A Sea of Emotions: A Look Back...A Look Ahead

As a leader in healthcare over the last year, have you felt as though you were on an emotional roller coaster? Has the uncertainty of healthcare reform caused commotion in your Finance Department, stress for the quality- and process-improvement personnel, anxiety in Medical Records, and angst in the halls of your cardiology practices? 

I would speculate that we have not experienced such change (or this fast of a pace of change) in healthcare since the adoption of Medicare in the early 1960s. Indeed, managing change and leading an organization during times of significant transformation requires great leadership skills, keen negotiation abilities, and outstanding communication skills. Turbulent times require individuals who can steer teams in a common direction while navigating speed bumps and detours along the way.

The healthcare reform movement has been driven nationally by the Patient Protection and Affordable Care Act (PPACA), which was enacted into law in March 2010. The far-reaching implications of the Act have been, and continue to be, debated vigorously by politicians with expectations from some that the laws and regulations will be overturned.

Corazon believes that regardless of the political party in the White House or controlling Congress, significant healthcare regulatory change is in our future. In fact, it’s already here! As a nation, our pattern of escalating healthcare spending is not sustainable, and the existing healthcare paradigm must change. In this situation, we particularly like a quote from English novelist Arnold Bennett:

“Any change, even a change for the better, is always accompanied by drawbacks and discomforts.”

These “discomforts” have crated a sea of emotions that have characterized the past year. We challenge every organization to harness this emotional energy and redirect it in a positive way.

The Year in Review: Did We Really Survive?

Over the past year, as we have traveled the country in our consulting and recruitment practice, we have witnessed emotions ranging from fear to anger to denial, as a result of reform. And no area of the hospital was immune, as these changes affect all areas of healthcare, from the administrative suite of hospitals to cardiologist offices, even to editorial rooms of newspapers in communities across the country.

It is not unusual for Corazon’s consultants to see fear on the faces of cardiologists who are faced with continued reductions in reimbursement, increasing practice expenses, and pressures to implement electronic health records in their offices while demonstrating meaningful use. These factors have caused many physicians to consider a move from private practice to a variety of other relationships and affiliations with hospitals. For instance, a significant number of cardiologists are seeking employment as way to not only stabilize their economic future, but also to focus on patient care rather than the “business” of medicine.

There has also been substantial interest from physicians in affiliation models such as co-management and management service agreements. These models provide an opportunity for physicians to partner with hospitals in order to guide operations, drive practice standardization, and commit to quality outcomes.

As we work to help negotiate the proverbial “win-win” as physicians and hospitals join together in a variety of ways, many emotional issues need to be considered and overcome, including a history of mistrust/distrust. Clearly, open forums where honest communications and dialogue about tough issues related to compensation, quality outcome targets, and bonus payment threshold are a must to ink the deal. A new (or refreshed) foundation of trust needs to be built in order to achieve consensus on contractual terms so that the new “partnership” can succeed.  

Another change that has created significant waves of emotion is the recent release of the American College of Cardiology/American Heart Association/Society of Cardiovascular Angiography & Interventions Percutaneous Coronary Intervention (PCI) Practice Guidelines consensus document, which has broad implications for PCI clinical practice. New practice guidelines for PCI have not been issued since 2005. 

The much-anticipated new document is comprehensive, and provides important guidance on patient selection criteria, phamacotherapy, and adjunctive device utilization. These guidelines also elevate primary PCI without on-site open heart surgery from a Class IIb to IIa, and elevated elective PCI without on-site open heart surgery from a Class III to a IIb classification. The guidelines define the IIb classification, saying that elective PCI might be considered in hospitals without on-site surgery provided that appropriate planning for program development has been accomplished, and rigorous clinical and angiographic criteria are used for proper patient selection.

The guideline changes have evoked a variety of emotions in cardiovascular  programs across the county. Hospitals that have been prohibited from performing elective PCI without on-site open heart surgery are pleased about the opportunity to now offer this important clinical service in their community. 

On the other side of the issue — and emotional spectrum — are hospitals with full-service programs that may now feel very threatened, as they anticipate new competition for PCI patient volume.

Another component of healthcare reform that is causing significant angst is related to regulations for Value-Based Purchasing (VBP). Hospitals will be challenged to demonstrate compliance with clinical proceses of care measures and the patient experience thresholds. The baseline measure for each hosptial has been set through data that has been collected from July 1, 2009 through March 31, 2010.

Beginning in 2013, CMS can withold 1% of the base DRG payment for hospitals with a weighting of 70% related to clinical processes of care measures and 30% related to the patient experience thresholds. Each measure is scored for achievement and improvement thresholds, and the higher of the two scores is used. The 1% withold will fund incentive payments for hosptials that hit achievment and improvement  targets.

There have been 12 clinical process of care measures identified for 2013. Of note, 7 of the 12 measures are directly related to the cardiovascular patient population, and an additional three meaures are related to antibiotic provision for surgical patients, which has implications for open-heart surgery patients.

Thirty-percent of the total score is related to the patient experience as reported through Hospital Consumer Assessment of Healthcare Provider Systems (HCAPS) scores. Corazon advocates that patient satisfaction be “front and center” for all hospitals, and managed in parallel with quality outcomes.

Clearly, hospitals in denial about the impact of these regulations may find themselves at risk if they are not devoting resources to manage practice, documentation, and data collection processes. The estimated dollars related to the potential 1% withhold nationally in the first year of implementation is $850 million. There will be winners and losers, but no NEW dollars to fund this program will be made available.

In 2014, CMS plans to add clinical process of care measures for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia mortality. Patient safety and multiple healthcare-acquired condition measures will be added as well. A 12-month performance period (July 1, 2011 through June 30, 2012) is in progress in order to set three 30-day mortality measures.

The VBP program continues to layer requirements, and the withhold gradually will increase to 2% by 2017. This program has the potential to provide significant rewards to programs that are able focus an effort on improving and managing clinical processes and patient satisfaction. Likewise, there can be a significant threat to the hospital’s bottom line if measures are not achieved.

The Year Ahead: An Optimist’s View

Although the current healthcare regulatory environment can be overwhelming, we remain optimistic that programs focusing energy and resources on this effort can be winners — delivering better care while making some revenue in the process! 

Corazon’s advice for the New Year is as follows:

• Work to build trusting relationships with physician partners. Be sure your organization is proactively seeking dialogue with qualified physician partners. Remember, if YOU are not talking with them, your competitor likely is.
• Create internal dashboards to monitor and track improvement progress against important clinical and patient satisfaction parameters. Form committees and workgroups that include administrative, physician, and bedside clinician representatives in order to drive change.
• Hold meetings with representatives from Finance and Medical Records to assure all understand the implications of VBP and all are engaged with physicians. Only then can you hope to CONSISTENTLY achieve appropriate documentation and coding.
• Actively engage the medical staff in the application of evidence-based medicine as a means to achieve best practice outcomes. Focus on controlling quality AND cost. Drive standardized practice through the development of order sets and EHR-driven pick-lists that hardwire care. 
• Empower your staff to be patient care ambassadors who deliver quality care and respond to satisfaction issues. The goal is for patients and family to be DELIGHTED with the care received at your hospital. 
• Evaluate strategies to grow your market share, including the provision of PCI without open-heart surgery on site if clinical and business considerations are positive. If you are a tertiary provider, consider ways to partner and support community hospital expansions to PCI. Such partnerships can work to maintain open heart and other tertiary referrals, or shift market share that is going to other tertiary centers back to your organization as a result of the new relationship.

Concluding Thoughts

Corazon believes that the best way to manage change is to have a solid plan in place, followed by diligent and focused implementation. Some organizations may need to take a step back in order to work on putting an overall cardiovascular strategic plan in place. Others may need to leverage their strategic plan to create a detailed action plan that guides activities, assigns accountable parties, and sets timeframes for accomplishment.

Our belief is, if it’s not written down with accountable parties and deadlines assigned, things are not likely to get done.

I end with a quote from American statesman Dean Acheson:  “Always remember that the future comes one day at a time.” 

So, let’s get to work!  Corazon wishes you much success in the new year — make 2012 a banner year for your organization!

Sue is a Senior Vice President at Corazon, offering consulting, recruitment, and interim management for the key hospital service lines of heart, vascular, and neuro specialties. To learn more, visit www.corazoninc.com or call (412) 364-8200. To reach Sue, email sheck@corazoninc.com.