CAP Practice Management Committee
Once a largely theoretical construct, value-based care (VBC) is rapidly making the transition to an applied payment model. The Department of Health and Human Services (HHS) expects 30% of all provider arrangements to fall under an alternative payment plan by the end of 2016. By 2018, this number jumps to 80%. HHS also intends for payments made through programs like the Hospital Value-Based Purchasing Program and Hospital Readmissions Reduction Program to constitute 85% of all hospital payments by 2016 and 90% by 2018. Of course, HHS is only one section of a larger payment system, but many commercial payers are taking similar steps toward a value-based model of reimbursement.
What is Meant by “Value-based” and Why Should I Care?
One facet of VBC is to shift the focus from a volume-driven environment (ie, “fee-for-service”) to one driven by lower costs and better patient outcomes. While this shift may involve activities that are unfamiliar to pathologists, the ability to navigate changes and, more importantly, demonstrate value will prove critical for pathologists to succeed in a VBC model.
As the reach of VBC grows, more of your practice’s revenues will be tied to your quality and value performance. If you are a pathologist or practice manager, the impact on your practice’s financial well-being is therefore an obvious impetus for concern.
How can I Demonstrate Value?
As the CAP’s Practice Management Committee (PMC), we know the value the pathologist provides in patient care. We also understand that demonstrating value under new payment models can be a daunting task, so we’ve pulled from committee member experience and selected 2 simple guideposts to help your future efforts.
1. RIDE: Review, Implement, Document, Explain
Demonstrating value does not always require original research. It’s often more practicable to implement recommendations developed by thought leaders (eg, Mayo Clinic or ARUP Laboratories) as a small health care improvement project within your practice. This approach saves time and allows project results to demonstrate pathology as an agent for innovation, improved quality, and cost containment.
Although not a formal methodology, we have developed the mnemonic RIDE as an outline of the basic steps required when undertaking health care improvement projects:
- Review. Review your practice’s existing operations and associated costs. Operational efficiencies will change, so without accurate baseline data, the results of your project will lack substantiation. CAP members should complete the Value Impact Analysis Workbook to collect baseline data and Project Planner Workbook to plan their timeline. Remember that deadlines are paramount in establishing the importance of your project.
- Implement. Build the appropriate team for your project. Review new guidelines with your team members and decide which is most appropriate to test in your practice.
- Document. Take careful notes and document success criteria (eg, length of stay, cost reduction, improved diagnosis) affected by the implementation of your project. Be sure to also document your team members and their respective roles.
- Explain. Notify your practice leader of the benefits (or drawbacks) of your project upon completion. Leadership may vary according to the governance structure of your practice or laboratory.
RIDE can be applied to many different health care improvement projects. Retrospective reviews can demonstrate how tests newly validated in the laboratory will generate cost savings or will lead rapidly to a precise diagnosis, which then may be treatable. If you have recently introduced a new immunostain or molecular biology test, document cost savings or develop a prospective analysis. For example, enterovirus molecular testing can reduce hospital admissions, length of stay, and administration of antibiotics, thereby generating significant cost savings to the patient and hospital.
Sometimes even the smallest changes in practice can prove to be great demonstrations of value for you as a pathologist. For example, one PMC member recently spearheaded a health care improvement project to update RBC transfusion guidelines at an East Coast hospital. The project was built on shifting extant guidelines to one of patient blood management (PBM), “an evidence-based, multidisciplinary approach to optimizing the care of patients who might need transfusion” supported by the American Association of Blood Banks. By organizing a team around the project and documenting changes—including condition-specific parameters and new dosing recommendations—this simple but well-structured project eventuated in a 5% cost reduction, or approximately $150,000, per year.
In another example, an East Coast institution conducted a laboratory audit as part of their utilization program. A review of audit results demonstrated that serum methylmalonic acid (MMA) was not being ordered correctly. In an effort to reduce unnecessary testing for MMA and promote evidence-based practice, the lab leveraged Mayo Medical Laboratories Pernicious Anemia Testing Algorithm to develop new MMA guidelines. The utilization team then documented the results of their initiative through educational letters sent to clinicians, an article in the hospital newsletter, and the addition of a popup notification for their electronic medical record system. From a baseline of 57 tests per month, there were decreases of 7%, 49%, 72%, 65%, 88%, and 67% during the first 6 months of the new guidelines being implemented. Total cost savings were approximately $5500, and the number of MMA tests ordered decreased by up to 88%. This successful example of RIDE is predicted to lead to better diagnostic practices for determining B12 deficiency.
2. Learn by Example and Lead the Change
A logical first step toward demonstrating value to a health care organization under a VBC model is to formalize, measure, and advocate for your role as a member of an integrated care team. As pathologists, we should take our cue from Improving Diagnosis in Health Care, a recent report from the Institute of Medicine (IOM) that states as its main goal to facilitate more effective teamwork in the diagnostic process.
The report even recommends that the Centers for Medicare and Medicaid Services develop “current procedural terminology (CPT) codes and provide coverage for additional evaluation and management activities not currently coded or covered, including time spent by pathologists, radiologists, and other clinicians in advising ordering clinicians on the selection, use, and interpretation of diagnostic testing for specific patients."
Legislators often refer to IOM reports in guiding local and federal policy. For example, duty hour restrictions are enforced largely due to the suggestions of an IOM report. So what changes can you implement in your practice to proactively demonstrate to your health care system that pathology is a vital component of the clinical care team?
Take Advantage of Opportunities to Present to Colleagues
Both anatomic and clinical pathologists are often called upon to present at clinical tumor boards and clinical care conferences. These conferences will present you with an ideal forum to engage with clinical colleagues to ensure they understand the nature of pathology and laboratory practice. Such open dialogue is necessary for pathologists to effectively integrate into the care team.
For example, frank and clear discussions between pathologists and treating clinicians in open forum sessions allow consensus regarding when and how pathology diagnoses will affect treatment decisions during patient care. Working together with your care team, you can structure your reports and communications to ensure that clinicians have the concise, clear, and complete pathology information needed for directed treatment planning. Ensuring that the treating clinical team can find and understand relevant pathology information within pathology reports can go a long way in preventing damaging misunderstandings. At the same time, open dialogue and continuous report improvement maintains understanding, trust, and confidence between you as a pathologist and the clinical care team. Having the full support and understanding of the clinical care teams for pathology services is invaluable both for safe patient care and for advocacy for pathology services at an institutional level.
Similar to the RIDE methodology mentioned earlier in this article, the importance of documenting participation in conferences and tumor boards cannot be underestimated. For example, the University of Washington carefully documents all involvement in clinical care conferences, including the time in conference, preparation time, and any other associated costs (eg, transit). With the support of clinical care teams, Pathologists are then able to include conference participation time as part of hospital pathology cFTE.
Continued documentation of time and effort as part of the care team could also allow easy transition should CMS actually provide coverage for such services as suggested in the IOM report. Quality improvements developed as part of integrated clinical care discussions are documented and discussed during monthly pathology quality assurance conferences. These quality improvements, with associated metrics, can be rolled up to the health system administrators to increase understanding and visibility of pathology initiated and directed patient safety initiatives.
We believe that pathologists should go one step further and take the initiative in proactively offering to join discussions related to pathology issues with patients. Helping patients understand more about the role of pathologists in their treatment and the nature of pathology practice could help facilitate communication and support the call of the IOM, the CAP, and other organizations call for greater care team integration.