Accountability in health care often means that primary care practices are liable for the cost and quality of a patient’s care across the continuum of care. In the old, diminishing fee-for-service reimbursement system, practices were only reimbursed based on actions within their own office.
Now, in new reimbursement models like ACOs, PCMHs, risk-based contracting, and alternative payment models, shared accountability is king.
“The idea that you are accountable for what happens after people leave your office is no longer just a philosophical discussion. It's dollars and cents.”1
Attribution Outside of Your Practice
Accountability is related to the concept of attribution, which is the process where a payer assigns responsibility to a physician for some or all of the healthcare services received by a particular patient.2
When total spending on a patient’s healthcare services is attributed to a single physician, as much as 63% of the spending that is attributed to the physician can result from services billed by other physicians.3
Overall, better data to categorize spending and performance will give primary care practices more control over their reimbursements.
Better Data for Accountability
Hospitals & Health Networks Magazine poses a good question on the topic of data sharing between providers: “How can a primary care doctor know that his patient visited an independent physician to obtain more pain meds...without such sharing of data?”4
Many primary care practices have absolutely no idea if one of their patients visits an independent specialist, or what the specialist recommended.5
Given the fact that PCPs are now accountable for their patients’ care wherever it takes place, primary care practices need data and systems that tell them where and with whom their patient receives care.
Payers, such as the Centers for Medicare and Medicaid (CMS), will occasionally offer claims data to practices. This gives practices some idea of the overall care their patients are receiving. But claims data is not enough. It’s many months old and tells practices about people who are already sick. Instead of claims data, what practices really need is timely clinical and service-level data, along with the ability to analyze it.
Equally, EHRs collect huge amounts of information but they aren’t always able to analyze the full spectrum of clinical and service-level data. For some EHRs, “most of this data is hidden, inaccessible, or meaningless.”6
Solution: Electronic Closed-Loop Referral Management
Leading primary care groups use electronic referral management software to track specialist performance metrics related to closing referral loops. Metrics such as time-to-treatment and consult report compliance allow primary care groups to see, usually for the first time, their own referral patterns and the performance patterns of their specialists. This holy grail of referral performance information helps PCP practices track closed-loop referrals and meet requirements for high-quality patient care.
In the new data-rich accountable world, PCP practices need to manage referrals and share and analyze data in ways that fee-for service and its legacy revenue cycle management systems and business processes never contemplated7. Once PCPs have this useful referral performance data, it can “unlock hidden value from existing systems to help meet lofty performance improvement goals.”6
1 Primary Care Alliance meeting, February 2016, Pittsburgh, PA
2 Personal communication with Harold D Miller http://www.chqpr.org/staff.html
3 Miller, Harold D. "Measuring and Assigning Accountability for Healthcare Spending."
4 Hospital and Health Networks Magazine http://www.hhnmag.com/articles/6996-at-himss-day-1-big-name-it-vendors-hospital-systems-commit-to-finally-make-interoperability-a-reality
5 The Milbank Quarterly http://www.ncbi.nlm.nih.gov/pubmed/21418312
6 Physicians Practice http://www.physicianspractice.com/blog/transitioning-health-data-performance-improvement
7 2016 HIMSS Cost Accounting Survey http://s3.amazonaws.com/rdcms-himss/files/production/public/FileDownloads/2016-cost%20-accounting-survey-executive-summary.pdf
