This article originally appeared in the November/December issue of PSQH.
We are in the midst of tremendous change in healthcare, and physician advisors are needed to be the lighthouse guiding our physician colleagues in the turbulent waters. The notion that a physician advisor only needs to know how to determine a proper level of care is well past us at this point, because organizations have realized that physician advisors can, and are, impacting healthcare organizations in many other equally important ways.
Board Certified physician advisors (CHCQM-PHYADV) have the tools to be the agents of education and change within their healthcare organization – because we understand the clinical and non-clinical aspects of the care we provide. Physicians are taught how to care for patients first and foremost, and that will always be our responsibility. But do we know how to efficiently move a patient through the hospital, through transitions of care settings, and through the entire care continuum? What are the mundane issues that decrease hospital throughput and efficiency that can be significantly improved with some simple focusing and coordination of the clinical care team by the physician advisor?
Physicians are also generally not taught how the systems that are built around us work. How does care translate into reimbursement? How is the quality of care measured? How do the systems around us either improve the safety of our patients or place them at risk? When can you rely on an insurer to tell you if a certain procedure is covered, and when are you expected to know that yourself? Did you just provide free care to an insured patient because you did not know the rules? These issues are age-old, but still not widely understood to this day.
The pace of change in healthcare today makes it imperative that our physician colleagues not only understand where we are, but where we are going. CMS publishes many thousands of pages of new guidance and regulations every year, sometimes to fulfill a Congressional mandate but usually to further changes related to CMS’ long-term vision. That vision for the next several years is how to pay for value instead of quantity.
The advent of the Center for Medicare and Medicaid Innovation (CMMI) has brought an unprecedented emphasis on population health. Innovative models such as the Bundled Payments for Care Improvement (BPCI) initiatives, Pioneer and Next Generation Accountable Care Organizations (ACOs), and Comprehensive Care for Joint Replacement (CJR) are all programs to pay for value and efficiency instead of volume of care. Many health systems have implemented strategic plans and are participating in these models today. What we have seen, though, is that physicians often still lack an understanding of how to use the additional flexibilities afforded by these programs to yield the greatest chance of sustainable success.
Change is not limited to healthcare systems either. The Quality Payment Program, comprised of two parallel pathways called the Merit Based Incentive Payment System and the Advanced Alternate Payment Model pathway, is arguably the biggest change of all because it will affect practically every Medicare participating physician. Care we provide in 2017 will begin affecting our professional reimbursement in 2019 in a big way. Overlaying such a complex program on top of an already complex healthcare delivery structure presents great challenges that physicians need to run to understand, not run away from.
The Protecting Access to Medicare Act (PAMA) will soon change how physicians order many radiologic studies. The law requires CMS to track how often the studies we order are supported by appropriate use criteria. Providers that consistently order studies that may not be generally indicated may be subject to prior authorization requirements when ordering CTs, stress tests, PET scans, and similar studies. The implications on provider workflow and reimbursement are large, needless to say.
Edward Hu, MD, CHCQM-PHYADV
Howard Stein, MD, CHCQM-PHYADV
Ronald Rejzer, MD, CHCQM-PHYADV
On behalf of the American College of Physician Advisors Board of Directors