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Affordable Care Act – Obamacare

Avoid payment confusion while maximizing the service advantages of preventive care

When we work worth practices in adult primary care, OB/GYN, and pediatrics, we often recommend they consider proactively recalling patients for preventive visits. Because preventive visits are usually reimbursed entirely by insurance with no patient cost-sharing, helping patients stay current with preventive care can be a win-win for patients and the practice. A preventive visit recall effort can also help your practice address challenges like: Lower demand and productivity during the first quarter of the year, when patient deductibles reset Summertime revenue shortfalls because of lower visit volume Excess demand for pediatric check-ups during back-to-school and back-to-camp seasons Disengagement of patients who have lost touch with the practice and aren’t monitoring their own health Uncertainty about whether some patients are still connected to the practice Recalling patients for preventive visits allows you to better balance the demand for your clinicians’ time. If you add more preventive slots and book them during times when your practice is slower, you’ll also add predictable revenues. Your patients will benefit, too, because they’ll see their physicians when the practice is less hectic and more appointment options are available. When practices reach out to patients to book an overdue preventive visit, it’s usually a marketing effort that is well-received. Often patients hold off on booking a check-up because they are unaware that many preventive services are covered without a copay—so they’re delighted to hear that an annual physical is something that won’t cause financial pain. There is one avoidable snag in booking preventive care that often trips practices up, however, and it’s a pitfall that puts patient relationships at risk: Not all services that could be provided in a typical check-up are considered preventive from a billing perspective. That can lead to “surprise” patient costs and bills. These unexpected costs can be very upsetting. Even though the causes are usually just innocent oversights, some patients will feel they’ve been cheated or deceived. One way unexpected out-of-pocket costs occur is when a problem is discovered or revealed by the patient during a preventive visit. If the problem requires additional work or tests, that usually means an

By |2022-01-01T22:51:53-08:00January 26th, 2017|
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Copays are declining, but that’s not good news

A recent Peterson-Kaiser Health System Tracker study revealed an interesting finding: average copayments are declining. Their study, which analyzed claims data from Truven MarketScan, found that average copay amounts paid by patients decreased by 26% from 2004 to 2014. Seems like a positive trend for patients and practices ... except that it's not. It's part of a shift that's actually making out-of-pocket costs harder for patients to prepare for and understand. That makes them harder for practices to collect. The Peterson-Kaiser analysis found that while copays declined by 26%, coinsurance increased by much more, 107%.* Payers may be emphasizing coinsurance because it is assumed, like deductibles, to be a more powerful tool to discourage unnecessary utilization of services. But for patients who need care, coinsurance can be another cause of 'surprise' obligations, since it's not always easy to calculate the amounts due. Patients may also easily confuse copays -- which are standard amounts for services like office visits, prescriptions, or the ER -- with coinsurance, which can only be calculated after determining what services are needed. This difference can lead to reluctance to pay, or fear of being incorrectly charged, especially when the amounts are significant. Here's a chart from the Peterson-Kaiser report: Coincidentally, but not surprisingly, the report also found that total cost-sharing continued to rise steadily and steeply. The analysis found that total out-of-pocket costs rose 77% from 2004-2014 -- much faster than wages. Besides the 107% coinsurance increase, deductibles increased 256%(!). For practices, this means that effective patient collections continues to be crucial to profitability. Not only are patients accounting for an ever more significant proportion of earned revenue, their payment responsibility will almost certainly continue to be confusing. It's crucial to help patients understand and prepare for the amounts they will be expected to pay. Be sure you also offer options like credit-card-on-file, mobile payments, payment portal, and payment plans to encourage their compliance. *I also wonder how much of the decline in copayments is due to patients using more preventive services, which carry no copay by law under the ACA. This could bring the average

By |2022-01-01T22:51:55-08:00July 10th, 2016|
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Patient-centered medical homes: what’s behind all the hype? [Power Up webinar series]

A key factor in the patient-centered movement gaining traction is the Affordable Care Act and its intention to improve population health and reduce healthcare costs in the United States. This is expected to be accomplished through improved patient satisfaction, coordination of care and better clinical outcomes. The Patient-Centered Medical Home (PCMH) is viewed as a path to accomplish this and CMS is offering financial incentives to primary care practices that become recognized as a PCMH. The idea of PCMH was developed through a consortium of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association. Together they developed joint principles for the PCMH including the provision that each patient would have their personal physician and their care would be directed by the practice, ensuring care was coordinated and/or integrated as deemed appropriate with an expected level of quality, safety and enhanced access, as well as establishing appropriate payment for these efforts. There is national growth in practices achieving recognition as a PCMH with the front-runner of recognition programs being offered by the National Committee for Quality Assurance. In 2011 NCQA’s standards increased to include guidance on developing chronic care management programs, enhancing patient engagement and improving patient outreach, and aligning with EHR and the new healthcare Meaningful Use criteria. NCQA’s program promotes goals to: Improve the patient experience Recognize clinicians’ efforts Provide confidence for purchaser: value for money spent on quality care CMS led the pack with financial incentives for the PCMH, but other payers have also emerged with bonus and payment systems that recognize the PCMH, improved outcomes and patient satisfaction In 2013 NCQA announced the Patient-Centered Specialty Practice recognition program. The development of this program was motivated by the discovery of reporting discrepancies between referring physicians and specialist. The PCSP program is designed to improve communication and access. Yes, there’s a lot of buzz about the focus on being patient-centered and improving the patient experience, but the programs are only growing in importance. If you haven’t already done so, it’s time to get information, make the commitment

By |2022-01-01T22:52:02-08:00November 17th, 2014|
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How to work with hospitals and systems without losing yourself [Power Up Webinar Series]

Hospitals are acquiring or partnering with medical practices at break-neck speed and for good reason. It makes sense to align with physicians in a changing marketplace. It will strengthen the hospital’s position for both bargaining power and marketing their brand.   Physicians on the other hand, fear the unknown and are often uncertain about the strategies they should take to protect or improve their future. If you are approached about the possibility of joining forces with a hospital do you know what you would do? Here are some things for you to think about. The first step in consider partnering with a hospital is to clarify the opportunity by gathering information. Examine your own motivations. What is it you hope to gain and is it realistic?   At the same time, it’s important to understand the hospital’s agenda and determine if, in fact, their motivations are clearly aligned with yours. Remember all successful relationships are built on trust. You can avoid a head-on collision if you ask the difficult questions and get honest answers upfront. At the same time, you must we willing to be open in your communication by discussing what you want and hope to gain, and what concerns you may have. Whether it’s about their motivations, their leaders or how they want to structure the contract. If it doesn’t feel right, it probably isn’t going to work unless you resolve the issues that make you uncomfortable with the deal. It is only through honoring your differences and negotiating in earnest that you can work toward common goals that align motivations and lead to success.   In order to share your future you must develop trust and common goals, and build a vision that everyone stands behind. Check out my free mini-webinar on working with hospitals and systems without losing yourself, presented by the AOA -- part of the Power Up series.

By |2022-01-01T22:52:03-08:00November 10th, 2014|
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The ACA grace period’s perverse payer incentive, and why hospitals would like to pay some patient premiums

Health Affairs has a nice analysis of the ACA's 90-day grace period on cancellation of enrollment for subsidized patients who miss premium payments.  But one piece of the puzzle that their article doesn't touch on is the perverse incentive for health plans not to vigorously pursue those missed premiums. Under the grace period, plans are required to reimburse providers for services rendered in the first month that the patient misses a premium payment, but not in the second and third months.  However, the services a patient might need in months two and three could -- perhaps even most-likely would* -- greatly exceed the value of the premiums missed.  This is why some hospitals, and now even some physicians, have started investigating whether they can pay these premiums on behalf of patients; they realize that they could be denied thousands in payments owed to them because of a patient's failure to pay a much smaller amount.  And this is why health plans would undoubtedly prefer that those patients not pay their premiums -- and are unlikely to make any special efforts to collect them. The idea of providers paying these premiums to protect their own position has analogs in other markets. For example, a bank might pay off a mortgagor's tax lien to avoid losing the entire value of the property if the government forecloses.  But in our world, it's not clear if other regulations that touch upon payment relationships could hold against providers who try to pay off patient premium obligations.  Health Affairs notes that CMS has already made a public statement discouraging such efforts. While the AMA, MGMA and others continue to urge reform of the grace period provision, it's reasonable to assume that payers will continue to argue that the related laws actually prevent providers from stepping in to pay premiums, and that the grace period rule should remain unchanged.  (And, presumably, they'd argue against another solution, such as deducting the value of missed premiums from provider reimbursements.) The bottom line is, the grace period seems unlikely to disappear any time soon.  It remains very important that physicians,

By |2014-10-26T14:09:05-08:00October 27th, 2014|
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Will the ACA bring a wave of new patients? Prepare for the best

Will the ACA bring a big increase in patients to your practice? For most of the practices we've been working with, the ACA's impact on patient volume is still pretty unclear.  Since we're less than a month into the new coverage year for ACA exchange plans, and the open enrollment period continues through March 31, we're still at the very early stages; the actual impact is hard to gauge at this point.  Moreover, the impact may vary widely based on local demographics, practice type, and state participation in the Medicaid expansion. But we're still advising practices to take steps to prepare for more volume -- whether it comes from the ACA or their own marketing.  Readying your practice for growth is good business.  Better processes not only allow you to handle more volume, they help you serve all of your patients more effectively. Preparing your practice to handle more patients is the subject of my upcoming webinar sponsored by Kareo and hosted by Physicians Practice.  Join me on Feb 6 for this free presentation entitled "Position Your Practice for Growth: Responding to the Dynamic Healthcare Market."  I plan to share some ideas that can help almost any practice prepare from and profitably realize more growth -- whether from the ACA or their own internal marketing efforts.  Plus time for your questions!

By |2022-01-01T22:52:10-08:00January 20th, 2014|
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Will 2014 be a better year for your medical practice?

This is certainly a reasonable question to ask considering the rapid-fire change, threats and unknown factors medical practices face due to the Affordable Care Act.   But here are a few things you can do to deal with all of this. First, keep your eye on the ball.   Don’t throw up your hands in frustration, but follow the news and the legislation that is likely to impact the way you practice medicine, your future stability and the care and service offered to your patients.   Read everything you can and keep your cool. In other words, don’t throw your hands up in despair.  Put the emotions aside and be prepared to respond.  If you know what’s coming down the pike you can be practice-ready and take strategic actions rather than wait, feel the panic and be reactive, which typically leads to poor, costly decisions.  Well thought out decisions will explore not only the potential threats, but the opportunities that are available to you and your colleagues without compromising your integrity or patient care and service. Next, look at the numbers.  How well did your practice perform compared to prior year and compared to other practices in your specialty?  Benchmarking will help you examine the trends so you can examine areas where performance was disappointing and seek ways to bolster them for next year.   The numbers tell the story of past performance and give you an opportunity to set future goals that keep the practice stable and on financially solid ground. Don’t make squeezing cost a primary focus.  Sure, it’s normal to focus on costs when reimbursement is tight and may get tighter, but in reality you can only squeeze costs so much.  If you focus most of your efforts on costs you are likely to reduce quality and service. The highest expense for a medical practice is staffing, but the old saying: “You pay peanuts, you get monkeys” is true.  Hire well – highly skilled and experienced people; respect them, pay them well and set high expectation goals and staff well help your organization to me more profitable.  Physicians  and managers can

By |2022-01-01T22:52:11-08:00December 23rd, 2013|
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Six steps physician leaders and practice managers can take to improve the patient experience

Leadership sets the tone for the entire practice.  Staff will model your commitment and follow your expectations.  Much of the manager’s role focused on managing practice finances, maintaining practice viability, and keeping a highly motivated and efficient staff that is respectful and trustworthy.  Add to the list a new yardstick that changes how physicians get paid based on a patient experience that improves compliance to result in better outcomes. Develop a plan and set up programs to help staff understand how the patient experience relates to both outcomes and practice finances. Show your commitment through continued communication and actions that reveal a consistent effort to improve the patient experience. Give staff the education and tools to succeed in delivery consistency in your customer service organization-wide. Coach staff to improve performance.  Provide them with the support and encouragement with implementing essential changes on the road to being more patient-centered. Manage progress well.  This means conducting a baseline patient satisfaction study based on key performance areas and periodic follow-up to be sure targeted areas of improvement results in satisfactory results. Set your goals for becoming a best practice. Be explicit in what you expect and intend to achieve.  Honor each person’s contribution and celebrate successes that achieved along the way. Leaders have the ability to set the stage for success, instill a sense of pride and hope within the organization, and meet the challenges of strengthening the relationship between the clinical practice and the patients they serve.  In the end, we seek to improve the health of our patients, enjoy the relationship we have with patients and be among the best.  

By |2022-01-01T22:52:11-08:00December 14th, 2013|
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ACA out-of-pocket costs: Vindication isn’t always sweet

The New York Times reported today that "On Health Exchanges, Premiums Maybe Be Low, But Other Costs Can Be High." This is something we've been talking about for a couple of months now -- often getting skeptical looks here in our super-blue home-town.  But it's not about partisanship.  The ACA is simply accelerating the trend of payers pushing more responsibility onto patients -- a trend that has been gathering momentum for many years.  It's not unexpected if you've been watching how health plans have been evolving. Still, it is discouraging if you had hoped the exchange plans would offer better patient protection against big out-of-pocket costs -- and it also means that the burden that practices face to collect more of their revenue from patients keeps growing. The AMA's 2013 National Health Insurer Report Card (NHIRC), published earlier this year, revealed that health plans across the country were placing about 25% financial responsibility for cost of care onto patients: Aetna Anthem Cigna UHC Medicare 20.40% 23.10% 25.90% 23.40% 24.60% The target 2014 patient responsibility proportions that were set for all ACA plans skew even higher than this -- even the "silver" level, where subsidies are targeted, pegs patient responsibility at 30%: ACA Bronze ACA Silver ACA Gold ACA Platinum 40% 30% 20% 10%   These "actuarial values" were fairly widely reported prior to the exchanges even opening (here's one link from MSN), so it's a bit of a mystery why the Times is reporting this as news at this point.  It's critical that consumers understand what they're getting into when they sign up for coverage, and the media should have been on top of this key information.  (Especially if you've not purchased coverage before, the terminology behind patient responsibility payments -- co-insurance, deductibles, copayments, out of pocket -- can be very confusing. Many new patients are likely to be confused and possibly quite disappointed.) We expect that this means practices will need to be even more careful and sensitive in dealing with privately insured patients, especially in January, when deductibles re-set.  Some patients will be more confused than ever --

By |2022-01-01T22:52:11-08:00December 9th, 2013|
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The threads of payment reform and quality programs are coming together

It seems like forever now that practices have been dealing with multiple, complex, incentive and penalty initiatives from the federal government: Meaningful Use, PQRI/PQRS, eRx, PCMH and, more recently, "value-based" programs (value-based purchasing for hospitals, and the upcoming value-based purchasing modifier for physicians). If you're like us, the onslaught of these programs has seemed more like a series of separate carrots and sticks (amplified by private payer programs that have built on the government's pay-for-performance approach) than a coherent strategy for driving change.  Rarely do notices about these programs include helpful guidance as to how they're interrelated.  (Perhaps it would just be to hard to fit those details in amongst the deadlines, bureaucratic details and confusing specs!) That is why it is at least helpful to finally be seeing -- after years of programs popping up and interrupting practice operations, demanding attention without saying why (except when why was 'get a bonus' or 'avoid a penalty') -- the outlines of inter-connectedness among all of the government's many programs. For example, Medicare's Physician Compare website provides information about a physician's participation in various quality initiatives, like PQRS and ePrescribe.  (This is perhaps a good opportunity to remind you to check this -- and all -- the directories in which you or your providers are listed.  There are often errors -- if contact, specialty or location data is incorrect on a key directory, it can cost you patients.  And if the CMS has incorrect data about your participation in important incentive programs, you'll want to follow up on that immediately to remedy their data or your submissions.  As we say all the time, this need to check goes for payer directories (!) and public directories like Healthgrades and Vitals.) Anyway, a sample of quality participation data as it is displayed on the Medicare site appears below.  For some patients, knowing you're participating in these programs could make the difference in selecting your practice: Besides PQRS participation, the Physician Compare site shows participation in ePrescribe and Meaningful Use as well. Of course, the integration of this data into directories is just the beginning. 

By |2022-01-01T22:52:12-08:00November 26th, 2013|
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Still time (but not much!) to avoid a PQRS penalty in 2015

There is still time for providers to avoid the PQRS penalty for 2013 reporting, which will mean a 1.5% deduction from Medicare reimbursements in 2015 (ouch!).  The following two methods still apply for individual providers: -Submit via a qualified EHR vendor -- if your EHR is provided by a vendor that has been permitted by the CMS to submit directly, submitting data could be much easier than you think.  Be sure to contact your vendor to find out what their capabilities are.  Even if not qualified to submit directly, your vendor may be able to help you submit via a registry -- the second method available to not just avoid the 1.5% penalty in 2015, but also earn a .5% incentive for 2013. -Submit a single, valid measure via a single claim.  You can do this!  This approach will not permit you to earn an incentive this year, but you will avoid the penalty in 2015 -- and you'll have gotten your feet wet for more comprehensive compliance in 2014.  (Do it now -- don't delay -- to be sure your claim is accepted and qualifies.)      

By |2013-11-24T17:46:46-08:00November 24th, 2013|
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Could the ACA-mandated grace period be problematic for your practice?

Many practices already suffer losses from surprise payment retractions by health plans.  These can occur when patients attempt to exploit system update lags after leaving their employer (and therefore the employer's plan) or the grace period after failing to maintain payments on their own policy.  (So, the patient knows he's not paid his premium or that he's left the employer plan, but also knows he's still "covered" because of payment grace period or because of the 30-day window to elect COBRA coverage -- even though the coverage will eventually be retroactively cancelled to the last paid day.) Any retraction of payment for services already rendered is a blow for providers and their practices, but most state policies regarding timely payment of claims and premium grace periods help limit the exposure for retraction of reimbursement to 30-45 days. However, the Affordable Care Act (ACA) contains a provision that mandates a much longer grace period -- 90 days -- for subsidized plan participants.  The ACA authors intended that plan members who receive subsidies be allowed more leeway for missing payments because of lower incomes and possible hardship -- but, the longer grace period also creates opportunity for abuse and financial exposure for practices. Hospital and physician groups made note in the ACA comment period of the potential for the grace period to result in uncovered services being rendered.  Extending the grace period increases the likelihood that significant services can be provided before a plan can be cancelled for unpaid premiums.  Providers argued that plans should have to bear these costs -- especially in the case of subsidized membership, since plans would presumably be receiving at least part of the premium cost from the government.  However, in the final rule, the CMS allowed plans to deny claims in months two and three of the grace period.  This means that payments already issued to providers could be retracted -- leaving practices and hospitals on the hook for the cost of care already provided. How can practices prepare for and protect themselves from these unexpected costs?  A few things to evaluate: Has your state negotiated

By |2013-11-09T18:08:14-08:00November 11th, 2013|
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