In the past few editions of this newsletter we started to address the factors that will impact the “Change on the Horizon for Compensation Models”. This article continues that discussion with the topic of measuring or demonstrating the value of the services that are provided in your ob-gyn practice and effectively marketing this value to patients and payers.
The continuing struggle with high employee healthcare costs forces employers of all sizes to shift from defined benefit plans to defined contribution plans which are creating a dramatically different market for commercial insurers. This movement has significant downward pressure on reimbursement across providers as insurers move from the traditional fee-for-service reimbursement schemes to paying for value.
In this evolving payment mechanism, value is defined quality divided by cost. To improve value, a group must improve quality and/or drive down costs. We know what low or reasonable cost means but a consideration of the quality concept is worth a closer look.
While quality often has a subjective feel to it, a concerted effort is being made in healthcare to quantify quality. The following are elements of the current quality definition:
- The fitness of the provider or institution to satisfy a defined need
- Objective measurement of clinical processes and outcomes
- Everything that affects patient value …
- Including customer service, which, ironically has inherent elements of subjectivity
What will your ob-gyn practice need to do to be deemed a quality provider?
- Provide consistent, high quality ob-gyn care
- Adopt and implement leading best practices
- Minimize unnecessary variation in services
- Avoid duplicative or inappropriate care
- Provide superior customer service
- Do all of the above with a focus on patient-centeredness - cultural sensitivity, communication, and patient safety
Now is the time to consider the quality demands that are being placed on your practice and to determine if you are ready for value based reimbursement.
Within the physician provider community there has been a growing support for Accountable Care Organizations (ACO) and the “Patient Centered Medical Home” (PCMH) concept. The National Committee for Quality Assurance (NCQA) has developed a PCMH Recognition Program for primary care practices meeting certain specific criteria. While ob-gyn practices are not currently eligible for this recognition that the practice is a quality provider, NCQA does intend to begin recognizing specialty practices by the end of 2013. Standards are expected to be released in the Spring of 2013. The NCQA indicates that it will focus on:
- Access and communication including timely appointments and effective communications with patients;
- Collaborative agreements between PCPs and specialists;
- Accurate and timely information exchange related to referrals, test results and medications;
- Care coordination between the PCP and specialist;
- Performance measurements that demonstrate continuous specialty-specific quality improvement; and
- Meaningful use of health information technology in support of patient care.
While NCQA recognition for PCMH has become an industry accepted standard measure for quality and value in primary care practices and may soon be one for specific specialties, ACOG has developed an equally valuable designation program for its members. The Safety Certification in Outpatient Practice Excellence for Women’s Health Program (SCOPE for Women’s Health Program) contains similar elements that focus on value of care by certifying a culture of safety in ob-gyn practice. However, SCOPE does not focus on all of the same aspects as the NCQA PCMH recognition process. The SCOPE program is currently being refined based on participant feedback and will be re-launched with a new name in May 2013 to mark and celebrate its one year anniversary.
SCOPE takes into consideration specific criteria related to the clinical operations of your ob-gyn practice and also the role of all other staff including allied health professionals, office manager, business office, and reception. SCOPE requires a site visit be conducted following the submission of specific documentation. NCQA only randomly conducts site visits to about 5% of the practices seeking certification. Accordingly, the SCOPE process provides a more in-depth and perhaps more thorough review of safety as done in an office setting.
Another program called the ACOG Voluntary Review of Quality of Care (VRQC), established in 1986, provides comprehensive peer review consultations that focus on the standardization and quality of care being provided in the hospital setting. This is an important program to consider as hospitals and ob-gyns deal with pay for performance issues as well as investigate further collaboration in light of some payers moving to bundled payment for specific services.
The patient centric focus of SCOPE and VRQC on safety and quality outcomes demonstrates value and will be a useful tool for negotiating payment rates with payors as the reimbursement system moves to value based reimbursement. Achieving certification in SCOPE or PCMH will demonstrate the value of your practice and provide excellent marketing points in the changing reimbursement environment.
For additional information on these programs visit the ACOG web site.
L. Michael Fleischman