Why are we so stressed about Mergers ending, ACO’s Failing, Value Reimbursement implementation?
Why are we so stressed about Mergers ending, ACO’s Failing, Value Reimbursement implementation?

The answer may be within ourselves and our institutions. As Vince Lombardi might have said “Data isn’t everything, IT IS THE ONLY THING”. Each day there are articles about failure and confusion and it makes every provider have to think about the business they are in.

We are in the business of providing care for patients in Hospitals, Ambulatory Surgical settings, Physician offices, Nursing homes and others. What counts more than anything right now is understanding where you are positioned.  While it is true that things are changing around us, we have to look carefully within to see what it is we are changing and what our data tell us about how we are doing. Recently an article appeared in the February 11th edition of Modern Health Care which cites payment to executives based on outcome of patients. Is this a bizarre anomaly or the future? There are no criteria that can link executive pay to the rendering of direct patient care.

What is presented absurd and frankly does a disservice to the clinical staff. Think Veterans Administration and how administrative incentives negatively affect care. It is the worst form of gamesmanship.

It is time to go back to basics and rethink about how our patients are managed while understanding how different and unique each patient is. Certain administrative data present a broad brush stroke but doesn’t reach the truth about the “Care”.

Some ACO’s have been misled into thinking they can earn big bucks by frankly restricting care rather than integrating management. One does not have to belong to an ACO to understand how well their patients are doing. Rather it is important to look at the individual cases that make up each patient panel and pick a sample for “deconstruction”. Essentially this is an exercise that is clinical, financial and operational; all data regarding a patient encounter is reviewed against practice standards or best practice. From a financial perspective the review parses the clinical documentation to assure that it supports the diagnosis, and that the coding of such cases really understands and respects what has been done clinically. Finally this exercise in Practices, Hospitals and other facilities is the only way the “larger body” of data will make any sense. Whether one uses the Electronic Record or still a paper record, the effort must be made to assure clinical excellence and support for payment.

“Deconstruction” and then reconstruction of a case with the appropriate supporting data is as important for learning and improving practice and outcomes then only reviewing aggregate date. The most important idea is to get behind the data by going to the source of their origin.

In thirty (30) years of doing these exercises in many academic medical centers and other providers, we have found that the participants (clinicians, Revenue Cycle management folks and others) receive great insights about care and resources used and finally whether the Reimbursement supports the use of resources. We should also remember that “Coding” was never intended nor can it measure resource use.

This is the time to begin looking within; we are advising our clients to create such a program with all of the players who drive the Revenue Cycle. The strength gained from knowing how well you are doing based on your own controlled investigation takes the “scary” out of every change coming in your direction.

Cathy Idema, BSN, MPH, FAAHCC.

President and CEO

Website: www.hsmn.com

Email: Cathy@hsmn.com

Phone: 866-908-4226

Health Systems Management Network, Inc

A Revenue Cycle Company cited by Modern Health Care magazine as one of the best, largest and longest established in its field.