Thinking Differently About Data to Enhance the Patient Experience, Operations, and Reimbursement

Many providers feel that they’re already in data overload. However, by approaching their data in a new way, healthcare practices and organizations can discover underlying issues that can lead to operational enhancements, improvements in the patient experience, and increased profitability.

It is critical to look at data differently to navigate risk, reputation, and reimbursement successfully.

Outdated data models and analytics do not provide practices with the full picture, and rarely identify actionable insights. It is critical to look at data differently to navigate risk, reputation, and reimbursement successfully. Failing to do so can spell disaster . . . in a number of ways.

Risky providers who fail to adhere to policies (e.g., obstetricians who do not assess the risk of shoulder dystocia) or perform at a subpar level (e.g., whose patients experience high rates of sepsis after prostate biopsy) can lead to serious issues that ultimately can result in significant payouts in malpractice lawsuits. Providers often lose large chunks of time in the defense of lawsuits through depositions, meetings, and the courtroom itself. Many providers rate the experience of being sued as the worst life event they have ever faced, and this is a major cause of the epidemic of physician burnout.

From an economic standpoint, the damage caused to the provider or practice’s reputation by a serious adverse event can dramatically reduce patient volumes. This is becoming increasingly more significant, because reputational injury is magnified through social media and online provider reviews. Even the largest practices can take a serious financial hit, and smaller practices could end up having to close their doors.

A few years ago, I was working with a GI practice that hired our team for a consulting engagement. The practice was looking for ways to cut costs, become more efficient, and improve the experience for their patients. What they discovered went much deeper.

For years, the practice had gone along completely unaware that one of its GI practitioners was putting many of the practice’s female patients’ lives in danger. Although women accounted for a large portion of the doctor’s patients, he never once found a reason to perform a biopsy on any of his female patients undergoing a screening colonoscopy. Fortunately, one of the things the practice had asked us to do was to help them deploy a data measurement system into their operations to identify any gaps in quality, safety, and patient engagement.

Through the use of this data measurement tool, they gained critical insight into the doctor’s poor performance. To our surprise, the news did not seem to come as a shock to anyone, as it was common knowledge that the doctor in question had a negative approach to and opinion of women in general. They already knew the dangers this attitude posed, but they didn’t know how to deal with it. Once the issues were brought clearly into focus through the measurement process, the issue could no longer be ignored, and the practice was able to act quickly to rectify the situation.

Eliminating these types of risk and creating a safe, high-quality environment of care for patients is critical to success. It helps practices and organizations be the best they can be so that they can position themselves to achieve growth by developing a powerful “value story.”

The Value of a Value Story

A practice’s value story is a critical component of the foundation necessary to enhance reimbursement negotiations. Often, reimbursement negotiations with insurance companies are uncomfortable for providers, mainly because the providers have not measured their market value and have no credible justification for reimbursement increases. At times, this can lead to ignoring reimbursement contracts, even though these contracts are arguably the highest value asset the provider group owns. Creating a value story with relevant, specialty-specific measurements changes this dynamic, and empowers the provider group to negotiate reimbursement based on hard evidence rather than emotion. An evidence-based negotiation strategy almost always results in improved revenue and lower stress throughout the process.

How Measurement Tools Lead to an Optimized Value Story

Returning to the GI practice I mentioned earlier, without a measurement system in place, they were unable to successfully negotiate their reimbursement. They simply did not have credible evidence of their value. Through basic measurement, they were able to identify their value gaps: in this case, an underperforming physician. Empowered with that knowledge, they closed the gaps before negotiating, and before an adverse event created reputational injury. After they had closed their value gaps, they were able to create and support a value story for the practice with credible, relevant, specialty specific data points like high performance for all providers in screening colonoscopy for both men and women.

Through evidence-based negotiations, they were able to increase their reimbursement to a much higher level than they had achieved before creating a value story. Through this process of measurement, the practice was able to increase quality, avoid adverse events and lawsuits, help an underperforming physician, maintain their reputation with patients, and increase practice revenue through better negotiations. All this was made possible through simple, scientifically developed measurement tools.

Measure What Matters: Quality, Safety, and Patient Engagement

It is possible to approach the sea of healthcare data in a new way. By focusing on the few data points that matter, practices are able to identify risk, operational improvement opportunities, and value gaps. This process should be simple, economical, and not time consuming for either providers or practice managers. Analytics based on claims data (typically used by health insurance companies) has a role in population health management, but it has significant limitations in defining a value story, and is ineffective in identifying risk or measuring quality. The best source of data to create a value story is through measurements of individual patients and individual providers.

As a response to these issues, we developed the Physician Empowerment Suite (PES) (www.sehealthcarequalityconsulting.com/solutions/physician-empowerment-suite/ ).

A good data measurement tool will allow providers to pull data easily and efficiently.

Practices can use a tool like ours, which is comprised of a patient experience component that measures patient engagement and satisfaction to help improve reputation, mitigate risk, and build a foundation to improve reimbursement, and a clinical effectiveness component that measures 20 key, specialty-specific metrics, such as adenoma detection rates and physician burnout, for example.

By using a tool such as the PES, practices and other healthcare organizations can position themselves for success. Failing to measure data, however, can position those same entities for failure. Measurement is the key to staying alive in today’s healthcare environment, and healthcare providers that understand this and take a proactive approach stand a much better chance of survival.

Providers Should Own Their Data

A variety of people and organizations measure provider value, such as Internet patient reviews, insurance company scorecards, and Medicare measurements. Providers should own their data, rather than relying on someone else, like an insurance company, to measure their value. By owning the data, providers have the opportunity to close any value gaps before using the data to enhance reputation or negotiation for reimbursement.

Collecting and analyzing these types of data is more critical now than ever before, and setting a system of measurement in place can equate to:

• Optimized reimbursement from payer negotiations;

• Membership in narrow networks;

• Improved reputation;

• Reduction in bad debt; and

• Fewer malpractice claims, payouts, and related expenses.

The Top Four Reasons Every Practice Should Focus on Measurement

Prevention

The ability to provide factual data that can detect and correct damaging factors could save an entire practice, not to mention many lives. If the GI practice had not utilized a measurement tool with the initial intention of enhancing its value story in the hopes of improving reimbursement negotiation, they might never have uncovered the doctor’s issue with female patients. This could have resulted in women having undiagnosed colon cancer and potentially dying from it. Beyond the most critical factor of lives being at risk, the doctor and the practice could have ended up the target of one or multiple malpractice lawsuits.

Reputation

A reputation can make or break a practice. A bad reputation can hinder growth significantly and send patients running for the competition. A positive reputation, on the other hand, can lead to an increase in patients, which, in turn, impacts the bottom line in a big way. Using measurement tools to find out what patients are saying about their experience with the practice and staff is a critical component of success and allows practices to make changes to improve the patient experience. If you are not measuring your patients’ experience, someone else will, and they won’t be as kind with the way they present the results.

Control

Healthcare providers are always being measured, whether we’re aware or not. Health plans, large employer groups, and others are using low-accuracy claims systems to measure practices. It is better to take control of the measurement process than to have it be something that is being done to you. Using a measurement tool like ours will compute high-quality data for your practice and outweigh those low-accuracy systems.

Once you are in control of your own results, it is much easier to correct and push back against any negative issues that arise. The data also help you gain control, not just externally but also internally. The results that practices can gain through measurement help evaluate the practice staff, providing a better understanding of what is going on within internal management. With the information calculated from a measurement tool, it is easier to motivate and manage practice staff.

Reimbursement

Just one negative claim about a practice could kill its value story during negotiations, and significantly lower that practice’s ability to enhance its position to negotiate reimbursement more effectively. Measuring your practice provides you the potential to collect thousands or even millions of dollars for a much lower investment in the right tools.

The reimbursement process is a complex, intricate web, and without the proper foundation to build a case using a well-crafted value story and the right resources, it’s a difficult negotiation to win (Figure 1).

Figure 1. Delivering distinctive value every step of the way. FFS, fee-for-service.

The Time is Worth It

A good data measurement tool will allow providers to pull data easily and efficiently. This process will only take the practice manager about 10 to 20 minutes per month. For the doctors, it should take around two minutes to review results each month. You have the potential to gain an increased value story by sacrificing a few minutes per month.