Follow practice guidelines for better care, profits
Negotiate HMO payments based on guideline use
With the renewed interest in reducing medical errors and increasing quality of care, practices might want to consider negotiating a separate arrangement with managed care plans that increases their reimbursement for adhering to clinical guidelines. That’s the recommendation of David A. Hess, director of contracting for PMSCO Healthcare Management and Consulting of Harrisburg, PA, a subsidiary of the Pennsylvania Medical Society.
Choose most prevalent diseases
Hess says that kind of arrangement could work something like this:
— Propose using clinical guidelines that would cover the most prevalent and costly diseases within your practice as it relates to the health plan’s members. If you have a smaller practice, ask the health plan’s medical director what the most prevalent condition is that affects the health plan’s membership, and choose a corresponding guideline.
— To simplify things, propose using two of the health plan’s clinical guidelines. "It is not worth the time to enter into lengthy negotiations/meetings with the health plan over guidelines and measures," says Hess. However, it’s wise to request that the physicians in your group have an opportunity to review the proposed guidelines for possible modifications. It is also reasonable to request literature references and background information used to support the clinical guidelines.
— Highlight the guidelines that can be easily convertible into economic performance measures. You will have to work with the health plan to determine how these measures will be defined to ensure they accurately reflect the clinical guidelines.
— Determine how this information will be standardized and entered into the plan database.
— Develop a description of the reports (including reporting time periods) that will be used to determine if the clinical guidelines are being met. One way you can do this is to use current medical record reviews the plan already performs as part of its HEDIS requirements.
—- Determine the price for your services on a per guideline basis. Remember, your goal is to "increase reimbursements, on the margin, to your practice," says Hess. Pick a price that is reasonable based on the size of your practice and the number of the health plans members affiliated with your practice.
Prorate payment based on performance
Hess suggests performance awards of 100% of the allotted monies for achieving 10% better than the national average. Prorated payments should also be considered. For example, should your group meet the national average, 70% of the allocated dollar amount for meeting the national average should be paid. A prorated schedule is also envisioned for adherence at a level between the national average and 10% above this level, as well as 10% below the benchmark.
Tip: Besides this price, also request a separate payment from the health plan to cover the cost of educating staff about these new clinical guidelines, updating internal documentation and procedures, and ongoing in-house audits to determine how well the practice is performing.
— As to timing, consider establishing nine months as the adherence period. Guidelines and measures should be established prior to implementation. Adherence measurements would require one to two months to record and report, with payment made soon after.
— Try to structure the arrangement so it automatically renews on a yearly basis with an annual 3% to 4% increase in the per-clinical guideline rate identified above, Hess recommends.
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