CKD PRACTICE

EDITORIAL                                                                                                    ADVISORY BOAR...

SWOT Analysis Leads to
Nephrology Practice Success
       y analyzing a practice’s             in competitive m...
(Continued from page 3)
expanding into new service lines can
create pressure for physicians, who are
busy caring ...
Seeing Opportunities. Next, the          calls to get their patients in to see a    naturally apply to our skill sets. Mor...

Practices Feeling the Effects of MMA
       he Medicare Prescription Drug           As mandated under MM...
“Nephrologists need to understand the impact of the MMA in order to
 ensure the future viability of their practices,” says...
(Continued from page 7)
The CAP Program                            about CAP. “First, individual physi-   ...

Minnesota Group Gets P4P
         any experts advocate paying      of what effect P4P will have on        ...
(Continued from page 9)
UnitedHealth Group.                       tions overlook important opportuni-      l...
should never be used as rigid rules.”
   Guidelines are a good starting
point for evaluating physicians,

Recruiting the Best Nephrologists
            hen a nephrology practice      from training programs ...
Beyond Nephrologists
Recruiting another nephrologist, how-
ever, may not be the answer. Much of
(Continued from page 13)
NPs and 59,000 PAs working in the         NP with a primary care background, ...

Practice Aims to Increase Efficiency
       he nephrologists and endocri-       Medicaid does not pay for dia...
(Continued from page 15)

activities and to support us in delivering
quality patient care.                     ...
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  1. 1. OPTIONS CKD PRACTICE ™ IMPROVING PATIENT CARE THROUGH INCREASED PRACTICE EFFICIENCY October 2006 EDITORIAL Reform Forces Practices to Be More Efficient 2 STRATEGY SWOT Analysis Leads to Nephrology Practice Success 3 MEDICARE REFORM Practices Feeling the Effects of MMA 6 REIMBURSEMENT Minnesota Group Gets P4P 9 BUSINESS MANAGEMENT Recruiting the Best Nephrologists 12 CASE STUDY Practice Aims to Increase Efficiency 15
  2. 2. EDITORIAL ADVISORY BOARD Reform Forces Practices to Be More Efficient Michael Germain, MD hysicians nationwide are feeling the effects of changes brought about as a Practicing Nephrologist P result of the Medicare Prescription Drug Improvement and Modernization Act of 2003. This year, the provisions of the act make it imperative that all Western New England Renal & Transplant West Springfield, Mass. physicians operate more efficiently than they have at any time in the past, says Robert Provenzano, MD, a nephrologist and chief operating office of St. Clair Debra Lawson Specialty Physicians in Detroit. Provenzano is a member of the editorial board Director of Reimbursement of CKD Practice Options and is president of the Renal Physicians Association, in Nephrology Associates of Tidewater Rockville, Md.. Norfolk, Va. As our writer, Deborah Neveleff, explains in the article on Medicare Reform on page 6, some practices may be struggling as they are paid based on the new Suanne Petroff, NP lower rate for medications they administer to patients. In the past, nephrologists Registered Nurse were paid based on what the federal Centers for Medicare & Medicaid Services Western New England Renal & Transplant (CMS) calls the average wholesale price (AWP). West Springfield, Mass. The Medicare reform act eliminated AWP, however. Starting this year, nephrologists are being paid based on what CMS calls the average sales price Robert Provenzano, MD (ASP) plus 6%. Nephrology Chair In the reimbursement article on page 9, we explain a strategy nephrologists can St. John Hospital Medical Center pursue to establish a pay for performance (P4P) program. While P4P is not wide- Associate Professor of Medicine spread among nephrologists, our article explains that a nephrology group in Wayne State University Practicing Nephrologist Minnesota has been involved in a P4P program for the treatment of patients with St. Clair Specialty Physicians, PC CKD for two years.. Another way to increase efficiency is to hire additional Detroit providers or consider hiring a nurse practitioner or physician assistant. The Business Management article on page 12 addresses these hiring issues. Seeking Russell Silverstein, MD to increase efficiency, a number of nephrology practices are using midlevel prac- Practicing Nephrologist titioners, rather than hiring new physicians. With some supervision, midlevel Dallas Nephrology Association practitioners can assume some of the work that physicians would do otherwise, Dallas such as providing primary care, following up on office visits, and working with dialysis patients. These practitioners also are used to staff chronic kidney disease Tom Turner clinics and vascular access centers. Practice Administrator East Bay Nephrology Nephrologists also can do an analysis of the practice’s strengths, weaknesses, Berkeley, Calif. opportunities, and threats (SWOT). In the Strategy article on page 3, nephrol- ogists and practice experts discuss the value of a SWOT analysis. Jeff Weintraub Over the coming months, CKD Practice Options will write about factors hav- Chief Executive Office ing a significant effect on nephrology practices and we will continue to include Southwest Kidney Institute articles on how practices can operate more efficiently. Tempe, Ariz. James Weiss, MD Renal Endocrine Associates Monroeville, Pa. Richard L. Reece, MD Contributing Editor Phone: 860/395-1501 Fax: 860/395-1512 Publisher E-mail: Rreece@premierhealthcare.com Premier Healthcare Resource, Inc. 150 Washington St. Morristown, NJ 07960 888/457-8800; Fax: 973/682-9077 publisher@premierhealthcare.com This newsletter is published by Premier Healthcare Resource, Inc., Morristown, N.J. © Copyright strictly reserved. This newsletter may not be reproduced in whole or in part without the Editor written permission of Premier Healthcare Resource, Inc. The advice and opinions in this publication are Joseph Burns not necessarily those of the editor, advisory board, publishing staff, Premier Healthcare Resource, Inc., or 508/495-0246 the views of Ortho Biotech Products, LP, but instead are exclusively the opinions of the authors. Readers editor@premierhealthcare.com are urged to seek individual counsel and advice for their unique experiences. 2 Practice Options/October 2006
  3. 3. STRATEGY SWOT Analysis Leads to Nephrology Practice Success y analyzing a practice’s in competitive markets. “Without a tices typically face several common B strengths, weaknesses, opportu- nities, and threats, nephrolo- gists can make strategic business and focus on strategic planning, physicians can lose track of who the competition is and what the competitors are doing,” challenges that strategic planning can address. “First, many nephrologists are spread too thin,” he says. “They are clinical improvements that can Fabrizio says. “In addition to monitor- constantly on the go, especially in larg- enhance the strength of their business ing competitive forces, strategic plan- er cities, where they may have multi- and improve the quality of care they ning efforts help nephrologists opti- ple office locations and serve patients deliver. mize their contracting relationships in different hospitals and dialysis cen- “Strategic planning is absolutely with hospitals and determine how well ters. A big challenge for nephrologists essential in enabling a nephrology they manage referral relationships. is trying to define the scope of their practice to create a valued product for Finally, strategic planning helps practice and their target market area, its community,” says Robert nephrologists capture market share by while remaining sufficiently flexible to Provenzano, MD, a nephrologist and pinpointing opportunities to develop accommodate marketplace changes, chief executive officer of St. Clair new relationships with hospitals and such as new business opportunities or Specialty Physicians in Detroit. dialysis centers and determining the competitive threats.” Provenzano also is president of the practice’s staffing and technology Declining reimbursement is a sec- Renal Physicians Association, in needs when expansion is desirable.” ond challenge nephrologists face in Rockville, Md. Most physicians, of course, are pri- virtually all markets nationwide. marily interested in clinical quality. “Employing a good billing staff is one Improving Relationships Still, there is a link between a strong key to profitability and continued Nick Fabrizio, PhD, FACMPE, a con- business model and the quality of care practice viability,” Fabrizio notes. “In sultant with the Medical Group physicians provide, Fabrizio explains. the face of declining reimbursement, Management Association’s Health “No margin, no mission,” he asserts. nephrology practices require staff to Care Consulting Group, in “If doctors do not have a profitable handle billing and collections to Englewood, Colo., agrees that strategic practice, they cannot do the things ensure optimal charge capture and planning for private practice physi- they want to do, such as purchase reimbursement. A competent and cians is important in all specialties. state-of-the-art equipment or expand knowledgeable administrator is of “Strategic planning and marketing are into new patient-care services. great value as well.” crucial to the success of a medical prac- Practices should generate sufficient tice,” says Fabrizio, who has worked profits both to cover overhead Service Support with numerous nephrology groups and expenses and to enable the physicians A third challenge is ensuring ade- other practices. “Physicians are so busy to take advantage of exciting clinical quate revenue to support services that with clinical care that they often do opportunities that will help them may be only marginally profitable. not focus on the fact that their practice enhance their care.” “For example, the care of patients is really a business. I have worked with Provenzano agrees, saying, “A prac- with chronic kidney disease may gen- nephrology groups that constitute mil- tice’s business success gives physicians erate only a limited margin, so lion-dollar businesses. Having a busi- the opportunity to invest in expan- nephrologists need to cultivate other ness of that size without a strategic sion that will bring more services and revenue streams in order to create a plan puts the group at a disadvantage.” greater access to patients.” viable business as a whole,” Fabrizio This disadvantage is especially acute Fabrizio notes that nephrology prac- says. “But if not planned properly, (Continued on page 4) “A practice’s business success gives physicians the opportunity to invest in expansion that will bring more services and greater access to patients.” —Robert Provenzano, MD, St. Clair Specialty Physicians Practice Options/October 2006 3
  4. 4. STRATEGY (Continued from page 3) expanding into new service lines can create pressure for physicians, who are busy caring for patients.” Factors for Strategic Planning ick Fabrizio, a consultant with the Medical Group Management Strategic Planning Such business challenges can be N Association’s Health Care Consulting Group, in Englewood, Colo., lists several factors for nephrology groups to consider when embarking on addressed through an analysis of a strategic planning process: strengths, weaknesses, opportunities, • Choose consulting assistance carefully, and ask for references. “The key and threats (SWOT), commonly used is to get value for your time and monetary investment,” Fabrizio says. as a framework for strategic planning • Require a pre-analysis of the group, including financial and market in both small and large businesses in share analyses, and operational practices, so that the strategic plan is many industries. Fabrizio often con- based on a framework of data. ducts SWOT analyses in his work with • Divide all strategies into actionable steps that will help the group medical practices. progress toward its goals. St. Clair Specialty Physicians per- • Commit the plan to writing and set clear deadlines and responsibilities. forms a SWOT analysis annually. “The plan should specify who is doing what, when and how. Otherwise “The SWOT analysis helps physicians the plan will fall by the wayside,” Fabrizio says. determine what initiatives to pursue in • Accept that strategic planning will require an investment of time on the context of their practice’s business the part of the group’s physicians. plan and ensure that they are investing • Maintain the right attitude. “Physicians have to decide that they their money wisely,” Provenzano says. really want to develop a plan, and then be ready to implement it,” SWOT analyses are typically done says Fabrizio. —DJN with all physicians present. “Probably the most useful part of the whole exer- doctors included on this list,” he notes. to ameliorate problems. Physicians cise is that all the physicians are com- “But the group had not been using this should begin to resolve some of these municating with each other in real strength to its full potential. We devel- issues before they build a plan. New time, which is rare given the time con- oped an inexpensive marketing cam- strategies can easily be undermined if straints of daily practice,” Fabrizio says. paign directed toward hospital, dialysis underlying weaknesses are not Defining goals is the key to perform- companies, and referring doctors that addressed first.” ing a successful SWOT analysis. highlighted the practice’s strong repu- Weaknesses may be relatively small “Physician practices must define goals tation for quality care.” and easily addressed, or they may be that are consistent with their mission Broad coverage of an area is another more complicated. “Most groups have and vision,” Fabrizio notes. strength that can be marketed success- a mix of weaknesses,” Fabrizio says. Assessing Strengths. Through a fully, Fabrizio continues. “First, prac- “Issues that require solutions to be SWOT analysis, physicians first con- tices must know their market share implemented over a longer term might sider practice strengths. The strengths and the scope of their coverage,” he include ineffective group governance, of a practice might include high quali- says. “Sometimes, hospital marketing ineffective billing practices, or ineffec- ty care, a good reputation, good departments can help medical groups tive hiring practices. In contrast, a rel- employee relations, and low staff by providing a ZIP code analysis of atively minor weakness may be the turnover. where patients live. Then, groups can absence of a marketing plan, which “A group might have strengths that work with the hospital to publicize involves a straightforward solution.” the physicians don’t realize can be their services within this market area, A SWOT analysis helped St. Clair actively leveraged for business bene- thereby ensuring that patients and Specialty Physicians identify a major fit,” Fabrizio says. “For example, quali- referring doctors know who they are.” weakness: an inability to grow rapidly, ty care can be meaningfully parlayed Identifying Weaknesses. The sec- causing a loss in market share. into business success.” ond part of the SWOT analysis is to “Through the SWOT analysis, we Recently, Fabrizio worked with a identify weaknesses. “Physicians developed a targeted approach to nephrology group whose physicians should be candid in their assessment of expansion by hiring a real estate attor- were all in a magazine listing the com- the practice’s weaknesses,” Fabrizio ney and developing direct recruiting munity’s 100 top doctors. “That was a asserts. “While it may be difficult to initiatives,” says Provenzano. “As a tremendous strength for this practice, acknowledge weaknesses, seeing a list result, over the last 18 months we have especially since other nephrology in black and white helps physicians grown to a size that helps us meet our groups in this large area did not have take the next step in designing a plan objectives.” 4 Practice Options/October 2006
  5. 5. Seeing Opportunities. Next, the calls to get their patients in to see a naturally apply to our skill sets. More group assesses its opportunities. specialist. If they see a nephrologist and more, successful practices are using “Opportunities often include strategies right there in the hospital, this neph- practice managers to make their prac- related to expansion, such as establish- rologist will start getting referrals.” tices more efficient, which make them ing services at a new hospital, develop- A more difficult part of analyzing more competitive.” Provenzano says ing a new service line such as inter- opportunities involves assessing which that practices can either hire a dedi- ventional nephrology, opening a new types of revenue streams to pursue. cated practice manager or assign prac- office location to prompt an increase “The group needs to examine its tice management duties to one physi- in market share, or opening a dialysis strengths and weaknesses and know cian, who carves out specific time for center or a vascular access center,” says what its competitors are doing,” this purpose and whose administrative Fabrizio. “Other opportunities might Fabrizio says. “For example, physicians role is subsidized by the practice. be relationship-oriented, such as culti- might decide to develop ancillary ser- Considering Threats. A practice’s vating closer relationships with refer- vices because their competitors offer final step in the SWOT analysis is to ring physicians or dialysis companies. these same services. While that might consider its threats. “Most obviously, Nephrology practices can build up be effective, timing must be consid- other nephrology practices can be their sources of revenue by carefully ered. If the physicians open a new ser- threats,” Fabrizio says. “Other threats assessing the different opportunities vice line after the market is saturated, can include non-nephrology practices that exist.” they may achieve only a small market offering nephrology care, hospitals, A SWOT analysis helped the St. share without much promise of gain- and dialysis companies.” Clair physicians identify opportunities. ing more, reducing their return on “Our basic business model is patient- investment. Selecting a new business Making a Plan focused care for chronic kidney disease opportunity should be informed by The strategic plan for the practice (CKD) and end-stage renal disease clinician time availability, physician should support the group’s goals. The (ESRD),” explains Provenzano. expertise, reimbursement levels for the plan also should reflect its strengths, “Using patient-focused care as our tar- service, patient demand, and competi- address its weaknesses, and take into get, we identified vascular access as a tors’ positions.” consideration opportunities and major opportunity, and built two vas- Once nephrologists express interest threats. The plan can then be devel- cular access centers. We also wanted to in a new opportunity, the group must oped into actionable initiatives as the streamline CKD care in the outpatient have a good administrator or business group defines its top priorities. “We setting, so we created a nurse-directed, manager to help them pursue it effec- look at the group’s goals, priorities, and physician-supervised clinic based on tively. “A business manager can per- limitations in the context of the clinical practice guidelines, data col- form an informed cost-benefit analysis SWOT analysis and then move the lection, and auditing for quality.” of new investment possibilities as well group forward based on priorities,” as manage new relationships on behalf Fabrizio explains. A Hospital Presence of the physicians,” Fabrizio says. It may be difficult for a group to find Having a strong presence in the local “Furthermore, too often physicians try time to meet for one day and write a hospital is important to the business of to pursue a new business opportunity strategic plan. “In my experience, a nephrology practice. “Like other spe- without management assistance, and retreat planning sessions are neces- cialists, nephrologists typically find become frustrated by the amount of sary,” Fabrizio says. “Pre-retreat ses- that they need to be visible in the hos- time diverted from patient care. This sions include an analysis of the group’s pital in order to get new patients,” can delay implementation of the pro- financial circumstances and market Fabrizio notes. “They get to know the ject, perhaps indefinitely.” share, and also involve one-on-one internists and other referring physi- “Most doctors are busy doing what interviews with each physician who cians and need to be immediately they are trained to do: taking care of will attend the retreat.” available. Physicians do not want to patients,” Provenzano observes. “We —Reported and written by Deborah J. spend excessive time making multiple may shy away from activities that don’t Neveleff, in North Potomac, Md. “Selecting a new business opportunity should be informed by clini- cian time availability, physician expertise, reimbursement levels for the service, patient demand, and competitors’ positions.” —Nick Fabrizio, PhD, Medical Group Management Association Practice Options/October 2006 5
  6. 6. MEDICARE REFORM Practices Feeling the Effects of MMA he Medicare Prescription Drug As mandated under MMA, reim- Practice Options and president of the T Improvement and Moderniza- tion Act (MMA) includes a number of provisions that are affect- bursement on bundled drugs in 2006 is 106% of ASP versus payment at 95% of AWP in 2003. As a result of these Renal Physicians Association, in Rockville, Md. Those nephrologists who may feel ing nephrology practices. In some changes, total reimbursement to the effects of MMA most significantly cases, the effect on practices is signif- nephrologists has declined sharply include those who treat patients with icant. The act is driving changes in since 2003. kidney or bladder cancer, Miller com- how care is provided and causing “ASP has had a negative financial ments. The ASP plus 6% rates for the nephrologists to renew their efforts to impact on nephrology practices,” says drugs used to treat patients with these increase practice efficiency. Jennifer Searfoss Miller, JD, the exter- cancers are significantly lower than In particular, three aspects of nal relations liaison for the Medical the purchase price of these medica- MMA are having a significant effect Group Management Association, in tions, she says. on nephrology practices. They are Englewood, Colo. As external rela- provisions that call for reimburse- tions liaison, Miller coordinates Practice Analysis ment based on average sales price MGMA advocacy efforts with other Most MGMA members are analyzing plus 6% (rather than the earlier specialties and medical organizations. their business operations to determine method which was based on the In fact, some practices that can no the effect of ASP on their practices, average wholesale price). One of the longer offer drug therapy services have Miller explains. “Clearly, nephrologists most significant aspects of the act is shifted patients to a hospital outpa- need to understand the impact of the Medicare Part D, the prescription tient setting, she adds. MMA in order to ensure the future drug plan for senior citizens. The Some nephrologists also have found viability of their practices,” she says. third aspect of the act that may have a need to be more aggressive in negoti- “But across specialties, some physicians a significant effect on practices is the ating the price of drugs, especially now are asking themselves, ‘Do I have the competitive acquisition program, that red blood cell growth factor has time and the resources for such an which would give practices a new been added to the list of drugs reim- analysis?’ Clearly, because of the extent way to acquire medications. bursed at ASP plus 6%, Miller adds. of these reimbursement changes, most “Some practices are joining group pur- practices are finding that it is well Average Sales Price (ASP) chasing organizations, while others are worth the time spent to analyze the As a result of the legislation, physi- simply trying to bargain with pharma- cost of the provision of care so that cians are being reimbursed for the cost ceutical distributors more strongly,” they can determine the break-even of medications based on ASP plus 6%. she says. “Because they command a point under the new reimbursement The ASP plus 6% rate for each drug is greater market share, larger practices system.” based on data provided by the manu- are more likely to be able to negotiate To accommodate ASP reimburse- facturers to the federal Centers for successfully with the drug distributors.” ment, St. Clair Specialty Physicians Medicare & Medicaid Services Robert Provenzano, MD, a nephrol- has tried to maximize the number of (CMS). ASP incorporates all aspects ogist and chief operating office of St. appropriate patients with anemia who of sales prices, including any rebates, Clair Specialty Physicians in Detroit, receive treatment. “We have a system discounts, or other considerations that agrees. “Larger practices may be able to to flag anemic patients for referral to the manufacturer may give to its negotiate a lower drug price,” he says. one of our anemia clinics,” Provenzano largest buyers. For nephrology prac- “If so, they will have to outlay less cap- says. “That way, we can maximize the tices, the move from AWP to ASP ital for inventory.” Provenzano is a percentage of our anemic patients who plus 6% affects all Part B drugs. member of the editorial board of CKD are treated, improving care quality as As mandated under MMA, reimbursement on bundled drugs in 2006 is 106% of ASP versus payment at 95% of AWP in 2003. As a result of these changes, total reimbursement to nephrologists has declined sharply since 2003. 6 Practice Options/October 2006
  7. 7. “Nephrologists need to understand the impact of the MMA in order to ensure the future viability of their practices,” says Jennifer Searfoss Miller, JD, of the MGMA. “But across specialties, some physicians are asking themselves, ‘Do I have the time and the resources for such an analysis?’” well as optimizing the efficiency of our to list all of the drugs they take and doughnut hole occurs for patients who anemia management program.” ensure that these drugs are covered by are not receiving subsidy once they the formulary of any plan they are use $2,250 in prescription drug bene- Medicare Part D considering,” she adds. fits and before they use $5,100 in ben- Medicare Part D is another aspect of Also, physicians can highlight a few efits. The patient is responsible for the MMA that is affecting nephrology important issues that patients should 100% of all costs between the $2,250 practices. “Patients of all physicians, consider when selecting a plan. First, and $5,100. including nephrologists, are asking for Medicare beneficiaries may not be Finally, Miller says, patients should guidance regarding plan choice,” familiar with utilization management also be aware that there might be an Miller says. “But physicians should features typical of managed care plans. arduous appeals process if coverage of definitely not recommend specific Nephrologists may want to explain a drug prescription is denied. Part D plans to their patients.” these features, which prescription drug Miller cannot say whether Physicians should avoid making plans are likely to incorporate. “For Medicare Part D has affected the care plan recommendations because their example, a number of drug plans nephrologists provide. “But a scenario objectivity could be questioned if they require prior authorization,” Miller in which a nephrologist prescribes a have relationships with pharmaceuti- says. drug for a patient and learns that the cal companies or health plans affiliat- Some plans may have tiered benefit drug is not on the patient’s drug plan ed with the Part D plans they recom- levels, in which generic drugs would is likely,” she says. Although formula- mend, Miller comments. “Besides, have a low copayment, preferred ries must include at least two drugs physicians don’t really have the time brand name drugs would have a high- from each class, nephrologists may for Part D plan analysis,” she adds. er copayment, and nonpreferred drugs have to use an alternative drug if the Understanding the appropriateness of would have the highest copayment. initially desired drug is not on the for- the available plans for each patient Step therapy is another pharmacy mulary and the alternative is equally could be quite burdensome, she says. management tool. Under step thera- effective. “CMS has very clearly stated that py, a drug plan would require a patient Certainly, Medicare Part D has cre- physicians should counsel patients to to try the least expensive drug first ated additional complexity for med- learn more about the plans them- when multiple drug options exist. The ical practices, and nephrologists need selves,” Miller says. For patients seek- plan will cover a more expensive drug to understand their own role in satis- ing information about Part D, physi- only if the physician can show that fying each plan’s specific utilization cians can direct patients and their the less expensive drug is either harm- management requirements. For exam- families to the Medicare site on the ful or not effective. ple, the need to obtain prior autho- Web (at www.medicare.gov) to Some plans offer coverage when rizations can increase the administra- review Part D plan formularies. patients reach the doughnut hole in tive burden on nephrology practices, “Physicians should encourage patients Medicare Part D coverage. The Miller notes. (Continued on page 8) Physicians may want to get information from the Web. Epocrates Inc., a company in San Mateo, Calif., (at www.epocrates.com) provides plan specific data, including formulary information and whether prior authorization is required. From the site, physicians can download for- mularies onto a handheld device. Practice Options/October 2006 7
  8. 8. MEDICARE REFORM (Continued from page 7) The CAP Program about CAP. “First, individual physi- one gets paid and the vendor can As stipulated in the MMA, physi- cians within a group practice may attempt to obtain reimbursement cians will have the option of using not opt into the CAP program,” directly from the patient.” the Competitive Acquisition Miller explains. “Either all of the Provenzano does not expect CAP Program (CAP) to acquire drugs. physicians in the practice must par- to be a viable alternative for most Once CAP is in place, physicians ticipate for all of the drugs covered nephrology practices. “CAP is not will be able to choose to accept reim- by the CAP, or none of the physi- likely to be attractive to large prac- bursement based on ASP plus 6% for cians can participate,” she says. tices, because they would be forego- most, but not all infusible and Second, CAP participation would ing the drug margins on Medicare injectable Part B drugs administered in the office setting, or to participate in the CAP program. Practices “In order to participate in the CAP program, choosing CAP will receive medica- tions from BioScrip Corp., a special- a practice must maintain two different ty pharmacy company in Elmsford, processes for obtaining drugs. One would be N.Y. In April, CMS named BioScrip to be the specialty pharmacy provider for the Medicare fee-for-service patients and for CAP. BioScrip will ship medica- one would be for private-pay patients,” says tions to a doctor and will bill the Medicare program directly. Jennifer Searfoss Miller, JD, of the MGMA. CMS has said there are several ben- efits for physicians who choose to par- ticipate in CAP. For example, physi- add to the practice’s administrative patients and would still be responsi- cians would not need to tie up their burden. “In order to participate in ble for keeping stock on hand for capital in an inventory of drugs or col- the CAP program, a practice must commercial patients,” he explains. lect beneficiary co-payments. Experts maintain two different processes for “If CAP is complicated or adds to the advise physicians, however, to evalu- obtaining drugs,” Miller says. “One practice’s administrative burden, ate the program carefully. “The CAP would be for the Medicare fee-for- even small practices may not choose is meant to be an alternative for physi- service patients and one would be for to participate, but rather may simply cians who no longer want to be in the private-pay patients and Medicare stop offering anemia treatment.” business of buying and billing for med- patients taking drugs not covered by “In general, most physicians prob- ications,” says Miller. the CAP,” she adds. ably do not fully understand the The CAP program was scheduled A third concern relates to the com- CAP program, and may make deci- to begin Jan. 1, but was postponed. plexity of the program and the physi- sions based on incomplete informa- In April, CMS said the program cian’s financial risk. “When physi- tion,” Provenzano says. would begin on July 1, and that more cians communicate with the vendor Determining whether to partici- information would be forthcoming. to obtain a drug, they are essentially pate or not will require a thorough Unless changes are made, Miller submitting a claim,” Miller says. review of the advantages and disad- believes CAP may not be attractive “Then, another claim is submitted vantages of CAP. “Nephrologists will to many practices. “Unless they are after administration to the Medicare have to analyze the use of all drugs by taking significant financial losses on contractor for the administration of all physicians in the group,” Miller drugs under ASP reimbursement, the drug. The practice must include says. “Reimbursement will vary quar- practices that have evaluated the many modifiers and additional coding terly, but acquisition cost will not CAP program have not found it information. If the appropriate infor- realistically vary each quarter.” appealing,” she says. mation is not included or if the infor- —Reported and written by Deborah J. Experts have a number of concerns mation is incorrect in some way, no Neveleff, in North Potomac, Md. “CAP is not likely to be attractive to large practices, because they would be foregoing the drug margins on Medicare patients and would still be responsible for keeping stock on hand for commercial patients,” says Robert Provenzano, MD, of St. Clair Specialty Physicians. 8 Practice Options/October 2006
  9. 9. REIMBURSEMENT Minnesota Group Gets P4P any experts advocate paying of what effect P4P will have on There’s fee-for-service, capitation, M more to physicians who meet performance measures and follow treatment guidelines. nephrology practices. “There are very, very few health plans offering pay-for-performance initiatives for and salary, and they are all bad,” says Leonard Schaeffer, MD, who until he retired earlier this year was chairman Toward that goal, health plans and the treatment of chronic kidney dis- of WellPoint Inc., a large managed the federal Centers for Medicare & ease,” says Robert Provenzano, MD, a care organization in Indianapolis. Medicaid Services (CMS) are devel- nephrologist and chief operating offi- “Pay for performance can improve oping and using pay for performance cer of St. Clair Specialty Physicians the quality of care, improve value in (P4P) initiatives to improve quality. in Detroit. “The few that have dab- what we pay for, and encourage the While P4P is not widespread among bled in it have yet to go into it a big adoption of information technology nephrology practices, a nephrology way.” Provenzano is also the presi- and electronic medical records.” group in Minnesota has been involved dent of the Renal Physicians in a P4P program for the treatment of Association, a professional organiza- Costs and Quality patients with CKD for two years. tion in Rockville, Md. The common goal of all P4P pro- Michael G. Somermeyer, MD, a Although more than 100 health grams is to make evidence-based nephrologist with the 16-member plans offer P4P initiatives to primary medicine the standard of care, says Kidney Specialists of Minnesota in care physicians, few have developed Schaeffer. Wellpoint pays perfor- Robbinsdale, Minn., says the effort programs for specialists and fewer still mance bonuses to primary care physi- has been beneficial to patients and have programs for physicians who cians who demonstrate improved physicians. “We think it will be the treat patients with CKD. clinical outcomes, use evidence- wave of the future,” he adds. Michael Germain, MD, a nephrol- based medical procedures, improve ogist with Western New England prescribing rates, implement infor- Improving Quality Renal & Transplant Associates in mation technology, and have high “Whether physicians like it or not, it West Springfield, Mass., says, “In levels of patient satisfaction. The is quickly becoming the gold stan- some very strong managed care mar- company is designing P4P programs dard of many health plans and the kets, such as Minnesota and southern for specialists, including nephrolo- government,” Somermeyer com- California, there are a few contracts gists, Schaeffer says. Initial efforts ments. “Public statements from CMS for nephrologists treating patients have involved collecting data on officials are filled with allusions to with CKD. The devil’s in the details, end-stage renal disease (ESRD) treat- the fact that CMS plans to go head- however. There hasn’t yet been that ment, and CKD likely will follow. long into P4P. It’s not a matter of if; much done in this area for us to know As Wellpoint is doing, Somer- it’s when. Our experience with P4P its effect on the quality of care.” meyer’s group began its involvement has been very positive. We believe Jeff Weintraub, chief executive with P4P under an ESRD disease that it improves the quality of care.” officer of Southwest Kidney Institute management initiative in 2002. “We P4P programs involve paying more in Tempe, Ariz., believes that effec- believed we could apply the same to physicians based on their perfor- tive P4P programs can lead to a sig- principles to CKD, and the health mance in meeting predetermined nificantly improved continuum of plans agreed,” Somermeyer says. quality metrics. Most P4P programs care and early diagnosis. “Good pro- Today, Kidney Specialists of provide modest financial bonuses of grams create a model structure of Minnesota has P4P contracts for the 1% to 5% of a physician’s total rev- care,” he says. treatment of patients with CKD with enue from a specific plan. Some health plan executives agree. UCare Minnesota in Minneapolis Since there are so few programs in “Right now there are three ways we and Medica, a nonprofit health plan place, some nephrologists are unsure pay doctors, including specialists. in Minneapolis that is affiliated with (Continued on page 10) “The few health plans that have dabbled in P4P have yet to go into it a big way.” —Robert Provenzano, MD, St. Clair Specialty Physicians Practice Options/October 2006 9
  10. 10. REIMBURSEMENT (Continued from page 9) UnitedHealth Group. tions overlook important opportuni- lends itself well to disease manage- The group gets a bonus based on ties to improve care and control costs ment and P4P programs because it meeting specific measures, such as through disease management and has a predictable linear progression monitoring for and treating patients P4P initiatives targeting CKD,” says and has easily measurable, standard- with anemia, Somermeyer says. Michael Baxley, MD, regional med- ized laboratory markers on which to Other measures include monitoring ical director for AmeriChoice, a construct clinical pathways for mon- lipid levels and hypertension, and health plan in Chicago that serves itoring disease progression and com- monitoring for comorbidities associ- government employees. Ameri- plications,” he explains. “The ated with CKD. Choice is part of UnitedHealth K/DOQI guidelines for CKD provide Group, the large managed care orga- explicit, proven approaches for National Efforts nization in Minneapolis. “Most man- delaying progression and treating Somermeyer and other nephrologists aged care professionals appreciate the comorbidities.” believe P4P programs for CKD will long-term benefits of successfully Experts agree that the K/DOQI become more common over the next managing chronic illnesses,” he says. guidelines could be used with any several years. Later this year, CMS P4P program. “The progression of will start a P4P program for the treat- K/DOQI Guidelines CKD can be kept under control, both ment of patients with ESRD as The guidelines from the National financially and at the level of patient required under the Medicare Kidney Foundation’s Kidney Disease health, through the optimal use of Prescription Drug Improvement and Outcomes and Quality Initiative guideline-driven treatment,” says Modernization Act of 2003. The act would be ideal for implementation in David B. Nash, MD, director of the requires CMS to develop a three-year any P4P program, says Somermeyer Office of Health Policy and Clinical demonstration project to test a case- whose group follows these guidelines. Outcomes at Thomas Jefferson mix adjusted payment system for a Known as the K/DOQI guidelines, University Hospital in Philadelphia. bundle of ESRD services. A portion they have been in place since 2002. “The benefits of increased clinical of the payment will be linked to Baxley agrees, saying, “The attention to CKD guidelines extend ESRD-related quality measures. The K/DOQI guidelines are a useful start- to patients and the health plans that demonstration is scheduled to begin ing point for managed care organiza- serve them.” The goal of any guide- later this year. tions developing P4P initiatives. lines is optimal care, he adds. CMS may follow the ESRD Health plans should expect nephrol- For patients with CKD, nephrolo- demonstration project with a similar ogists to use the guidelines to define gists delivering quality care would project for the treatment of patients the five stages of CKD and to follow begin disease detection at an early with CKD, says Barry M. Straube, the interventions prescribed for stage, provide treatment aimed at MD, the chief medical officer for patients at each stage. The guidelines delaying progression of the disease CMS Region IX (California, are still fairly new, so they are just and prevent complications (such as Arizona, Hawaii, and Nevada). For starting to be in widespread clinical anemia, malnutrition, osteodystro- CMS, any proposed CKD demon- use.” In addition, efficiency of care phy, and acidosis), and treat comor- stration projects would focus on could be a factor in P4P programs, bidities (such as cardiac disease, vas- chronic disease management, but health plans have yet to develop cular disease, and diabetes), patient-physician partnership, reduc- ways to measure efficiency among Provenzano says. Guidelines are use- ing costs, increasing efficiency, and specialists, including nephrologists, ful for each of these goals, he adds. rural health delivery, Straube says. he comments. The quality of CKD services, as mea- Guidelines, particularly those from Words of Caution sured in a demonstration project, K/DOQI, also are useful to physicians Nash adds a caveat, however. “We could lead to P4P, he adds. seeking to develop the internal dis- have to remember, especially if we National health plans also may ease management techniques applic- consider using guidelines for any pay move toward P4P for patients with able to meeting health plan quality for performance measures, that they CKD. “Many managed care organiza- initiatives, adds Somermeyer. “CKD are merely guidelines,” he says. “They “It’s the wave of the future. Whether physicians like it or not, it is quickly becoming the gold standard of many health plans and the government.” —Michael G. Somermeyer, MD, Kidney Specialists of Minnesota 10 Practice Options/October 2006
  11. 11. should never be used as rigid rules.” Guidelines are a good starting point for evaluating physicians, UnitedHealth Group Provenzano adds, but could lead to rigidity of care. What’s more, the Develops P4P Metrics nitedHealth Group has long been a proponent of P4P initiatives, effectiveness of guidelines is unknown, he adds. Nephrologists also are concerned about using guide- U says Mark C. Rattray MD, national medical director for the UnitedHealth Premiums Designation program. “Our intention is to lines because they would likely need determine methods to reward specialists who demonstrate effective and to implement sophisticated informa- cost-conscious treatment methodologies, including non-proceduralists tion systems, which can be extremely such as nephrologists,” Rattray says. costly, he cautions. The Premium Designation program uses various standards to measure “We don’t want to end up subject performance and adherence to guidelines among physician practices. In to the law of unintended conse- the program, UnitedHealth divides medical specialists into procedural- quences with a system that not only ists (such as surgeons), and non-proceduralists (such as allergists, neurol- costs more but in which patients do ogists, pulmonologists, and nephrologists). Those physicians who hit cer- worse,” Provenzano says. “What’s tain targets get rewarded with more referrals and bonuses. UnitedHealth worrisome is whether nephrologists defines the program us a P4P initiative, Rattray says. will place too much emphasis on The UnitedHealth Premium Designation program collects 24 months complying with performance mea- of national data on measures, applies quality screens to create specific sures that carry rewards and not metrics, designates physicians meeting the criteria, conducts subsequent enough on important measures of analysis and analyzes regional efficiency benchmarks; and designates appropriate care that do not.” physicians who meet or exceed comparative market cost criteria. Officials of the American Medical Started last year, the program has focused primarily on hospitals. Association and the Medical Group UnitedHealth is still collecting data on specialists, says Rattray. Non-pro- Management Association have ceduralists will be evaluated for treatment efficiency in episode treatment voiced similar concerns, saying P4P groups tied to a condition. In addition, they will be evaluated for com- programs impose unnecessary admin- pliance with guidelines and clinical rules developed by agencies such as istrative burdens on physicians. They the National Committee for Quality Assurance and professional organi- express concern that no one knows zations such as the National Kidney Foundation. how big a bonus needs to be to make Quality metrics would be drawn from established national guidelines a difference in quality, and whether and standards. Efficiency of care would be measured at a local market incentives will be sufficient to pro- level, Rattray says. The evaluation would be done by specialty, compar- mote appropriate utilization without ing individual physicians with other specialists in their own market. The creating incentives to underutilize data would be case-mix and severity adjusted to reflect individual physi- other necessary tests and services. cian practices. P4P critics also say that no one The overall focus on specialty practices in any P4P initiative would be knows what information technology on patient safety, compliance with guidelines, sequencing of care, and systems providers should adopt procedural effectiveness. “Guideline compliance would be the single to comply with P4P guidelines, or who most important element of any P4P initiative at the physician level,” should pay for this technology. AMA Rattray says. —MS and MGMA officials are concerned about what adjustments should be addressed, Weintraub of Southwest inevitable role in CKD treatment,” made to P4P programs designed for Kidney Institute expresses the view he says. “They will grow in populari- specialists as compared with those of many nephrologists and practice ty among health plans.” designed for primary care physicians. administrators. “We expect these —Reported and written by Martin Sipkoff, in While all of these issues need to be programs to play an important and Gettysburg, Pa. “The devil’s in the details. There hasn’t yet been that much done in this area for us to know its effect on the quality of care.” —Michael Germain, MD, Western New England Renal & Transplant Associates Practice Options/October 2006 11
  12. 12. BUSINESS MANAGEMENT Recruiting the Best Nephrologists hen a nephrology practice from training programs cannot keep vacation time, reasonable call sched- W is growing, the partners must work harder and at the same time recruit new practition- up. The number of open positions for nephrologists far exceeds that of renal fellows entering practice. ules, clinical work limited to nephrol- ogy, adequate support staff, and short travel times to dialysis centers. ers to take up the slack. But before The United States Renal Data Seasoned nephrologists also are adding staff, nephrologists should Systems, in Minneapolis, reports that interested in lifestyle considerations. consider the options carefully, the prevalence of patients with end- because new staff will shape the prac- stage renal disease is expected to Recruitment Delays tice’s future direction, says Martin H. increase to 650,000 by 2010, mean- But once a nephrologist is hired, it Osinski, president of Nephrology ing there will be 160 or more ESRD can still take 12 to 14 months to USA, a recruiting and consulting patients for each practicing nephrol- acquire a state license, find malprac- firm in Miami. ogist within four years. tice coverage, and get hospital privi- Practices have several options, says Meanwhile, Osinski reports that leges, says Bruce Guyant, manager of Osinski, who has 20 years of experi- the supply of fellows is limited by nephrology operations for Comp- ence in nephrology recruiting. They funding for nephrology fellowship Health, a recruiting company in Salt can hire a young nephrologist out of positions. In addition, more graduat- Lake City. Also, the new physician fellowship training, a seasoned ing fellows are specializing in inter- will likely need time to sell a home, nephrologist, or a midlevel practi- ventional nephrology and transplan- buy a home, and wait for his or her tioner, such as a physician assistant or tation than they were in the past, he children to complete the school year. nurse practitioner. This third option adds. While many practices in desir- The wait will be shorter if the recruit is becoming increasingly popular. able locations may have little prob- is nearby, Guyant says. A growing number of nephrology lem finding nephrologists, practices In general, it is difficult to place practices are turning to midlevel in less desirable cities and towns are nephrologists anywhere except the practitioners, rather than hiring a struggling to find new hires, he says. East and West coasts or in rural areas, new physician. With supervision, And, all practices will feel the short- Guyant says. Also, it is easier for a midlevel practitioners can assume age soon, he adds. group to hire a new nephrologist some of the work that physicians than it is for a solo practitioner to would do otherwise, such as primary Upward Mobility hire one because candidates suspect care, following up on office visits, and Another problem is that many new solo practices are less stable than working with dialysis patients. They hires no longer wish to stay in one groups. also staff chronic kidney disease clin- place, Osinski says. “There’s a tenden- Practices having trouble filling ics and vascular access centers. cy for doctors to look at opportunities positions can hire a locum tenens more as jobs than as careers,” he com- physician (which can be more Finding a Match ments. “They’re apt to see a better expensive than hiring a full time It’s time to start planning for recruit- opportunity elsewhere and move on.” physician) or might consider hiring a ment when each nephrologist in a Since physicians are willing to physician nearing retirement, practice is seeing more than 75 dialy- move, more seasoned nephrologists Guyant says. Since older doctors gen- sis patients, Osinski says. And, that may be available for recruitment, erally want to go to the Sun Belt and number should be lower if the doc- Osinski says. About half the nephrol- are looking for less strenuous work, tors have significant travel time to ogists he places are mid-career physi- hiring one may not be a solution for dialysis centers and hospitals. cians looking for a new practice, and every practice, he adds. “But every Hiring a young nephrologist from a unlike new doctors, they tend to day that a spot is unfilled and renal fellowship program can be diffi- know exactly what they want. They patients are not being served, repre- cult since the demand for nephrolo- focus on higher compensation, oppor- sents literally thousands of dollars to gists has been growing and supply tunity to become a partner, more the clinic,” he says. Non-nephrologists will be needed to play a larger role as nephrology practices wrestle with higher patient volume. 12 Practice Options/October 2006
  13. 13. Beyond Nephrologists Recruiting another nephrologist, how- ever, may not be the answer. Much of What Practices Want From PAs he following are some required duties for nephrology physician assis- the work in a nephrology practice can be done by someone else, such as a midlevel practitioner or even a gener- T tants listed in recent job postings: • On-call time al internist, recruiters say. • Dialysis rounds Non-nephrologists will be needed to • ER evaluation play a larger role as nephrology prac- • History and physical tices wrestle with higher patient vol- • Hospital rounds ume. In addition to the rapid growth of • Management of anemia patients in a weekly clinic patients with end-stage renal disease • Office practice (ESRD), clinical practice guidelines • Transfer and discharge planning call for a greater role for nephrologists • Work in a team with clinical nurse managers, social worker, and in the treatment of chronic kidney dis- nephrologist. ease (CKD). Source: Job postings on the Web site of the American Academy of Nephrology Physician The flood of patients will force Assistants (at www.aanpa.org). nephrologists to reduce or eliminate their traditional role of primary care One key impetus for midlevels is • Are more likely to follow practice providers for ESRD patients, says Kurt Medicare’s two-year-old payment sys- guidelines, and following guidelines Mosley, vice president for business tem for treating dialysis patients. The is essential in meeting clinical out- development at The MHA Group, new G-code system replaces a flat comes, which increasingly are being physician recruiters in Irving, Texas. monthly fee with graduated payments tied to payments. For this reason, some nephrologists based on the number of visits. • Are hard workers. A 2004 survey by may consider using general internists Nephrologists who see patients once a the American Academy of to do primary care with patients, he month are paid less than they were Physician Assistants found that, on adds. There are no significant obstacles before, but they are paid more if their average, PAs work 45.5 hours and to such a strategy, either in billing or practice sees these patients four times a have 80 to 85 outpatient encounters obtaining hospital privileges, although month. Under the new rules, a mid- a week and almost one quarter of the generalist should get some extra level provider can see these patient the them shared call with physicians. training from a nephrologist. other three times. Robert Provenzano, MD, president In this way, mid-level practitioners PAs or NPs of the Renal Physicians Association free up nephrologists to see more Nurse practitioners and physician (RPA), says his multispecialty practice patients. “All physicians, and particu- assistants tend to get lumped together, in Detroit, St. Clair Specialty larly nephrologists, are facing but there are some key differences Physicians, has 11 general internists increased patient volumes and between them. NPs can work inde- along with 18 nephrologists. A gener- decreased time,” Provenzano says. pendently in some states and they earn al internist provides general medicine “They have to spend less time with somewhat more than PAs can earn. to nephrology patients, Provenzano each patient.” And since NPs started as RNs and says. One potential problem with using Among the assets of midlevel practi- often have worked for many years as a general internist in a specialty prac- tioners are the following, Provenzano front-line nurses, they tend to put a tice is that referring internists in the says. They: strong emphasis on patient care. community might view the general • Can perform a wide variety of tasks, On the other hand, PAs are trained internist as a threat and send referrals such as working in dialysis facilities, to support physicians and always must elsewhere, he adds. seeing patients in office practices, work under a physician’s supervision. making hospital rounds and even PAs can round and write notes on Midlevel Practitioners taking call. their own, but they cannot write To help share the workload, St. Clair • Are trained to cooperate collabora- orders, Provenzano says. “If they want- Specialty Physicians has five nurse tively in a team. Collaboration is ed to give an order they have to call a practitioners. “We’re seeing more and important because the midlevel physician and the physician would more practices moving in this direc- practitioner is often used to take have to personally convey the order to tion,” Provenzano says of using nurse over office visits after the nephrolo- the unit nurse,” he explains. practitioners. gist makes the initial assessment. At last count there were 106,000 (Continued on page 14) Practice Options/October 2006 13
  14. 14. BUSINESS MANAGEMENT (Continued from page 13) NPs and 59,000 PAs working in the NP with a primary care background, new midlevel practitioners when it United States, but the greater ranks of but she was unhappy with nephrology opened a vascular access center. “We NPs does not mean they are easier to and quit to return to primary care. were looking for people who know hire. While NPs are available across Still, Weintraub wants to hire midlev- that kind of work or want to learn it,” the country and practice independent- el professionals. “We now have two Weiss says. ly in some rural areas, PAs are concen- NPs but I would be thrilled to have The group now has four NPs and trated on the East Coast and work five,” he says. “But NPs experienced in two PAs, who coordinate the patient’s exclusively with physicians. dialysis are hard to find right now.” transition from the hospital back to Nephrology accounts for a tiny frac- One solution is to encourage in- the dialysis unit, and the practice plans tion of what midlevel practitioners do. house staff to get midlevel certifica- to use them for office follow-ups. In a 2004 survey by the American tion, Weintraub comments. Dialysis “They explain or amplify what the Academy of Physician Assistants, technicians and nurses would make physician is saying to the patient,” 0.5% of PAs said they worked in ideal nephrology NPs because they are Weiss adds. nephrology. The American Academy already familiar with the work and of Nurse Practitioners reports that enjoy it, he adds. He is currently pay- A Team Approach most NPs tend to be in family practice ing for one tech in his practice to train Since patients may feel slighted and other primary care fields, and 20% to be a nurse. He would consider pay- when they are handed off by the are in adult care, which covers a wide ing for a nurse’s NP training, he says. nephrologist to the midlevel profes- variety of specialties including sional, Weiss advises doctors to nephrology. Integrating Care introduce the PA or NP to the Nephrology practices report that when patient as part of a team that will pro- Focusing on Training midlevel professionals are hired, they vide care. “For dialysis patients, I Since there are no formal training pro- are typically assigned one specific job explain that I’ll be seeing them once grams for midlevel practitioners in and then are given more tasks when a month and the mid-level practi- nephrology, they have to be trained on physicians and staff become more tioner will see them three times a the job. “In training, midlevel practi- comfortable with them. David month,” Weiss says. “Almost always, tioners will apprentice with a physi- Rathvon, a PA at Capital Nephrology the patients accept the arrangement. cian for a period of time, maybe three in Raleigh, N.C., says he was the first The patients see that now two people months,” Provenzano says. “They go midlevel professional the practice (the PA and the physician) know to the dialysis unit, the hospital, the hired eight years ago. His first assign- them well.” clinic.” ment was providing primary care for Weiss challenges the widespread The RPA is considering a formal dialysis patients. Today, the six- notion that midlevel practitioners, training program for midlevel practi- nephrologist practice has four full-time who are paid about one-third of tioners, using nephrologists to mentor midlevel practitioners and one part- what nephrologists make, can save them, Provenzano comments. timer. In addition to working with money for the practice. “If you hire a Once trained, midlevel professionals dialysis patients, he and other midlev- PA or NP in order to make more tend to stay put for many years. The el professionals treat CKD patients and money, you will be disappointed,” 2004 AAPA survey found that on handle follow-up visits in the office, Weiss says. “There are also some average, nephrology PAs had been but they don’t insert lines or perform redundancies and inefficiencies with their current practice for more biopsies, he says. when two people see a patient, no than six years, and some had been with “People used to be hesitant about matter how well they work together,” the same group for 10 years. how PAs and NPs would fit in, but he explains. “But it’s safe to say that But some midlevel professionals there has been a huge shift in opinion NPs and PAs can do some clinical move on, especially when they come in the past 10 years,” says James Weiss, activities that would otherwise from another specialty. Jeff Weintraub, MD, a nephrologist at Renal Endo- require a physician’s time.” CEO of Southwest Kidney Institute, crine Associates in Monroeville, Pa. —Reported and written by Leigh Page, Tempe, Ariz., says he once hired an The practice recently hired three in Chicago. “We now have two NPs but I would be thrilled to have five,” says Jeff Weintraub of Southwest Kidney Institute. “But NPs experienced in dialysis are hard to find right now.” 14 Practice Options/October 2006
  15. 15. CASE STUDY Practice Aims to Increase Efficiency he nephrologists and endocri- Medicaid does not pay for dialysis your time that goes to all of the sup- T nologists in Renal Endocrine Associates in Pittsburgh, Pa., are developing several strategies care. Medicaid pays the dialysis facil- ity for the services provided but does not pay for the physician’s care relat- portive efforts, especially the paper- work, malpractice issues, along with hospital requirements,” he adds. “If aimed at increasing practice efficien- ed to dialysis. Similarly, for patients you work a 12-hour day, you’d like to cy. Given that the greater Pittsburgh who are eligible for Medicare and feel that at the end of 12 hours, a sig- area has one of the highest concen- Medicaid, the practice gets paid only nificant number of the patients trations of Medicare patients in the for the Medicare portion of the care, you’ve seen that day had received country, the group faces unusual Simonton says. high quality care as opposed to feel- challenges. “You get what you get from ing that you spent an excessive per- Reimbursement has declined Medicare and you don’t get anything centage of your time dealing with as a result of the Medicare Prescription else,” she says. “But in other states, administrative issues.” Drug Improvement and Moderniza- practices will get perhaps 20% from tion Act of 2003 and so the group has Medicaid for dual-eligible patients. Evaluating Options been forced to find ways to become These days, that 20% after Medicare As a result of the administrative bur- more efficient while continuing to can make a significant difference. If den and decreased reimbursement, the meet its commitment to provide high you have a reasonable Medicaid pop- practice has made changes. To offset quality patient care, says James Weiss, ulation, at least you know you’ll get the loss of income that it had before MD, one of 16 physicians (11 nephrol- that 20%.” But if a patient has the MMA went into effect, the group ogists and five endocrinologists) in the Medicaid as a primary insurer or is in has been developing a CKD clinic to practice. The group has 50 employees a Medicaid HMO plan, the practice treat patients, opened a vascular access including six physician extenders gets no reimbursement for providing center, is expanding a clinical research (nurse practitioners and physician dialysis care to those patients. facility, and is seeking to generate rev- assistants). Some 80% of its patients “Our biggest challenge is trying to enue from real estate ownership. are on Medicare. maintain high quality care and an “We started our vascular access cen- “For a group like ours, Medicare is acceptable lifestyle for the physicians ter in January,” says Weiss. “That is by far the dominant force in this mar- and staff in this setting,” Weiss com- going very well and it provides high ket,” says Weiss. ments. “We often have discussions quality care. It provides much better about how we can offer high quality service for our patients than we could Market Challenges patient care, while running a success- provide before and brings in some Lisa Simonton, the group’s executive ful business, and also having some extra money that helps to offset the director, adds that private payers also kind of a quality lifestyle. We want to financial difficulties of delivering care present hurdles. “The private payers have a good mix of all three. We need in the office. bring their own challenges,” she says. to be cognizant of the different needs “We’re also seeking to improve the “In recent history, as Medicare has of physicians who are at different financial standing of the practice by changed its rules and regulations relat- stages in their career and family life. getting involved in investing in proper- ed to the care of dialysis patients, the “Of course the staff and physicians ties and in joint real estate ventures,” private payers have had to catch up or also want to feel some satisfaction so he adds. “We’re early in the process. decide if they were going to catch up that at the end of the day they feel We’re the landlords for one of the dial- with Medicare rates, and because they good about what they have done that ysis units where we work. are so dominant in our marketplace day and not feel as if they’re further “The other thing we’re doing is you do what they want or you don’t behind than when they started the expanding our clinical research,” he participate with those plans.” day,” Weiss says. “There’s a percent- says. “We are early in that process as Another challenge that makes age of your time that goes to patient well, but these are steps that we believe Pennsylvania unusual is that care and there’s a large percentage of will help us to diversify the group’s (Continued on page 16) “We started our vascular access center in January. That is going very well and it provides high quality care for our patients.” Practice Options/October 2006 15
  16. 16. CASE STUDY (Continued from page 15) activities and to support us in delivering quality patient care. RPA Offers Practice Strategies Clinic Visits ames Weiss, MD, and Lisa Simonton, MBA, of Renal Endocrine The CKD clinic offers an example of how the practice seeks to offer care J Associates in Pittsburgh, Pa., have been involved with the Renal Physicians Association for many years. Each one says the RPA has proven to more efficiently. “We have heard about be a valued resource for them in managing the practice outside Pittsburgh. other groups that have opened CKD The RPA is a national medical specialty association in Rockville, Md. clinics and we are looking to adopt “We are indebted to what the RPA has provided us in terms of education some of those ideas,” Weiss explains. “In about how to run an effective practice,” says Weiss, the association’s past the clinic, the physician would see the president. “A large percentage of our ideas and resources have come through patient on the first visit. Then, if the the RPA. We would be much further behind if we were not involved with patient fits into one of several cate- the RPA.” gories, he or she would be seen during the year by a physician assistant or by a would give providers the reassurance with the initial contact with the physi- nurse practitioner on subsequent visits. that we are all doing what we want to cian assistant and once the patient sees Maybe on every third visit, the patient have done,” explains Weiss. “And they that the doctor and assistant will be would see the physician. The clinic staff help reassure patients too because the working as a coordinated team.” would have protocols and algorithms to patients want to know that the care The CKD clinic would allow the follow that would mean we would mon- we’re giving has been structured and practice to be reimbursed at the physi- itor key care factors such as hemoglobin, reviewed by physicians. “Some patients cian rate if there is a physician in the blood pressure, and phosphorous. That express concern about being seen by a office who has a relationship with the would be the overall model. physician assistant instead of a doctor. patient even though the physician did “The protocols and algorithms These concerns almost always dissipate not see the patient, Simonton says. OPTIONS CKD PRACTICE ™ IMPROVING PATIENT CARE THROUGH INCREASED PRACTICE EFFICIENCY October 2006 Premier Healthcare Resource PRSRT STD 150 Washington St. U.S. POSTAGE Morristown, NJ 07960 PA I D Permit No. 664 S.HACKENSACK,NJ Provided as a professional courtesy by 08PCTCC0231 10/06