Clinicians play a critical role in revenue cycle management, as reimbursement is increasingly impacted by clinical outcomes and patient experience.
Given their crucial role, it is important that hospitals and health systems engage clinical staff early in understanding evolving reimbursement models like bundled payments, says Dan Mowery, executive director of industry relations and market intelligence at McKesson Technology Solutions.
Mr. Mowery recently spoke with Becker's Hospital Review about why the clinician's role needs to be part of an RCM strategy for value-based reimbursement.
Note: Interview has been lightly edited for length and clarity.
Question: How can hospitals and health systems successfully transition to value-based reimbursement?
Dan Mowery: I think part of it has been getting their clinicians more readily involved, engaged and educated. Provider leaders must also look at value-based care as being patient-centric care. And if you are going to be patient-centric and pull value-based care off well, then your staff has to be well-engaged, well-informed and well-prepared to meet these requirements.
When healthcare professionals think of value-based care, they think of reducing variability, participating in shared savings and really leveraging evidence-based care and best practices. All of this is going to increasingly involve the clinical staff and that needs to continue and accelerate.
To effectively accomplish this, organizations must educate and support clinical staff. For example, give clinicians access to a completeview of patient population data. This view must incorporate total utilization and cost, integrated with relevant content to help identify gaps in care, patients at risk for hospitalization, as well as other opportunities for cost savings or care interventions.
Hospitals and health systems need to also think about what needs to occur prior to a patient visit, after the visit and the other factors that may not be directly related to the reason that patient is receiving care. In terms of post-care, providers need to consider how they will transition the patient back into the community post discharge and what support systems are available. I am not saying that providers are not already thinking this way or adopting these behaviors — many are on this track already. But this type of thinking and behavior will only need to increase as the industry progresses down the journey to value.
Q: What role do clinicians play in the transition to value-based reimbursement?
DM: I think the clinician's role has evolved over time. People have compared value-based care to pay-for-performance on steroids. That's why I think the clinician's value and role has been increasing or has been increasingly influenced by reimbursement changes.
But I think we've always said, "You can't bill what you haven't documented." So clinicians have been at the front end of the revenue cycle for a while. Obviously what occurs on the front end now is a little different. When you think of all the forms of value-based care, certainly one of those is bundled payments, so hospitals and health systems consider, "Is this person eligible for this bundle at this time? Do we have authorization?" As complexity on the front end grows, healthcare organizations are finding the need for additional clinical perspective is also increasing. While this may have been happening for years, the pace has certainly quickened and the complexities have grown.
Engaging the patient is also a critical piece of value-based care. Therefore, clinicians are working with the patient wherever they're at and focused not just on helping them understand their clinical obligations, but their financial ones as well. The clinician's role here will only increase. Therefore, getting relevant content in the hands of the care team members is increasingly critical for hospitals and health systems.
Q: How can hospitals and health systems incentivize clinicians to give the appropriate care?
DM: You've got to have skin in the game. You've got to have aligned incentives or it really creates some dynamics that are difficult to manage to. But to have skin in the game you also have to support clinicians in that endeavor. It can't be a surprise. The clinicians need to understand what is being accomplished and why and what the value is. Clinicians must also understand how they are going to participate in any risk-based payment models, how it will impact their workflow and how they're paid. Clinicians must also understand how their quality measurements are going to be tracked along with when and how they will be informed of their performance against these measurements.
Those are all critical aspects. So looking at incentive programs, hospitals and health systems should look at what can be effectively measured, what can be reported and what can be made accessible to the clinician. This ensures that when allocations are processed, there are no surprises. Ideally, clinicians need to have a sense of involvement and influence in defining their reimbursement and have the ability to say, "I think this is incorrect and here's why."