As quality measures continue to factor into practice revenue, it is important for physicians to put their best foot forward with patients.
Over the past several years there have been many discussions in physician practices and hospital corridors that fee-for-service physician reimbursement has become outdated and runs counter to the goals of lower cost and better outcomes for patients. Industry insiders agree that changes need to be made to physician reimbursement models by rewarding physicians for "quality" patient interactions and better clinical outcomes instead of for the number of patients they see and how productive they are.
But making that type of change can be difficult.
Meryl Luallin, a San-Diego-based consultant/partner with SullivanLuallin says the time is ripe for medical practices to prepare for the coming changes. "[The U.S. Centers for Medicare and Medicaid Services] is now focusing on the Affordable Care Act (ACA) Triple Aim [which] … is better clinical outcomes with lower costs, with more engaged, happy patients," says Luallin. "And so, with all this focus, there's measurement going on constantly, where doctors and their organizations are monitoring patient outcomes, and also measuring clinical outcomes, as well as cost measures. But they are also monitoring patient satisfaction."
The term "quality" encompasses a number of government programs and private-payer quality initiatives. And with the elimination of the Sustainable Growth Rate Formula in the first part of 2015 through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the government has communicated its intent to replace the defunct formula with a new hybrid program called the Merit-Based Incentive Payment System (MIPS). While full implementation of MIPS won't affect physician practices until 2019, other quality initiatives like the Clinician & Group-Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS), one type of patient satisfaction survey, will be factored into small-group Medicare reimbursement formulas starting in 2017, for those participating in Physician Quality Reporting System (PQRS).
These patient satisfaction surveys ask patients about their subjective experiences at their doctors' offices, and rather than judge clinical competence, they ask patients questions concerning access to care, physician communication, and staff effectiveness. Luallin says that even if physicians score well, they must achieve higher than a 95 percent on the CG-CAHPS or they rank only at the 50th percentile when compared to their peers. And with a score of 88 percent, a provider is ranked at the 10th percentile, says Luallin, which means a reduction in bonus money from Medicare.
So in an effort to boost patient satisfaction scores, many practices are engaging the help of an outside "shadow coach" to observe low-scoring physicians during the patient encounter. Luallin says it is not just an effort to boost practice revenue; engaged patients will better comply with treatment plans. "There are many studies that show if patients feel valued and cared about by their doctors, and have more confidence in their physicians, they are more likely to be engaged in their own healthcare," she says.
The motivation for change cannot come from senior leadership, Luallin cautions. She notes that the practice’s best intentions won't matter unless a physician is interested in improving his or her patient satisfaction scores. The reasons for working with a shadow coach include improved compensation, better job retention, and/or the desire to be on an equal standing with other physicians in the practice. And better satisfaction scores will ultimately affect such varied factors as referral relationships, compensation bonuses, and professional working relationships within the practice.
Once the shadow coach is engaged and speaks with the physician, Luallin says her goal is to be as unobtrusive as possible during the patient encounter. She adds that she always steps out during "intimate" parts of the exam. The physician will typically introduce the shadow coach to the patient as someone who is writing a report, and will ask the patient for permission to observe the encounter.
Luallin is looking for positive physician-patient interactions. Does the physician personally greet the patient by name? Does he knock at the door before entering? Does he make eye contact with the patient, rather than looking at the computer as he asks questions? Does the physician respond empathetically to the patient complaint?
It is important for the physician to know that the shadow coach is not there to criticize technique, but rather, to point out areas where she could be more effective. For instance, Luallin says physicians often don't stop and offer sympathy to patients who share a difficult experience. But that doesn't necessarily mean disinterest.
"[The physician's] job is to ask the questions that help him figure out what's wrong [with the patient]. Then his expertise is to tell you what to do to make it right. Empathy has no part in that at all. [Yet] the key to improving the patient relationship is to be empathetic," she says.