AHS Community PracticesTrends and Strategies
November 2016
About this Initiative
� Objective:� The AHS is seeking innovative models to improve the delivery of needed health care services to headache patients.
� Develop tools to empower Academic and Community practices to deal with changing health care landscape.
� Bio:� Neil Parikh, MD, MBA� Neil Parikh, MD, MBA
� Clinical Instructor, UCLA Hospitalist
� Acknowledgements� AHS leadership
� Disclosure� Both academic and community projects have been financially sponsored by the American Headache Society.
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IN THE NEWS
Insurance companies opting
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companies opting out.
Premiums increasing.
Enrollment not meeting targets.
What does it all mean?
PRACTICE STRUCTURE TRENDS
� Generally speaking, there has been an increase in hospital employment, practice acquisition, ACOs
� Private practice is not dead and there may be a slight change in headwinds
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� Hospital acquisition of practices may be slowing down as many not financially viable acquisitions
� Insurance companies recognizing that decrease in number of practices leading to decreased competition
� Increased variety of direct pay structures
Successfully running a private practice is still challenging, but the pressure to move to employment may be lessening.
CONCIERGE, BOUTIQUE, RETAINER, DIRECT-PAY� Trends
� Survey of 14,000 physicians� 10% planning on shift to “concierge” in 1 to 3 years
� Survey of 22,000 physicians� 1 to 2% increase from 2012 to 2013 across specialties
� 4% of neurology practices are concierge or cash-only
� Challenges� Converting Patients
� “10%...doing pretty well”
� Attracting Patients� Marketing not taught in medical school
� Managing Patients� Pay more, Expect more
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only
� Models� Concierge: 24/7 access� Hybrid: Cash + Insurance� Menu versus Tiers
� Fixed fee per service
� Different membership plans for different levels of service
� Legal Considerations� Risk of being dropped as an in-network provider
� Co-pays can violate contracts� Medicare double billing
� Clearly defined non-covered services
Sources: “Neurologist Compensation Report 2013,” Medscape; “Cash only practice: what you need to succeed,” Medscape; “Concierge Medicine: Medical, Legal, and Ethical Perspectives,” Internal Journal of Law, Healthcare, and Ethics
GEOGRAPHY OF UCNS HEADACHE DIPLOMATES
United Council for Neurological Subspecialties: Diplomates 6
Understand the geography you are practicing in.
33 states with 5 or less headache specialists.
ACROSS SPECIALTY METRICS
Dermatologists
Endocrinologists
Family medicine physicians
Gastroenterologists
Internal medicine physicians
Neurologists
Psychiatrists
Rheumatologists
Median Compensation 2014
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Based on site interviews, mean RVUs for headache specialists is ~5,000 largely because of procedures
$- $50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000
Cardiologists
Dermatologists
0 1000 2000 3000 4000 5000 6000 7000 8000 9000
Cardiologists
Dermatologists
Endocrinologists
Family medicine physicians
Gastroenterologists
Internal medicine physicians
Neurologists
Psychiatrists
Rheumatologists
Median RVUs 2014
Source: American Medical Group Association's "2014 Medical Group Compensation and Financial Survey," a 2014 report based on 2013 data
VALUATION: INTANGIBLE ASSETS
200
250
300
350Number of transactions
Valuation of Goodwill
0
50
100
150
200
<10 10 to 20 20 to 30 30 to 40 40 to 50 50 to 60 60 to 70 70 to 80 80 to 90 90 to 100 100 >100
Number of transactions
Percent of preceding years net income
Source: The Goodwill Registry, Health Care Group 8
Goodwill is effectively your reputation.
Your value is determined by more than RVUs.
BEST PRACTICES: EASY WINS
� Utilizing Physician Extenders
� Follow up visits
� Patient communication (ie phone calls)
� Creating Procedure Days
� Increased volume of patients
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� Better utilization of botulinum toxin
� Templates
� Standardized intake forms
� Validated screening questionnaires
� Pre-authorization checklists
� Revenue Cycle Management and Analysis
Small, simple fixes can increase volume, increase revenue and decrease practice frustrations
Small BusinessSmall Practice
� Website
� Yelp: Patient reviews
� CRM = PRM
� Office management
� EMR/Medical billing
� HIPAA compliant communication tools
� Patient portals
Patient scheduling
Specialty
� Electronic diaries
� Pre-visit questionnaires
� Tele-health/remote monitoring
CHANGING THE WAY WE PRACTICE
� Networking� Patient schedulingmonitoring
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Conclusion
� Be aware of the news, the trends and impacts to your practice
� Understanding your value as a Headache Specialist
� Implement tools to make your practice more efficient
� Evaluate technologies in a constantly evolving delivery landscape
Headache is a misunderstood condition despite its immense physical, emotional, and economic consequences. In order to advocate for your practice and ultimately your patients, you will be charged with educating physicians, insurers, and executives about your important role in mitigating the impact of this complex disease process.
By effectively articulating the high-quality, cost-effective care you already deliver, you will ensure the growth of this important field.
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Question and Answer
� Thank you for your participation.
� Please direct questions to [email protected]
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� Disclaimer: the author accepts no liability for the accuracy or completeness of the information, advice or comment contained in this presentation or for any actions taken in reliance thereon. While information, advice or comment is believed to be correct at the time of publication, no responsibility can be accepted by the author for its completeness or accuracy.
Resource slides
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Road Map� Last time…
� Independence versus Integration� Hospital Employment versus Independent Practice Association
� This time…� Ends of the spectrum: ACO vs Concierge
Establishing your value
“Current trends in physician employment represent neither a
necessary nor sufficient condition for true
integration; value-added integration does not � Establishing your value
� Community Need versus Supply of Specialists
� Cost saving interventions� Keep employees at work
� Valuation techniques� Relative Value Unit� Fair Market Value
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integration does not necessarily require large-
scale physician employment and simplysigning contracts does not ensure progress toward more effective care coordination.”
Sources: Toward Accountable Care. Washington, DC: The Advisory Board Company; 2010.
ACA Will Increase Demand (2014 slide)
Numbers to Consider
� 8 million new entrants enrolled through market
� Only 28% of 28.6 million people eligible enrolled
� 54% female
Distribution of Potential Enrollees by Age
� 54% female
� 40% under age of 35
� 50,000 PCP shortage by 2025 Projected Physician Shortage (All Specialties)
Sources: Kaiser Family Foundation, Association of American Colleges, HHS.gov 15
Conclusions
� Significant rise in insured headache demographic
� Access to care potentially more challenging
ACO: Accountable Care Organization
� ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to a designated patient population
Total Number of ACOs over time Estimated Number of Lives Covered by ACO contracts
Source: Leavitt Partners Center for Accountable Care Intelligence 16
Physicians Taking the Lead
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51% physician led49% percent include a specialist group
75% believe 50% of population covered by ACO in next 5 years
Directors aware that institutions are transitioning to new delivery models
� About ¼ of centers are currently ACOs and another ¼ will become an ACO over the next few years
� 70% are unsure what the effect of joining/becoming an ACO will be on their center, 36%
27%
27%
9%
20%
40%
60%
80%
100%
Institute approach to becoming an ACO
Not currently considering an ACO model
Over next few years
Currently an ACO
Don't know what institutional level changes
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effect of joining/becoming an ACO will be on their center, while 30% believe there will be no change
� Most directors are not involved with their institution’s delivery model strategy
36%
0%
20%Don't know what institutional level changes are being considered
Source: AHS Program Director Survey, July 2014, n=11
55%
27%
18%
0%
50%
100%
Involvement in institutional strategy regarding ACO and/or delivery model
Aware of conversation but not involved
Limited Involvement
None
What does this mean for the specialist?
• Decrease in referrals to manage costs• Loss of referrals to affiliated specialistsUnaffiliated
• Create contracts with ACOs• Allowed to contract with multiple ACOs“Other” Entity
• Limited to one ACO because use E&M codeJoin an ACO
• Limited to one ACO because use E&M code• Entitled to shared savings depending on ACO structureJoin an ACO
• Generally for large multi-specialty groups• Start up costs estimated at $1.7 millionStart an ACO
Recognize ACOs in your community and evaluate options for clinical integration
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ACO Compensation Arrangements
9% 0%0%
ACOOther
50% or More Production 7%
5%6%
NON- ACO
� Majority of ACOs 50% or More Salary Plus Incentive
� Non-ACO and PCMH tend to compensate based on RVU
20
30%
24%
37%
50% or More Production Plus Incentive
50% of More Salary Plus Incentive
100% Productivity
100% Equal
100% Salary
23%
28%
31%
5%
Source: MGMA Physician Compensation and Production Survey: 2014 Report Based on 2013 Data – Key Findings
Headache Disease Burden and Awareness
� 36 million Americans, about 12% of the population, suffer from migraine headaches
� 3% of the population have chronic migraine with at least 15 days of headache each month for
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days of headache each month for at least 6 months
� “As Americans, we must recognizes the scope of migraine’s impact and deal realistically with this disabling disease.”
� Cindy McCain, 36 Million Migraine Chair
Insurers Perspective: Shared Savings� “Savings will come from physician pre-hospitalization interventions, alternative practice settings and patient interventions that improve the health profile of patients with ambulatory sensitive conditions so as to avoid events and expensive hospitalizations” – AMA
� Target Population Group
� Specific Disease
� Pre-Hospitalization Interventions
Comparative Cost of Management of
Status Migrainous Patient
Emergency Room Cost� Pre-Hospitalization Interventions
� Alternative Practices
� Outpatient Infusions
� Decreased ER visits
� ER Consultations
� Current Metrics
� CT and MRI utilization
� Decreased Co-morbidity risk
� Depression, anxiety, CVA, CAD
Emergency Room Cost
MD $1,900
CT Scan $1,000
Medication $1,000
Total $3,900
Carolina Headache Institute
Intervention $383
Total Savings Per Patient $3,517
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Employers Perspective: $29 billion cost
2000
2500
3000
3500
4000
4500
Non-Communicable Disease DALYsIn 2010, Per 100,000
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0
500
1000
1500
2000
Column1 Migraine Tension Type Headache
Industry Perspectives� “…a multidisciplinary approach to neurological care i.e. Headache Clinic…appears to be ‘low hanging fruit’ for an ACO and its neurologists.”
� The Accountable Care Guide for Neurologists
“Need to sell an ACO on the long term value of a patient. Even
though you can make a cost savings argument, it is not all a cost-play.
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� “Almost all ACOs right now are focusing on target populations within their total patient population… Most really are targeting related to a specific disease.”
� David Muhlestein,
Leavitt Partners
is not all a cost-play.
It’s really more about the stickiness. You want to prove you can hold
on to a captive population.”
-ACO Executive
RVU: Relative Value Unit
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� “Am doing well here, nearly my 2000th new patient so that’s great, but the institution is saying that I am not being productive, which would be a first for me in my life. LOL.”
Based on site visits, headache
RVU Comparisons
4718
5718
5023
7063
4797
6798
4296
6311
0
1000
2000
3000
4000
5000
6000
7000
8000
Primary Care Physicians Specialty Care Physicians
Work RVUs by Demographic Classification
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� Based on site visits, headache specialist work RVUs range from 5,000
� Compensation per RVU variable� Conversion Factor: $35.82
� Average per MGMA: $61.62
Source: MGMA Physician Compensation and Production Survey: 2014 Report Based on 2013 Data – Key Findings
Primary Care Physicians Specialty Care Physicians
$224,532
$375,767
$240,978
$425,590
$230,370
$389,982
$229,716
$398,387
$0
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$450,000
Primary Care Physicians Specialty Care Physicians
Compensation by Demographic Classification
Increased Transparency:Medicare Provider Utilization and Payment Data
� “Three Connecticut doctors billed Medicare for nearly 24,000 drug tests in 2012 – on just 145 patients.”
– Reuters
� “Pain and gain: An Alabama clinic stands out amid data on Medicare payments”
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clinic stands out amid data on Medicare payments”
–Washington Post
� “The highest-paid California doctor in the 2012 data was oncologist Minh Nguyen of Newport Beach, who was paid $11 million for his treatment of 793 Medicare patients.”
– LA Times
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