Health Care Reform for Physician Practice Manager

Health Care Reform will offer new sets of challenges for a physician practice manager (PPM) over the next ten years and even further into the future, regardless of the political controversy with each presidential election.

In order to manage this transition effectively, PPMs will need an open mind along with administrative knowledge, understanding of the health care system and project management skills. This significant transformation will affect everyone from the medical practice to government agencies, vendors, and more, which means cooperation and coordination of work projects will be essential in order to uphold the vitality of a medical practice.

Physician Practice Manager- Facts About Health Care Reform

Some of the facts related to our current health care system will explain why change is inevitable:

• Currently the United States’ health care system is the most expensive in the world and accounts for approximately one-sixth of the nation’s entire economy with no reduction in sight.

• The cost of running an efficient practice along with increasing demands within the health care system are forcing change in the way physicians practice medicine.

• Over the last ten years, medical expenses have increased an average of nine percent each year, according to PriceWaterhouseCoopers, and have overwhelmingly surpassed inflation. In addition to this, there has been an enormous increase in worker compensation.

• Medicare can no longer sustain itself without dramatic reform.

• Both the Medicare and Medicaid programs represent a substantial amount of dollars in the total spending in health care.

• Spending on Medicare will grow from approximately $500 billion in 2009 to $930 billion dollars by 2018.

• Approximately 47 million people are uninsured and do not have access to health care.

• In 1912, Theodore Roosevelt promised national health insurance as part of his campaign and improvements to the health care system have continued to evolve over the past one-hundred years and will continue to change in the future.
• Health care reform has been continual to accommodate growth and change in our country.

Examples of some key changes are (1) President Clinton’s creation in 1997 of the State Children’s Health Insurance Program (SCHIP) which provides matching funds to states for health insurance for children whose families’ income is too high to qualify for Medicaid but inadequate enough to pay for health care. (2) The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act (HCERA) of 2010 which was signed by Obama with the intention of expanding Medicaid, enhancing the efficiency of health insurance, and making care more accessible while cutting federal health spending.

We will now focus on key areas of development and improvement with the implementation of Information Technology (IT) to make data available between providers, insurance carriers, and patients. With this transformation, PPMs must learn how to coordinate patient information among other entities, maintain health information security and keep up with the on-going and often complex information presented on a regular basis. By 2020, our health care system will be predominantly digital. 2020 is not far off. We are talking about major change for the health care industry in only a few years.

If you stop and think how one medical record ties into everything from lab requisitions, office visits, procedures, hospital or ambulatory services, laboratory results, physician orders, documentation, billing, clearinghouse services, insurance claim processing, coding, practice management software, etc. it is enormous. All these little pieces of information and hardware/software performance must communicate in one language following national data standards for tracking, reporting, and protecting personal health information. One glitch in one area will disrupt the flow of information. Practice managers will need to know how to audit accounts and uncover the weak link when communications fail, whether it is a claim lost in cyber space or a lab not receiving a physician’s blood work requisition. Digital communication is the future and with it comes new sets of problems and resolution.

Focus will switch from the “sick visit” to “prevention and wellness” care, which means physicians will have to learn to change how they deliver patient care compared to the older, traditional methods. With focus on prevention, reimbursements will change based on how the physician promotes efficient use of health care resources and higher quality of care. The Physician Quality Reporting System (PQRS) provides financial incentives to doctors who report certain quality data. Beginning in 2015, physicians who are not participating in PQRS will be penalized 1.5 percent initially and then 2 percent in subsequent years.

Other key trends will concentrate on Electronic Medical Records, coordination of care, accurate documentation, and the avoidance of fraud and abuse.

IT compliance and data interactivity will drive practices into the forefront with more exposure of medical records and practice protocols resulting in increased audits. A prepared practice manager will maintain logs and incident reports in the event of an audit for practice protection.

In order for physicians to begin utilizing the Electronic Medical Record, the American Recovery and Reinvestment Act (ARRA) of 2009 created an economic stimulus package enacted by Congress to help stimulate the economy and consumer spending during the recession.

The HITECH Act allocates $36 billion in incentive payments for providers to adopt the use of EMRs. Late or non-adopters will see decreases in Medicare reimbursement starting in 2015 and fully phased by 2017. Practice managers will be involved with the implementation of EMRs and will offer support, knowledge, and encouragement during the transitional phase. It will be a challenging time because it will greatly affect the practice’s workflow, but the PPM must make sure that all physicians and staff members know how to operate the EMR at the accessibility level allowed.

Practice managers will need to monitor their physicians to see if they are following the guidelines for quality reporting. They will attend meetings sponsored by their hospital affiliation. Typically, these meetings are mandated by the hospital due to the financial benefit to both parties.

For example, many providers have recently become involved in a program referred to as Accountable Care Organizations (ACO). ACOs allow hospitals and physicians to work as a team, being accountable for a patient’s overall care. If through successful coordination of care, cost savings are attained, the ACO would be eligible to keep a portion of the attained Medicare savings.

Part of the practice manager’s role when working as part of an ACO team, will be following the physician’s reporting of patient care to the hospital. There are specific diagnosis codes and quantity of patients needed for an ACO to be a success, so constant supervision of this process will be required.

Health Care Reform does not come without a steep price. According to the Congressional Budget Office (CBO) the new reforms will cost approximately $940 billion over the next ten (10) years. Most of the spending will be on Medicaid expansion as well as insurance premium subsidies for individuals needing health insurance and small businesses participating in the health insurance exchanges.

New health industry fees, new taxes, and cuts in predicted spending for existing government health programs will be the means used to offset the exorbitant costs, with a goal of obtaining about $143 billion in excess during the next ten years.

Related Physician Practice Manager Content

• Certified Professional Biller Course
• Medical Practice Manager- Understanding Healthcare Business Processes and Work Flow
• Medical Practice Management- Physician Reimbursement
• What is practice management? AAPC