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Market Assessment
Both health systems and medical groups should assess and understand the local physician market to determine their best options. Ten questions for assessing a local physician market are: What is the physician supply/demand balance in the market by specialty? What types of care are delivered within the market, and what is referred out of the market? Where do cases that leave the market go, and why? What are the referral patterns within the market? For example, do referrals go freely across system lines, or is “leakage” being reduced? Are referrals influenced by narrow networks, clinically integrated networks, or some groups (for contractual reasons or other factors) not accepting some payer categories? Are some groups deemed to be of higher quality than others? What is the growth or decline in the patient population? How are patient demographics changing? How are physician groups likely to respond to the changes? Are physicians in some groups doing significantly better or worse financially than the market as a whole? How easy is it to recruit physicians to this market? Where does the market stand now in terms of these indicators: •Medicare cost per member per month? •Commercial costs per member per month? •Physician group revenues per RVU, per specialty compared to national benchmarks?
Medical Group Perspectives
A medical group’s perspectives on physician alignment and engagement opportunities can differ significantly based on the group’s demographics. Demographic categories include the group’s ownership status, type of group, performance and experience, and personality. Common traits within these categories are shown in
Health System Perspectives
Most health systems’ key initiatives depend on the involvement of its physician groups (both employed and independent). This tool illustrates the steps in the journey toward population health management and health system sustainability can be made without direct physician involvement.
Assessing the Situation
A successful physician strategy is built upon an understanding of: Perspectives of the health system seeking to develop or refine its physician strategy Perspectives of the medical group and physician practices (both employed and independent) with which the health system seeks to engage Relevant market conditions As a starting point, it is important to understand the perspectives of both health systems and medical groups (employed and independent). Both perspectives are important, and although they share certain common goals, they are not the same. Tool: Examples of Common and Organization-Specific Goals
Seaside Medical Group Case Study
Issues addressed in this case study include: Moving a physician group from fee-for-service towards a value-based focus Addressing physician compensation changes in a medical group Forming a multi-organizational clinically integrated network (CIN) Sharing finances in a CIN Governing and managing a CIN
Mountain View Case Study
Issues addressed in this case study include: Physician governance within a health system Integrating physician practice and other components of the management team Experiments in identifying population segments and tailoring approaching and resources to these segments Managing the cost/benefit ratio as
Case Studies
The two case studies offered in this toolkit address increasingly common situations in physician relations. Both are composite case studies based on the experiences of several actual systems and medical groups. In both instances, the organizations are moving aggressively toward accepting and managing more population health risk: Mountain Health System seeks to take its multispecialty physician group to a new level Seaside Medical Group facilitates a partnership and clinically integrated network involving several other organizations
FY15 IPPS Final Rule Overview
This document highlights important updates to the 2015 payment rates to hospitals under the FY15 Inpatient Prospective Payment System final rule.
CY15 Medicare Physician Fee Schedule Proposed Rule Fact Sheet
This document summarizes the revised policies pertaining to payment policies under the Medicare physician fee schedule for calendar year 2015 (CY15).
HFMA comments to CMS on the 2015 Medicare OPPS Proposed Rule
HFMA comments the 2015 Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Physician-Owned Hospitals: Data Sources for Expansion Exception; Physician Certification of Inpatient Hospital Services; Medicare Advantage Organizations and Part D Sponsors: Appeals Process for Overpayments Associated With Submitted Data; Proposed Rule (hereafter referred to as the 2015 OPPS Proposed Rule) published in the July 14, 2014, Federal Register.