In late June the Supreme Court voted to uphold the Affordable Care Act (ACA). That’s no longer news, although there are many who do not believe the decision by the nation’s highest court closes the door on controversy.
“I’d love to say it’s all downhill from here, but, unfortunately, I think it’s just a harbinger of things to come,” says Michael Sanderson, president of RemitDATA, a leading source of comparative analytics of reimbursement, utilization and productivity data for the outpatient provider market. “I think there’s still movement afoot in the House and elsewhere.”
As upheld, ACA requires, among other things, that Americans purchase health insurance beginning in 2014 or incur a penalty. That mandate, and other elements of the ACA, Sanderson says, will have an impact on physician practices.
Physicians do battle with reimbursement issues seemingly on a daily basis. But according to Sanderson, those battles will no longer be reserved for concerns over coding correctly and getting paid the correct amount in a timely fashion. Physicians are now faced with new quality bundle payment methodologies — Accountable Care Organizations (ACO) and the medical home concept.
The broader concern for physicians now becomes, how can they join these new models? And what should they expect as their share? According to Sanderson, these questions just raise the point that doctors need transparency.
“Doctors need to be in the know on what’s going on in their market,” he says. “Payers already know exactly what’s going on in these markets. The physicians have very little information, and they’re scared to death to have any kind of real shared information. They legally can have it, and we are encouraging physicians to get educated.”
For example, Sanderson suggests that before a cardiologist in the Dallas market walks into a Beta ACO how-do-we-split-the-pie meeting, he/she needs to know where he/she ranks. Is he/she being paid faster or slower? Is his/her staff less efficient or more efficient? Is he/she being denied more often? Does it cost him/her more to do business than peers? Is he/she a potential compliance risk because of his/her profile?
“There are so many ramifications to knowing and having real transparency,” Sanderson says. “It’s one thing to know about your own practice, but if you only know about your own practice, walking into any of these bundle payment methodologies and discussions, it’s suicide. Half of the docs are in the top half, and the others are in the bottom half, and neither of them knows who they are.”
Be a seeker
One of Sanderson’s strongest encouragements is for physicians to either get or stay informed. He suggests going to seminars, networking with peers, and staying on top of the trends and issues that impact physician practices.
“You have to be a seeker,” says Sanderson, noting that the physicians he sees at various conferences seeking information are the ones who will survive.
He also urges physicians to seek a source of comparative data.
“RemitDATA is one of those sources, but we’re not the only one,” Sanderson says. “Find a way to compare yourself to your peers. Medicare has offered the Part B Extract Summary Series data, and it’s free. It’s also called Best Data. You can go look at that for free to see how you compare. Now, it’s a bit dated; it’s usually a year old after it gets posted, but it’s real data that has been collected on all the Medicare transactions so you can see how you compare.”
Sanderson also points to great tools put out by Medical Group Management Association and American Medical Association. Those tools are more directional in nature and typically are not specific to a doctor in a certain market, but they can provide general information, such as 16% being an overall average denial rate.
Show me the data
Sanderson says the number of physicians seeking comparative and analytic data is on the rise. They are recognizing that a disproportionate transparency exists; that they are the ones who control 80% of health care costs, yet they’re in the dark. It’s still early as far as physicians knowing how to use the data, but the key is that more are asking for it.
“The information is out there, and doctors need to demand it,” Sanderson says. “It affects every decision in front of the doctor. One, should I sell the practice because we stink at what we’re doing? Number two, should I join this ACO? Three, should I sell to this hospital, since they’ve offered me a fair market price based on how I perform relative to my peers? Four, are any of our physicians doing things that make us an audit risk and subject to higher scrutiny? Five, do I have as much leverage as possible with my payers?
“Physicians need to maximize their leverage by demanding these types of tools,” Sanderson says.
Ed Rabinowitz recently wrote One More Dance, a book about one family's courageous battle against time and glioblastoma brain cancer. Read more about the book here.