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4 Approaches for Surviving Quality Challenges

Ken Yanagisawa, MD: ‘The pathway to quality success is complicated and, seemingly at times, convoluted, but it is vital to our livelihood and patient care.’

Changes in the healthcare system that link data reporting to reimbursement are stressing medical practices, but the Academy is working to help relieve that stress through strong support systems. The Board of Governors (BOG) stepped forward September 12 with a hot topics session, “Practical Solutions to Conquer the Quality Quagmire.”

“For our Academy membership, the goal is to share valuable information for individual practice success. The pathway to quality success is complicated and, seemingly at times, convoluted, but it is vital to our livelihood and patient care,” said session moderator Ken Yanagisawa, MD, formerly BOG secretary and now BOG chair-elect.

Patient Satisfaction

Denis Lafreniere, MD

Patient satisfaction has become an important barometer that affects Medicare payments to hospitals, physician payment models, and even treatment outcomes. At the same time, healthcare professionals have become frustrated with poor satisfaction scores in difficult care situations. However, there are ways to improve patient satisfaction scores, said Denis Lafreniere, MD, a former BOG chair.

“It’s all communication. It’s listening, explaining what’s going on, a respectful, courteous approach to the patient, and empathy. Of course, the technical skill, expertise and knowledge have to be there. People want to know you actually care and are listening to them,” said Dr. Lafreniere, professor and chief of the Division of Otolaryngology at Uconn Health.

It is important to be aware that people who complete patient satisfaction surveys are those who use the system more often. Their level of satisfaction is related to prescription drug costs and overall health expenditures. It is not necessarily related to the technical quality of care, he said.

A vexing situation for many otolaryngologists is patients who request a prescription for antibiotics for sinusitis. For a study, the University of Connecticut developed pamphlets for patients explaining that antibiotics do not help to treat a virus, and all physicians were instructed to tactfully explain this to patients, Dr. Lafreniere said.

“We were able to see a decrease in the amount of antibiotics prescribed. This was a conversation with the patients, and they walked out satisfied that they were getting the right care because now they understood what was going on,” he said.

In addition, practices must take a positive approach so all staff members emphasize to patients that they are receiving the best care available. Also, a medical practice must be transparent in patient interactions, Dr. Lafreniere said. Those interactions should include explaining the duration of tests or procedures, what will happen during a procedure, saying “thank you,” and having a positive closing with the patient.

Measuring Quality

Lawrence Simon, MD

MIPS and MACRA are two of the most prominent acronyms in the alphabet soup of quality measurements that are so overwhelming for many healthcare professionals. Lawrence Simon, MD, a member of the Academy’s Physician Payment Policy Workgroup, provided clear explanations of a complicated reimbursement system.

MACRA—the Medicare Access and CHIP Reauthorization Act—is the new system used to determine how healthcare professionals will be paid. It replaced the problematic sustainable growth rate that had to be adjusted annually, he said. MACRA uses quality reporting systems that are value-based.

There are two approaches used in MACRA’s Quality Payment Program to calculate payments—MIPS and APMs. MIPS—the Merit-based Incentive Payment System—will be used by almost all otolaryngologists to calculate their fee for service payment with Medicare. APMs—Alternative Payment Models—will not apply to most otolaryngologists.

“It is not rocket science. All it does is give you a new way of calculating how Medicare is going to pay you. That’s it,” Dr. Simon said.

Dr. Simon also explained the granular details of how quality is determined through quality reporting from medical practices. For otolaryngologists, the reporting process is simplified by using the Academy’s Reg-entSM Qualified Clinical Data Registry, he said.

Partnering with State Societies

Matthew C. Katz

Where do physicians go for help with all the complexities associated with national health system reform? A good start is their state specialty societies, which are increasingly partnering with state medical societies, said Matthew C. Katz, executive vice president and CEO of the Connecticut State Medical Society (CSMS).

Katz explained how CSMS, faced with a weakening relationship with local specialty societies in the 1980s, has evolved since the early 2000s. It reached out to the specialty societies through an expanded House of Delegates. The groups found strength by banding together.

CSMS developed statistic-based information exchanges and even formed an accountable care organization. It was all part of a concerted effort to become more involved in quality measurement so it could support state specialty societies. In addition, CSMS has worked with other state societies to develop systems to help with MIPS quality reporting.

“We see state medical societies as partners,” Katz said.

Dealing with Denial of Payments

David R. Edelstein, MD

As reimbursement models change, medical practices face increasing pressure to adapt to those changes, which can lead to more payment denials. David R. Edelstein, MD, has a simple and stern approach: “The sun should not set on a denial. It has to happen.”

Dr. Edelstein, a former BOG chair and chief of otolaryngology—head and neck surgery at Manhattan Eye, Ear, and Throat Hospital, said that denials start with poor documentation, failure to keep up with the medical literature, and an untrained administrative staff that lacks teamwork.

On the heels of a denial should come the speedy appeal that should be calm and reasoned.

“Appeals fail when you lose your cool,” Dr. Edelstein said. “Appeals succeed when you understand why and how you treat patients. Appeals succeed when you think of the audience—the insurance company.”

A key approach is establishing an office system that integrates paper, electronics, and people. “Computers help, but do not think,” he said, adding that the entire office staff—including physicians—must learn how the coding and insurance systems work.

“Know your rights and the patient’s rights” Dr. Edelstein said. “Learn about the local and national resources available. The Academy has your back. Think like the insurance company and understand the rhythm of their life. Engage the patient for best effect.”

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