By Richard D. Stier
The industry shift from fee for service to value-driven payment has begun. Your healthcare call center can be an essential resource for your organization as it pilots that transition.
Amid familiar acronyms such as HMOs, PPOs, PHOs, IPAs, and MSOs is ACO, “accountable care organizations.” ACOs have two critical roles: manage patients’ healthcare and measure and report patient outcomes. The ACO represents an intentional shift from being paid based on volume to being paid based on outcomes; the better you do for patients, the more you are paid.
“The shift from volume-driven to value-driven payment is inevitable,” says Paul B. Ginsburg, Ph.D., in an article published in the New England Journal of Medicine. “Getting limited shared savings while embarking on the needed investments to build the infrastructure and relationships for improving delivery is better than getting no rewards under the fee-for-service system.”
The ACO is a seemingly simple structure. First, it manages utilization. Second, when the utilization of services is to take place, it finds where it can be done most efficiently. Michael Sachs, chairman and CEO of Sg2, observes, “Whatever the unit of service is, you want to reduce it. Whether I buy the procedure at $4,000 or $5,000 isn’t terribly significant. It’s whether the procedure is done at all.”
Excess readmissions = less reimbursement: Reducing preventable or “excess” readmissions represents a significant financial opportunity. Beginning in 2013, CMS (centers for medicare and medicaid services) will compile national data on readmission rates for eight conditions. The three initially targeted conditions for penalties are congestive heart failure (CHF), heart attack, and pneumonia.
According to David Ollier Weber in the September 27, 2010, issue of H&HN Weekly, “Medicare payment reductions for excess readmissions are calculated by the observed rate divided by the expected rate, minus a standard quality value of 1.” Therefore, in one example, a one percent excess in CHF readmissions would result in a reimbursement decrease of $421,000 instead of $80,000. What could be the financial cost of a one percent excess readmission rate in two or three clinical service areas?
ACO or not, your call center empowers important opportunities: Regulations favor primary care physicians. ACOs view PCPs as the leaders of patients’ healthcare and relegate other parties to being cost centers. Whether or not your organization deploys an official ACO, the success of primary care leverages the ripple effect of multiple clinical services across the enterprise.
Opportunity: Make your call center an intentional referral engine for primary care physicians.
In order to improve patient satisfaction, ACOs must have a patient survey tool in place. Beginning in 2013, the CMS will reduce payment for 3,500 acute care hospitals by approximately $850 million. The potential loss for one two-hospital, 950-bed system is about $2 million. Hospitals can earn that money back – and more – if their patient satisfaction scores exceed those of their competition. ACO or not, improving your patients’ experience of care is especially important for the call center, which is frequently the organization’s first point of contact.
Opportunity: Conduct outbound patient surveys; document and trend results.
Opportunity: Raise patient satisfaction scores with distinctively positive call experiences. Outline themes for consistent agent opening and closing, provide agent supportive messages of the day, and flag caller specific opportunities with “silent selling points.”
ACOs must have systems to identify high-risk beneficiaries, develop individual care plans, and a process to promote evidence-based medicine, patient engagement, and coordination of care. Whether or not you have an ACO, aligning patients with referrals to the most cost-effective, clinically appropriate site of care based on their clinical requirements is key.
Opportunity: Deploy clinical triage with evidence-based protocols, such as Cleveland Clinic guideline protocols.
Preventable readmissions will trigger reimbursement reductions beginning in 2013. ACO or not, avoiding costly reimbursement decreases is an emerging non-optional priority.
Opportunity: Make post-discharge outbound calls to clarify instructions, reduce medication errors, answer questions, and schedule follow-up appointments.
These call center opportunities can increase your stream of referrals to primary care physicians, improve your patient’s experience of care, triage callers to the least expensive clinically appropriate site of care, and reduce excess readmissions. These opportunities are relevant and timely, whether or not your organization deploys an official ACO. The industry shift from fee for service to value-driven payment is underway. Your call center can be a vital resource for your organization as it navigates that transition.
Richard D. Stier, M.B.A., is vice-president of marketing at HealthLine Systems, Inc.
[From the February/March 2012 issue of AnswerStat magazine]