• Benign Prostatic Hyperplasia
  • Hormone Therapy
  • Genomic Testing
  • Next-Generation Imaging
  • UTUC
  • OAB and Incontinence
  • Genitourinary Cancers
  • Kidney Cancer
  • Men's Health
  • Pediatrics
  • Female Urology
  • Sexual Dysfunction
  • Kidney Stones
  • Urologic Surgery
  • Bladder Cancer
  • Benign Conditions
  • Prostate Cancer

Health care market shift presents opportunities


The changes in health care are fast and furious. Remember that in any massive change there is opportunity. For the office that is willing to make the changes, the silver lining is that health care is moving to a more retail environment. When the dust settles, the opportunity for your office to regain control of how your patients are treated is right in front of you.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

The changes in health care are fast and furious. Remember that in any massive change there is opportunity. For the office that is willing to make the changes, the silver lining is that health care is moving to a more retail-oriented environment. When the dust settles, the opportunity for your office to regain control of how your patients are treated is right in front of you.

The market shift in health care is not waiting for Medicare. Package pricing and other alternative models for payment are being implemented across the country. While not every office will be able to participate in these programs, some urologists are already moving toward the future. What can you do to prepare? Here are a number of steps to take.

Collect and understand patient data

One step involves patient data. We have been talking about data for a few years now. Data is essential for any practice moving to new payment models. You will need to understand what you do for a typical patient, what your costs are for your service mix, and how to identify outliers-both patients and providers. This data is in your practice management system and, for some, in your EHR.

To really get ahead of the curve, you will need to focus on quality data entry-both clinical and administrative-in order to truly rely on the data you are using. Focus staff training efforts on developing, selecting, and fully utilizing EHR templates for the diseases and symptoms that you treat. Acquire the tools and the skills you will need to capitalize on this unique data set.

Remember, payers have access to your activity data through billing but not full access to your clinical data through the EHR. Your ability to tie these databases can place you in a superior position to negotiate contracts and improve your financial viability.

Continue to the next page for more.


Pursue, monitor pathways

No one is better qualified to determine the correct diagnostic test and treatment for the urology patient than the urologist. Each practice should pursue pathways that are guideline- and literature-based “best practices” and are agreed to by all partners. “Medical necessity” should always be the overriding consideration in developing, interpreting, and using a protocol. Some pathways will be more detailed than others based on current clinical thinking, and of course you will need to update protocols as new data becomes available.

Each protocol developed by the practice will need to be monitored to find any variation in clinical performance. As you start these processes, you may find that the education and discussion required to truly implement these protocols are difficult. Start working through these issues now so you fine-tune protocols prior to basing contract payments on prescribed treatment patterns. These protocols and their outcomes, both clinically and in relation to patient satisfaction, can also be used to promote the practice to patients and other providers.

Don’t wait to start patient surveys

You will be required to collect patient surveys. Start now. You will be defined by payers based on your “value.” Although health care is slightly different than most other industries, it shares much with any other retail business. Patient satisfaction is coveted by all industries in today’s world. Everywhere you shop, you are asked to participate in satisfaction surveys. As patients begin to pay more for the services you provide, they are also going to shop for those services. If you are not collecting data on how patients view you, you are at a disadvantage.

Payers and other services are already collecting patient information and putting it on the web for all to view. Angie’s List is a perfect example of a service that helps guide patients to providers based on patient feedback. Do not let the market label you without your input.

Track, report quality

The elusive concept of quality of care is currently being tracked without truly measuring how services should be provided. Medicare has rudimentary tracking through the Physician Quality Reimbursement System (PQRS) that most agree does not truly measure quality of care but creates “busy work” for physicians. Private payers define quality in the form of which providers cost the least. Neither of these truly rate quality of care.

As a provider of care, the urology practice is in a position to drive the quality argument. The combination of protocols, patient surveys, and data analysis can provide you with valuable information that can be reported using the method of your choice.

Continue to the next page for more.


Open up financial discussions

As patients are financially responsible for more of the services that you provide, you will need to develop excellent communication and collection skills within the practice. Set your fees and discount policies to match your market. Patients are used to paying for goods and services like food, water, and other “necessities,” and they are used to paying for professional services like plumbers and legal fees; however, many still believe that health care is free of charge because they have insurance through their employer.

Training your staff and your patients to manage this change will take some effort, but it can be done. Dentists do it, so can you.

In addition to discussing your own fees, you will also have to speak more openly to the patient about other fees they may incur. Ambulatory surgery centers, hospitals, pathologists, radiologists, and anesthesiologists charge for their services as well. While it may not feel like your responsibility to inform the patient of these costs, as a manager of the patient’s disease process, the physician office is responsible for ordering and coordinating these services. And the fact is, these costs will likely end up falling back on the patient.

As the primary contact in a retail environment, customer service is a key driver to repeat business. These steps are all a part of training the patient about the cost of health care in the new high-deductible and higher co-insurance market.

Out-of-network providers are a complicating factor. It would be wise to place patients in touch with out-of-network providers to discuss fees prior to service if possible. Collect up front for your own services and refund patients as needed. You may also want to provide the patient options or contracts to allow for alternative funding for high-cost encounters. In the end, you do not want to be in the banking business, so avoid payment plans or keep payment arrangements to simple, short-term plans. CareCredit and other organizations may be worth the up-front cost to help in this regard. Look around for the best options.

Be proud of your value and sell it. With reasonable and defensible fees in your market, your staff can confidently explain your pricing and policies. Ignoring patient responsibilities is not an option!

Continue to the next page for more.


Expand your practice

Consider what you are doing in the provision of care to your patients and what is now required by PQRS, meaningful use, and patient surveys. Consider as well those services that you are best suited to provide and those services that are not being provided as readily in your market. Advising the marketplace via advertising to patients or through education and coordination of service with your primary care market are great ways to build new business.

Web presence is the wave of the future. You can develop advertising campaigns and notify existing patients and providers of new services offered. Marketing the business you want and steering clear of providing the services you do not can be very rewarding personally and financially.

Take note of your market

The evolution of the health care market is different in each marketplace. The formula for success is not a one size fits all. As you consider your practice direction for the future, you will need to be creative and observant. Alliances in your market will depend on local market pressures. Wealth of the population, insurance companies, networks, state regulations, and competition should all be taken into account as you approach best practices. Contracting for services with accountable care organizations by touting quality of care and cost efficiencies may be very lucrative.

The good news is that in most areas, urology is an underserved specialty. Stay active and connected. Competition among urologists does not require isolation. Networking locally is a key tool in today’s changing marketplace.

Don’t be afraid to ask for help

In change, there is opportunity. All businesses have had to reinvent themselves to stay relevant. If you can embrace change and stay ahead of the curve, the other side of reform opens new doors. There is a lot to consider at this time, and it is easy to get lost in keeping up instead of planning to get ahead. Ask for help if you need it. There are many services and groups like Physician Reimbursement Services that can offer help in the short term, freeing your resources to deal with urgent tasks that currently consume your workday.

In short, the market-based shift in health care delivery will happen. You can drive the bus or ride in the back. It is time to take charge and take advantage of the market opportunity.UT

More urology coding articles from Ray Painter, MD, and Mark Painter

How to use CPT 51356 for removing multiple stones

ICD-10 delayed, but don't put off preparations

Are you using the right physical exam templates?

Subscribe to Urology Times to get monthly news from the leading news source for urologists.

Related Videos
Anne M. Suskind, MD, MS, FACS, FPMRS, answers a question during a Zoom video interview
African American doctor having headache while reading an e-mail on laptop | Image Credit: © Drazen - stock.adobe.com
Man talking with a doctor on a tablet | Image Credit: © JPC-PROD - stock.adobe.com
Anne M. Suskind, MD, MS, FACS, FPMRS, answers a question during a Zoom video interview
Related Content
© 2024 MJH Life Sciences

All rights reserved.