Housekeeping
 Next Event
 Marketing Items
 Surveys
 Miscellaneous
Playing in the Sandbox
– Effectively Using
RVU’s for Physician
Compensation
Brian M. McCook, CPA
AMD
Learning Objectives
• Refresher on RVU’s
• Benchmark Data Options
• Explore opportunities for RVU compensation
models
• Non-clinical considerations
• Wrap-up
Intro to RVU’s
• Relative Value Unit – a measure of the
resources required to provide various
services.
– Time
– Level of skill required
– Resources needed
• RVU’s are assigned to each encounter, test,
procedure or surgery based on CPT codes
– Can assign values for non-clinical tasks, if
needed.
Total RVU’s Components
• Physician work – Time, skill, training and
intensity (w RVU’s)
– Compensation agreements tied to work RVU’s
• Practice Expense – Costs of delivering
services and maintaining a practice (pe
RVU’s)
• Malpractice – Professional liability (mp
RVU’s)
Other Important Terms
• Geographic Practice Cost Indices (GPCI)
• Conversion Factor (CF)
• Monetary value = Total RVU’s x GPCI x
CF
Example Calculation for CPT Code
99213
Relative
Value
Component
RVU’s
GPCI
Adjusted
RVU’s
CF
Medicare
Reimbursement
W RVU
0.97
1.000
0.970
$ 34.0376
$
33.02
PE RVU
1.03
0.936
0.964
$ 34.0376
$
32.81
MP RVU
0.07
1.934
0.135
$ 34.0376
$
4.61
Total
2.07
$
70.44
Benchmark Data Sources
• Several national surveys are conducted
annually
– MGMA
– Sullivan, Cotter and Associates
– Regional and specialty-specific surveys
Using Benchmark Data
• Understand how the data was derived,
including type and number of respondents
• May consider blending multiple sources of
data
• Be aware of potential inconsistencies that
exist in data
– RVU data using different fee schedules
Work RVU Compensation Models
• Can have various models and criteria – as complex
and creative as you want to be.
• Some sample models:
– W RVU Straight Model
– W RVU Tiered Model
• May have 2 or more tiers
• Consider tying into individual P&L’s - Must cover direct
expenses and allocated share of overhead to be
eligible for bonus.
• Be Careful – If too complicated, the physicians will not
understand and think they are being cheated!
RVU Sample
Other Items to Consider
• Models are transitioning to account for the shift
towards value-based care
– Resource Management
– Outcomes
– Quality
• Possible movement from fee for service to global
payments
• Payments for non-clinical time
– Administrative Time
– Education/Public Speaking
Other Items to Consider
• Consider tying compensation to nonfinancial factors as well
– EHR utilization
– Corporate citizenship
– Patient satisfaction
• Best models make sure physicians have
some “skin in the game”
• Simple can be better!
Components of a sustainable
model
• Expectations that must be established for
a long-term sustainable model
– Financial viability
• Comp model to support this initiative
– Allow for reinvestment
• Ramp-up for new doctors
• Technology
• Recruitment
– Must be a win-win for system and physicians!
Questions
What does all this mean?
• Develop a compensation plan that balances effort and
quality.
• Identify the metrics that are important to your
practice…and build around them.
• Be transparent.
• Try to keep as simple as possible.
• Make the physician compensation model a recruiting
tool for your practice!
AMD Health Care Services
AMD Health Care Services optimizes staff,
resources and revenues for hospitals
and physicians by offering solutions and direction to
complex practice management issues.
We provide an integrated approach to
physician practice success
from the financial, operational,
compliance and strategic perspectives.
Playing in the Sandbox
– Effectively Using
RVU’s for Physician
Compensation
Brian
McCook, CPA
bmccook@amdcpa.com
314-655-5564
www.amdhealthcare.com
The Patient Centered Medical
Home:
An Advanced Primary Care Model
Model
Derrick O’Connell, RN, MBA, Lean
Six Sigma Black Belt
20
The First Patient Centered Medical Home

1967 – American Academy of Pediatrics (AAP) first
termed the “Medical Home” as a centralized
location for care of children with special
needs with the following attributes:







Accessibility
Continuous
Comprehensive
Family-centered (Patient-centered)
Coordinated
Compassionate
Culturally effective
21
The Medical Home Model Evolves

2004 – The American Academy of Family Practitioners
(AAFP) developed a ‘Medical Home” concept
 2006 – The American College of Physicians (ACP)
developed an “advanced medical home”
concept
 2007 – The AAFP, ACP, AOA (American Osteopathic
Association) and the AAP (in conjunction with
the NCQA) develop: ‘Joint Principles of the
Patient Centered Medical Home’
22
The Joint Principles
Joint Principles of the PCMH:
 Personal Physician – Each patient has a personal
physician
 Physician Led Team Orientation – A team of health care
professionals provides comprehensive care
 Whole Person Orientation – The total bio-psychosocial
sphere of the person is the focus of health management
efforts throughout their complete life cycle

Chronic disease management
 Acute care
 Age appropriate care
 Care is coordinated across the entire continuum – Care
management helps to ensure effective care coordination across
all elements of the complex health system
23
The Joint Principles
Joint Principles of the PCMH:
 Quality and safety are hallmarks of the PCMH –
Engages in continuous quality improvement processes
 Practices are patient advocates
 Use of Evidenced Based Medicine and clinical
decision support tools
 Patients actively participate in decision making
 Patient experience data
 HIT is used to support optimal patient care
 Practices go through a voluntary PCMH recognition
process Development of a comprehensive QIP
 Enhanced access – Patients are able to access care in
more ways and at more times
24
The Joint Principles
Joint Principles of the PCMH:
 Appropriate payment – Payment supports the valueadded team concept of the PCMH
**The industry, overall, is moving towards value-based payment
methodologies. The PCMH Model of care provides the health care
delivery paradigm by which to satisfy the Purchaser Imperative.
25
Infrastructure
1.
2.
3.
4.
Organizational willingness to implement the PCMH
Health Information Technology (HIT)
Quality Improvement Professional(s)
Data analyst
26
Infrastructure
1. Organizational willingness to implement PCMH
a.
b.
c.
Strong Physician Champion(s)
Strong Change Agent
Strong Governance
i.
Quality Improvement Committee
ii.
Board support
27
Infrastructure
2. Health Information Technology (HIT)
a.
Electronic Medical Record
i.
Templates with clinical decision
support
ii.
Evidenced Based Medicine (EBM)
Guidelines
b.
e-Prescribing
c.
Registry functions
d.
Lab interfaces
e.
Future interface with Health Information
Exchange (HIE)
28
Infrastructure
3. Quality Improvement Professional(s)
a.
b.
c.
d.
Clinical background
Development of Quality Improvement Plan
i.
Policy & procedure development
Data management background
Liaison with Data Analyst
i.
Registry development
ii.
Report development
iii.
Clinical performance measurement
e.
Process improvement skills
29
Infrastructure
4. Data Analyst
a.
b.
c.
Ability to create queries in collaboration
with the Quality Improvement Professional
Report development
Registry development
30
Organizational Standards
 There are policies and procedures required for the
Patient Centered Medical Home

These are your organizational standards
 Make them focused and meaningful
 You will need to measure your organization’s
performance for these standards
31
Population Management
1. Understand your patient population
a.
Stratification
i.
ICD-9 Dx – unique patient count
ii.
Encounters
iii.
Charges
b.
Compare to Center for Disease Control
i.
National and regional
epidemiology
2. Develop Evidenced Based Medicine Guidelines
a.
Proven treatment guidelines based upon
science
i.
Reduce disparities
ii.
Industry standards
32
Population Management
3. High-risk sub-population(s)
a.
Barriers to Treatment Plan or medication
compliance
b.
Multiple co-morbidities
c.
High levels or inappropriate resource use
i.
Frequent ER or urgent care visits
ii.
Non-emergent ER utilization
iii.
Frequent hospitalizations
iv.
30-day readmissions
d.
Behavioral health histories
e.
Advanced age
f.
Pediatric at-risk populations
33
Synergy with Meaningful Use

The Patient Centered Medical Home has many
synergies with Stage 1 Meaningful Use

Stage 1 Meaningful Use requirements are embedded in
the 2011 NCQA PCMH Standards

Stage 1 Meaningful Use workflows and data capture
promote the functions of the PCMH
 It is advisable to achieve Stage 1 Meaningful Use
before, or concomitantly with your PCMH project
34
Standardization

The PCMH model and Meaningful Use
 Standardized templates in HIT/EMR
 Standardized clinic workflows
o Application of EBM Guidelines
o Doing the same right thing, at the same
right
time, all of the time
o Mistake-proof workflows for the application of
EBM Guidelines
 Develop condition-specific protocols
35
Enhanced Access
1. Same day appointments
2. Timely advice
a.
Telephonically
b.
Patient portal
3. Access to primary care outside of 8 am – 5 pm, M- F
a.
Non-ER venue of care
b.
Expanded office hours
c.
Urgent Care arrangement
4. 24-hour access to clinical advice
a.
Telephonic and patient portal
**The right care, in the right venue, when the
patient/customer wants it
36
Enhanced Communication



Goal is always to collaborate with the patient
 Patient-Centeredness
Keep the patient informed about their current status
and future plans/goals /responsibilities
Marketing materials to educate patients/families
 What is the PCMH
 How to access care and information
 Roles and responsibilities
 Provide access to EBM Guideline condition-specific
materials
37
Care Coordination
1.
Lab and diagnostic test tracking
2.
Coordinate and track consultant and specialist care
3.
Following up with patients when they miss
important appointments
4.
Tracking and coordinating inpatient and ER
transitions of care
5.
HIT interfaces to electronically exchange key clinical
information (may be dependent on HIE deployment)
38
Care Management

Goal is always to educate, coach and mentor
patients/families to their highest level of selfmanagement
 Improve Treatment Plan and medication
compliance
 Provide access to specifically trained professionals
for
chronic disease management education

Notification of gaps in care
 Age-appropriate
 Chronic condition
39
Performance Measurement &
Improvement


Clinical performance
 Age appropriate or preventive screenings
 Acute and/or chronic care
Utilization
 Hospitalizations
 30-day readmissions
 ER utilization
 Measure patient/customer experience
 Annual surveys
 CAHPS for the PCMH
40
Performance Measurement &
Improvement

Compliance with organizational standards
 Track, trend and report all measurements over time
 Develop performance goals based upon industry
standards/benchmarks or internal incremental
improvements
 Develop and implement corrective action plans for any
performance not meeting goals, standards or customer
requirements
41
The Patient Centered Medical
Home:
An Advanced Primary Care Model
Model
Derrick O’Connell, RN, MBA, Lean
Six Sigma Black Belt
42
PCMH & The Technology
SHIFT
Eric W. Humes
Keystone IT Consulting
What is PCMH?
(just in case you didn’t know)
PCMH = Patient Centered Medical Home
As defined by the Agency for Healthcare Research
and Quality (AHRQ), a PCMH is a medical home
that not simply a place but is also a model of the
organization of primary care that delivers the core
functions of primary healthcare.
5 Core Functions of PCMH
PCMH is built upon the following concepts:
1.
2.
3.
4.
5.
Comprehensive
Patient-centered
Coordinated
Accessible
Quality/Safety
1.
2.
3.
4.
5.
Examples of the 5
Functions
Comprehensive care – mental and physical health
needs, prevention and wellness, acute and chronic
care.
Patient-centered – relationship based; recognizes that
a patient’s family is part of their care team.
Coordinated care – increasing communication across
patient ~ family ~ hospital ~ clinics ~ community
services.
Accessible services – shorter waiting times for
urgent needs, enhanced hours, 24x7 phone/internet
based support..
Quality / Safety – evidenced-based medicine, clinical
decision support tools, reduced errors,
measuring/responding to patient satisfaction.
Technology’s Role in
PCMH
Health IT (HIT) can help to achieve each these
fundamental goals but primarily relates to:
• Coordinated care
– Communication between members of the care team
• Accessible Services
– Communication between patient and care team
• Quality / Safety
– Clinical data analytics tools, EMR systems, reduced
errors with eRx, data trending, dashboarding
•
Technology’s Role in
PCMH
HIT can support the PCMH model by collecting,
storing, and managing personal health
information, as well as aggregate data that can be
used to improve processes and outcomes.
• HIT can also support communication, clinical
decision-making, and patient self-management.
Technology’s Role in
PCMH
Question: Will significant investment in promoting
the adoption of health information technology (IT)
and meaningful use of electronic health records
(EHRs) through the Health Information Technology
for Economic and Clinical Health (HITECH) Act enable
primary care practices to become patient-centered
medical homes (PCMHs)?
Answer: No. While the adoption and meaningful
use of EHRs help support some aspects of the PCMH
model, HITECH programs and other current Federal
legislation are necessary but not sufficient for
driving widespread adoption of the medical home
model.
(Source: AHRQ)
The Needed SHIFT
HITECH offers some policy options that could ensure
EHRs are implemented in a way that supports
primary care transformation. These could include
the following:
1. Adding explicit functionalities that directly
support the PCMH model to the recently
released EHR certification standards and criteria.
2. Adding EHR meaningful-use requirements that
support the PCMH model for stages 2 and 3 of
the EHR Incentive Program.
HITECH is Necessary, but Not
Sufficient
• HITECH is not sufficient to support the PCMH
model.
• HITECH laid important groundwork to support the
PCMH model. However, its goals and processes
were not linked specifically to this model.
Without explicit linkage, HITECH will miss
opportunities to support the transformation of
primary care practices.
Three Major Limitations
of HITECH Act
1. The legislation does not specify from either a
technical or a legal perspective how primary care
providers will be able to communicate with the
practice’s “medical neighborhood”.
2. The meaningful-use concept does not entirely
overlap with the PCMH’s core principle of
comprehensive,
team-based
care
and
collaboration among staff within a practice.
–
MU certification criteria for EHRs do not explicitly
support the PCMH model.
3. HITECH’s requirements do not address improved
access to care [via digital means].
The CMS Can Still Adjust
Fortunately, as the CMS releases Incentive Program
regulations over time, they can create the needed
linkage between Meaningful Use stages 2 and 3 and
the PCMH concept.
Expand the scope of the Regional Extension Centers
(RECs) to provide education and technical assistance
to eligible Primary Care Providers on the PCMH
concept.
Critical HIT Capabilities for
PCMH
• Provide easily accessible services during and
outside normal business hours through multiple
communication mediums.
• Have systems to identify patients needing specific
interventions and to manage population
segments (e.g. complex health needs, post
hospitalization, etc).
• Coordinate care through organized and efficient
processes that facilitate timely bi-directional
information exchange between health
information databases.
Critical HIT Capabilities for
PCMH
• Utilize key elements of technology (e.g. eprescribing, clinical decision support, registries,
secure email, etc.) to deliver safe, high quality,
efficient health care.
• Engage patients in developing action plans with
trained healthcare professionals.
• Track and trend performance of the practice and
individual clinicians to improve quality/outcomes.
HIT plays a central role in enabling the functions of
a patient centered medical home, or any futurestate healthcare model.
Comprehensive HIT
Infrastructure is Key
• Movement away from isolated IT applications and
towards comprehensive HIT infrastructure.
• HIT must integrate into/support workflow
• HIT must enable the necessary functions of
delivering care and managing the population
– usability is key; structural capability alone is not enough
• Enable improved non-visit based access for
consumers to receive care, information, and
advice from the appropriate care team member.
• Access for consumers to pertinent educational
material. (Online patient education - videos,
presentations, FAQs)
Comprehensive HIT
Infrastructure is Key
• Enablement of self-management of care through
coaching, monitoring, tools, communication, peer
groups, etc.
– There is significant development work being done in
this area already with interactive secure patient web
portals and smart phone apps that connect patients
more closely with their health record and care
providers.
• Facilitate better customer service - allowing
patients to receive care when they want it and
how they want it, thus fostering better
relationships between patients and physicians.
Additional Resources
Additional resources available at:
http://pcmh.ahrq.gov
Questions?
PCMH & The Technology
SHIFT
Eric W. Humes
Keystone IT Consulting
Panel of Experts
Thank you for attending
Healthcare Stimulus 101 - May
2012
Next Event
Cape Girardeau – Dexter’s BBQ
Thursday, September 13
11:00am to 2:30pm
The LHE strives to make our seminars
educational in nature, knowledge-based and
encompass current subject matter. We
appreciate your feedback as we strive to
continue to bring these quality topics and
important issues to you. Thanks in advance!
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