintaining physician productivity is that of the Super Users. Our clients often utilize RNs, LPNs, MAs, and even administrative assistants in these roles. Many try to include MDs and CRNPs in their ranks as well. In most cases, placement of at least one in every office or department is optimal. One of the best aspects of this best practice is how their function will naturally evolve as your implementation moves through its stages and the fact that they can ultimately provide a permanent on-site resource for current and future Users.
Training successful Super Users often involves your training team taking a more involved and slightly lengthier approach. By providing robust initial training with routine follow up you can take advantage of the different ways a Super Users can ease the transition and be a permanent peer resource. Your training team should develop materials that will provide staff with content that includes hands-on training with a focus on clinical documentation tools, order entry, results review, and in-basket / message management. Epic and Allscripts are two vendors that provides excellent e-learning material to supplement your training initiatives. Including background on EHR adoption principles or the improvements achieved by switching to a new application in your training also plays a key part in allowing Super Users to calm the nervous apprehension of the coming changes in their peer to peer interactions.
A fully trained Super User can begin helping your implementation earlier than you would imagine. By combining their newly acquired knowledge of EHR fundamentals and their experience in their respective roles, they can provide valuable insight to your technical team along many steps of the system design and build processes. Additionally, early involvement and training will provide them with the experience and confidence to answer the inevitable questions that come along with any change of this magnitude. Their role will expand further by complimenting your "elbow level" support during go-live. By providing that support to their peers both pre and post go-live, they can be the on-site resource to quell the nervousness that many departments experience when the support teams take leave and ultimately turn into a permanent resource into the foreseeable future.
Electronic Health Records (EHR) Incentives - How to Decide
Between Medicare/Medicaid Programs

By Annamarie Monks, Principal Consultant
On January 3, 2011 registration opened for providers to enroll for EHR Incentive payments made possible by the American Recovery and Reinvestment Act (ARRA). Before registering, providers need to decide if they will apply under the Medicare or Medicaid program. It is one of the first questions in the registration process.
Many providers will not have a choice of programs as the Medicaid option is only available to providers whose Medicaid patients comprise 30% or more of their patient encounters (20%+ for pediatricians). Those providers who have a choice need to be aware of the significant differences between the programs.
The Medicaid program has a number of advantages including:
  • higher total payments
  • significantly higher first year payments
  • easier qualification met by adopting, implementing or upgrading a certified EHR
  • don't need to demonstrate meaningful use until Year 2
  • more flexible timeline
  • potential earlier payments – the first physicians who qualified under the Oklahoma Medicaid Program received payments on January 7, 2011!
  • the option to qualify based on the group practice payer mix instead of individual provider payer mix
  • some providers are ONLY eligible under the Medicaid program – nurse practitioners, certified nurse-midwives and physician assistants who practice in a PA-led Federally Qualified Health Center
To help make your decision, this table outlines the key differences between the Medicare and Medicaid programs EHR Incentive Payments.
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