19 minute read
LAW MIND
LAW MIND: IT’S NOT ALL ABOUT THAT RATE APPROACH How to NEGOTIATIONS with PAYERS
Ann M. Bittinger, JD, represents physicians and physician groups in transactions with other entities and with compliance with federal health care laws and in structuring their independent practices. Questions? Email
ann@bittingerlaw.com
PHYSICIANS MUST IMPLEMENT A LONG-TERM, STRATEGIC APPROACH TO
NEGOTIATING CONTRACTS WITH PAYERS. Gone are the days of trying to get a few dollars more per CPT code or a few numbers higher as a percentage of Medicare. Today, it’s about more than the rate. Successful physician groups are building strategic alignment with payers to provide quality care for reasonable prices.
Analyze Your Group
As in any successful negotiation, first you need to know what you bring to the table. I’m surprised how many clients can’t tell me how much their top three payers pay them for a colonoscopy, or how much those payers are supposed to pay them per their contract. Often those two numbers are not the same. First, get your house in order. Understand what the contracts say versus what the payers are paying you. If you’ve been underpaid for a while, that lemon can be turned into lemonade by using that fact as justification that the insurer should pay you more going forward.
How long does it take payers to pay claims? Which payers dispute claims or haggle about medical necessity, pre-authorizations and the like? A good practice chief executive officer will interview billing staff to learn the nuances of each payer before going to the negotiating table with the payer. This is important because often payers will not give an across-theboard increase but will carve out a few CPT codes and grant an increase on those, while leaving others the same or lowering them.
Also, what’s your payer mix? What is your private pay versus Medicare percentages of patients? Within the private payers, what payers represent what percentages? Within government payers, what percent are Medicare versus a Medicare managed care plan?
When you analyze this information, you will see trends. Once you lay the contracted charges and payments analysis on top of the payer mix percentages, you will identify which payer will give you the most bang for your buck, so to speak, to target for negotiations. This process can take anywhere from one to six months.
In addition, analyze procedures versus E&M coding for office visits versus diagnostics (and another subset of services you may provide). Would you be willing to sacrifice a lower rate for imaging, for example, to get a higher rate on procedures? Would the net outcome be an increase?
Expect the payers to offer a change like this in response to an offer by you for an increase: in other words, a “Yes, we agree to an increase on some but we are lowering something else.”
Clients often want to focus on costs of running the practice. While this is good from a practice management standpoint, my experience is that payers are not swayed by costs. Their first response is typically: “Well your biggest cost is physician payroll, so pay your physicians less.” Additionally, sharing physician salary information without the information being subject to a non-disclosure agreement is not a sound decision. Generally, the negotiations include confidential information, trade secrets or other information about the practice—which is not uncommon in some payer-physician arrangements—so you want the payer to sign a nondisclosure agreement.
Other than charges, collections and payer mix data, I suggest that clients analyze their groups in additional ways prior to the negotiations. What makes your group a better partner with the payer than the other groups? Do you submit claims cleaner and faster than your competitors? Do you have good relationships with the payer? Are the geographic locations of your clinics appealing to the payers’ patient mixes? Is there something about your endoscopy center that sets your group apart from other centers or hospitals? Identify and accentuate a value proposition.
Once you’ve done this analysis and are ready for presentation to the payer, set your sights on a reasonable goal, but don’t make the first offer and don’t draw a line in the sand during the negotiations. The payer-physician dynamic is changing. Groups need to be ready to think creatively about how to structure payments.
Keep in mind that the payer may know more about your practice than you do. Most major payers have sophisticated systems to analyze physician data. In the meetings I discuss in part II of this article, which is available now on the ACG Blog, it may be helpful to listen to the payer’s representative talk about what they see in the data that they have about your group, and compare that with what your data reveals.
CONTINUE READING this installment of LAW MIND on the ACG BLOG. Ms. Bittinger tells you what hidden clause to look out for in contracts, the most important legal provision in a payer-group contract, and how to approach a meeting with a payer: bit.ly/LawMind18
Determine your payer mix:
Which payers represent what percentage of your collections?
Determine what each payer is actually paying you:
Check CPT codes against EOBs or other data.
Compare what different payers are paying:
Identify outliers or trends.
Identify codes or procedures that could be targeted for improvement:
Group different services together and set a goal for increase.
Align incentives with the payers:
Research what payers’ hot-button issues are and try to address them.
Identify your strengths:
Create a marketing document that shows how you are a good partner with the payer (clean claims, geographic locations).
Set financial and timeframe goals:
Set a goal as to what you want to achieve and by when.
RWANDAGIVING RISE TO GI IN
IT WAS AN EXPERIENCE HE HAD LONG HOPED WOULD BE A PART OF HIS MEDICAL CAREER, BUT HE DISCOVERED THAT THE RIGHT OPPORTUNITY WAS NOT EASY TO FIND.
Steve P. Bensen, MD, had searched for a global health experience, but he lacked the “tropical medicine” or infectious disease background. So when a former medical school classmate and now colleague asked him to serve as a visiting gastroenterologist in Rwanda, he jumped at the offer. This was a chance to teach Rwandan medical students and residents about GI—something he does every day at the Geisel School of Medicine at Dartmouth.
Rwanda is a small country of 12 million in the heart of East Africa whose health care system had been decimated by its 1994 genocide. In a 100-day span, 800,000 Rwandans were killed, including many of the country’s physicians, nurses and other health care professionals. Bensen was the first gastroenterologist to participate in the Human Resources for Health Program (HRH), a consortium that sent teams of doctors, nurses and other health professionals for extended stays working with Rwandan counterparts to rebuild their health care system.
Photo top and on pages 26-27 courtesy of Eridana Harder, RN. Photo right courtesy of Dr. Steve Bensen and Connor Gordon.
—Dr. Bensen
Now more than four years since that visit, Bensen has completed a total of four trips. He considers himself “hooked” and views his experiences in Rwanda as “the highlight of my medical career.”
In several conversations with ACG MAGAZINE, Bensen shows passion and fervor for the work his team has done—and will do—in Rwanda. Most of his stories conclude not when success is realized, but with his vision for expanding these successes in the future.
In this Q&A, Bensen is joined by Frederick L. Makrauer, MD, of Brigham and Women's Hospital and Harvard Medical School. Makrauer discusses the work he and Bensen are doing to develop a GI fellowship program for Rwanda. They talk about the state of medical care and GI care, what makes the program successful, and how GI physicians and other health care professionals can participate.
“You end up getting more out of the experience than you’re giving,” Bensen said.
What prompted you to take your first trip to Rwanda?
SB: I first went to Rwanda four years ago. I was lucky enough to be talked into spending three months there by Lisa Adams, who is now the Dean of Global Health for Dartmouth College and Medical School. After my first stint I was hooked and have been returning every year since. It’s been an experience that has forever changed me, offering a different perspective that has become a mid-career avenue for a renewed sense of purpose.
Lisa asked me to participate as a visiting gastroenterologist with the HRH in Rwanda, a program she helped to establish and had brought to Dartmouth. HRH is a seven-year partnership involving the Rwandan Ministry of Health, the Clinton Foundation, and 11 other U.S. medical schools that is committed to rebuilding the Rwandan medical education and health care system. HRH has been successful in increasing the number of medical school graduates and physicians who have completed residency training in medicine, surgery, anesthesia, pediatrics and OB/ GYN. Before HRH there were just six residency-trained internists in the country; that number has grown to 70 today.
Rwanda
A small country of 12 million in the heart of East Africa whose health care system had been decimated by its 1994 genocide. In a 100-day span, 800,000 Rwandans were killed, including many of the country’s physicians, nurses and other health care professionals.
How about you, Dr. Makrauer?
FM: The founders of a cardiac surgical non-governmental organization in Rwanda alerted me that the country was eager to address the need for expertise in gastroenterology and hepatology. The opportunity to build a much-needed program from the ground up with extremely talented colleagues passionately committed to its success has made acceptance of the invitation very easy. Now there, I am constantly reminded of the benefits of learning and listening before choosing a solution or drafting a protocol.
What are the common GI diseases in Rwanda?
SB: Rwanda suffers from a significant burden of gastrointestinal disease. Conditions such as gastrointestinal malignancies, H. pylori-related peptic ulcer disease, advanced liver disease and its complications, noncirrhotic portal hypertension, acute and chronic diarrheal illness, malnutrition, and the gastrointestinal manifestations of the most common infectious diseases, such as HIV and tuberculosis, which are underdiagnosed and inadequately treated.
What medical resources—for example, endoscopic equipment— do Rwandan doctors use?
SB: The lack of endoscopic equipment, coupled with a lack of training and expertise in therapeutic endoscopy, hinders gastrointestinal specialized care. There are three referral hospitals where endoscopic equipment is available. Dedicated nurses and doctors at these facilities make the best of what they have to provide care. The equipment is often donated, used scopes from abroad, and maintenance of this equipment is a challenge. Likewise, consumables such as balloon dilators, variceal band ligators and biopsy forceps are in short supply.
Rwanda suffers from a significant burden of gastrointestinal disease. In 2017, during Rwandan Endoscopy Week (REW), 200 EGDs, 39 colonoscopies and five ERCPs were completed—the first ERCPs ever performed in Rwanda. 33% of EGDs revealed significant findings including peptic ulcer disease (16%), suspected gastric malignancy (4%), esophageal varices (4.5%), and gastric outlet obstruction (2.5%). Significant findings on colonoscopy included hemorrhoid disease (23%), suspected colorectal cancer (7.7%), and ulcerative colitis (one case).
What is the state of medical and gastroenterology care?
SB: Rwanda has made enormous strides over the past 10 years in recreating a health care system. In some ways we can learn from them. There is now universal health care coverage, and health care is free for the poorest 25% of Rwandans. An article in The New York Times highlighted that in some ways Rwanda has a more equitable health care system than the United States, although they lack our resources. We can learn a lot about resourcefulness from the Rwandans. After the genocide, Rwanda first focused on rebuilding a rich network of community health care workers to provide basic primary care. This is where you get the most bang for the buck. They are now focused on training nurses and midwives, and doctors in the fundamental specialties such as IM, general surgery, pediatrics and OB/GYN, however there are no subspecialty training or training programs in areas such as radiology, pathology, psychiatry or the surgical subspecialties. From a GI standpoint, there are only a handful of internists who can perform diagnostic endoscopic procedures and have expertise in the treatment of gastrointestinal conditions.
What is the background on the GI fellowship program? Dr. Makrauer, how did you become involved?
SB: There is palpable enthusiasm amongst Rwandan IM residents and young internists for advanced subspecialty training in GI, which does not currently exist.
The internists with whom I have been working propose a two-year subspecialty fellowship training program in gastroenterology that would develop the next generation of leaders in gastrointestinal health care and research, and that could serve as a model for other medical subspecialty fellowship programs. Through the Rwandan doctors I was connected with Dr. Makrauer from the Brigham, who was also busy at work facilitating the creation of a fellowship training program.
FM: In 2015, the University of Rwanda School of Medicine invited me to join their faculty in designing an urgently needed, sustainable GI fellowship program and providing faculty with the necessary skills in teaching and clinical research. I accepted without hesitation, fulfilling a dream of
“The MVP of the trip was not a physician but our biomedical engineer, Ben Sault. He worked tirelessly to make the most of all kinds of equipment. When a hospital found out he was on site, he was pulled in all directions…” —Dr. Bensen
Watch the full video: bit.ly/Rwanda-Video
sharing the principles of clinical care, teaching and curriculum development with the global health community.
How has that process progressed?
FM: The realities of limited funding and separation by distance and time zones made it imperative that teaching and learning occur through multiple technologies. The availability of worldwide broadband access, and the use of already-functioning applications for both weekly videoconferencing and a “virtual classroom” have quickly cemented strong, international professional relationships and the mutual respect necessary to resolve the program mission, governance and funding. Rwandan leadership of all phases of development is embraced as critical by all parties. All faculty recognize the value of bidirectional training opportunities for enhanced learning and scholarship.
—Dr. Bensen
Has the program been approved by the government?
SB: The program is just about approved through the Rwandan Ministry of Health.
Have your colleagues joined you on trips to Rwanda? Have your Rwandan counterparts made trips to the states?
SB: My first two visits to Rwanda were threemonth stays through HRH. My first visit had such an impact on me. I was 49 the first time I went, and I wished I had done it much earlier. I wanted others to have this experience. For my second visit, I brought several Geisel medical students and our third-year GI fellow.
Lisa made a point early on to all of us involved in HRH that it was important for physicians to have this type of experience at some point in their career, and she supported us in bringing over students. However she firmly believed that it was not fair to just
Photos at left on page 32 courtesy of Eridana Harder, RN. Photo on pages 32-33 courtesy of Dr. Steve Bensen and Connor Gordon.
be sending Dartmouth students and trainees to Rwanda. We should establish “exchanges,” through which our learners rotating through Rwanda should be matched by Rwandan trainees and physicians coming to the United States. I bought into that idea once I appreciated how valuable it was on both sides to share this cultural and professional exchange. We have brought over about 15 Rwandan resident physicians and faculty for extended stays at Dartmouth, and a similar number of Dartmouth medical students and postgraduate trainees have been to Rwanda. We all benefit. Deep friendships and professional relationships have been established through these exchanges.
The Rwandan residents we brought to Dartmouth a few years ago are now medical leaders in their country, some serving as the only IM doctors at large district hospitals. Others serve as junior faculty training medical students and residents at the four teaching hospitals.
You are involved in Rwandan Endoscopy Week (REW). What goes on during that week?
SB: This idea arose from my Rwandan colleagues, Drs. Vincent Dusabejambo and Eric Rutaganda, who wished to advance endoscopy in Rwanda. They and a few others formed the Rwandan Society of Endoscopy (RSE) a few years back.
REW is a collaborative effort born of relationships formed through HRH, RSE and previously established bilateral international physician exchanges. The goals are to provide direct patient care, train providers in therapeutic endoscopic skills, and advance gastroenterology as a subspecialty intensively over a short period of time. In 2017, REW was advertised to the public through national media and to referring providers at district hospitals. We deployed integrated US/Rwandan teams to the four referral hospitals with endoscopic capabilities. Six GI physicians, two nurses, two technicians and a biomedical engineer from the
—Dr. Makrauer
United States collaborated with RSE members—15 physicians and 18 endoscopy nurses.
GI consultations were performed on all patients referred for endoscopy to ensure appropriateness of procedures. Demographic data, procedural indication and results were collected with the online tool Google Forms. The majority of endoscopes were donated; many were outdated and not functioning optimally. The biomedical engineer repaired non-functioning devices; technicians provided training on the care of equipment; and nurses exchanged knowledge of patient sedation and monitoring. In all, the teams completed 200 EGDs, 39 colonoscopies and five ERCPs— the first ERCPs ever performed in Rwanda. Consistent with local practice, no sedation was administered but for the five ERCPs and several colonoscopies. Thirty-three percent of EGDs revealed significant findings including peptic ulcer disease (16%), suspected gastric malignancy (4%), esophageal varices (4.5%), and gastric outlet obstruction (2.5%). Instruction in interventional procedures included banding of esophageal varices, placement of esophageal stents, PEG tubes, and balloon dilation. Significant findings on colonoscopy included hemorrhoid disease (23%), suspected colorectal cancer (7.7%), and ulcerative colitis (one case).
The ultimate success of this initiative will rely heavily on local leadership, close international collaboration, and teams of technicians and engineers in addition to nurses and physicians.
In addition to physicians, what other health care professionals are critical to the team’s success?
SB: The endoscopy techs and nurses were key to REW’s success. Everyone pitched in to work long hours and provide much-needed care. The MVP of the trip was not a physician but our biomedical engineer, Ben Sault. He worked tirelessly to make the most of all kinds of equipment. When a hospital found out he was on site, he was pulled in all directions, fixing equipment such as ventilators and PICU incubators in addition to endoscopic equipment.
The monitor at the hospital in Butare, which had worked for years, went down. Dozens of patients were lined up for procedures. We felt helpless. We trucked Ben down from Kigali, which is three hours away. He found an older unit in a storage room that he rigged to work, literally saving the day. They still use the unit today.
Another day we were given a room in the operative theater. Dr. Stuart Gordon and our advanced biliary team of tech Kristen Sprenger and nurse Eridana Harder cranked out the first ERCPs in east Africa—five in total over an 18–hour period. The Rwandan nurses and doctors stayed with us the whole time—until we completed the last case.
What has your experience in Rwanda meant to you?
SB: My time in Rwanda has proven to be the highlight of my medical career. The most rewarding aspect of the experience for me has been the deep friendships and relationships I have established with my Rwandan colleagues.
What’s next?
SB: We are planning for the 2018 REW. We hope to extend REW to include more formal educational sessions and symposia the week before and after the intensive procedure week. We hold weekly teleconferences with RSE leaders, Dr. Makrauer and others in the Netherlands and Australia to move the GI fellowship program forward.
We will be recruiting faculty from the United States and abroad who are willing to serve as visiting faculty for three-to-four-week blocks starting in September. We want others to have the meaningful experience we have had. The Rwandans could use our help, so it is a win-win proposition.
GET INVOLVED
HOW CAN ACG MEMBERS GET INVOLVED? Do you need physicians and other health care professionals? SB: We would love to hear
from ACG members interested in an international experience. We could use both academic physicians and those in private practice, as well as endoscopy techs, nurses and biomedical engineers.
Andy Robinson, MD, who was in private practice in New Hampshire and recently retired, came to REW. He was amazing, using his years of experience to train two young Rwandan internists in upper endoscopy over the week at a remote district hospital. His team, with the most limited equipment and inexperienced group of Rwandans, performed the most procedures, with more than 70 unsedated upper endoscopies over four days. These patients had waited months to be seen, but no one could treat them. Now there are two Rwandan doctors continuing what was started during REW.
If any ACG member physicians, endoscopy nurses and techs, or biomedical engineers are interested, they can contact me at Steve.P.Bensen@hitchcock.org for more information.
