PYA recently presented “Blips on the Radar—Ground Clutter or Looming Crisis?” at the 2014 Alabama Hospital Association Annual Meeting. Topics covered included: ICD-10—What now? Hospital-Physician Transactions—The compliance wheel Value-Based Payments—What’s up with that? Physician Differentiation—What sets doctors apart?

1. Page 0June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
ICD-10…
What Now?
The Alabama Hospital Association – Annual Meeting
June 12, 2014

2. Page 1June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Agenda
• Updated ICD-10 timeline
• Managing your ICD-10 project
– Planning
– Communications
– Testing
– Training
Planning
Communications
Training
Testing

3. Page 2June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
There’s A Code For That!
Source: http://www.youtube.com/watch?v=GWJQSmqRLRk

4. Page 3June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
There’s A Code For That!
Source: http://www.youtube.com/watch?v=yKYwr31s4bk

5. Page 4June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Updated ICD-10 Timeline
PYA
May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
Planning
Identify resources
Create project team
Assess effects
Create project plan
Secure budget
Communications
Inform staff
Contact vendors
Contact payers
Monitor vendor prep
Monitor payer prep
Testing
High-level training for
test team
Level 1: internal
Level 2: external1
Comprehensive Training
Documentation
Coding
2
October 1, 2015 is the anticipated compliance date for ICD-10.
2014 2015
G
O
L
I
V
E
Confirm ongoing practice schedule to correspond with
new "go live"2
date
1
Monitor external testing periods, especially updates regarding CMS limited testing currently CANCELLED for July 21 - 25, 2014 for selected volunteers.

6. Page 5June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
ICD-10 Project Overview
Successful Go-Live
Training
Testing
Communications
Planning

7. Page 6June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
• Plan for dual ICD-9 and 10 codes for a brief period to address services
rendered before October 1, but discharged after October 1.
• Monitor physician documentation to ensure ICD-10 compliance.
• Monitor impact on claim-processing activity, claim denials, and rejections.
• Audit coder productivity and accuracy.
• Monitor patient satisfaction.
• Post-transition review:
– What’s working?
– What needs fixing?
• Schedule 30-day post-conversion claims assessment.
ICD-10 Go Live, The Day After…

8. Page 7June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Questions?

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Prepared for The Alabama Hospital Association Annual Meeting
Value-Based Payments
What’s Up With That?
The Alabama Hospital Association – Annual Meeting
June 12, 2014

10. Page 9June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
What is a
“Value-Based Payment” Model?
Value-Based Payment:
A payment model which rewards healthcare providers
for meeting certain predetermined performance
measures related to quality and efficiency.
Efficiency: The state or quality of achieving
maximum productivity with minimum wasted
effort or expense.
Quality: The standard of something as
measured against other things of a similar
kind; the degree of excellence of something
“quality of life” also the general excellence of
standard or level.
Value: The regard that something is held to
deserve; the importance or preciousness of
something: “Your support is of great value.”

11. Page 10June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Fundamentals Driving
Clinical Integration and VBP

12. Page 11June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Summary of Hospital VBP
Hospitals are not only
encouraged to promote
quality of care and patient
satisfaction, it is affecting
their
bottom line!
• In FY14, a payment reduction
of up to 1.25%.
The result of
these
measures are
available to
everyone.
Better
performance
equates to
better payments
(and ideally,
better outcomes
for patients).
Summary of
Hospital VBP

13. Page 12June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Physician Value-Based Purchasing
Similar to Hospitals
Physicians are encouraged to place value and performance above production.
Similar to Hospitals
Physician payments from CMS will be affected by the reporting and benchmarking of
these measures.
Similar to Hospitals
Physicians are accountable for reporting on quality measures.

14. Page 13June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Why Report?
•2015:
̶ Based on FY 2013 reporting.
̶ EPs who do not report under
PQRS subject to payment
adjustment of 1.5%.
•2016 and Beyond:
̶ Based on 2014 reporting and
beyond.
̶ EPs who do not report under
PQRS subject to payment
adjustment of 2.0%.
Payment
adjustment based
on percentage of
total estimated
Medicare
Physician Fee
Schedule allowed
charges:
EP –
Eligible
Providers

15. Page 14June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
More Reasons to Report
Physician Feedback Reports
FY15 implementation of physician feedback report adjustments
for physician practices with greater than 100 physicians.
FY17; physician feedback reports will be sent to all physicians in
the country at which point payment adjustments will be made
(similar to Hospital value-based purchasing).

16. Page 15June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Why Clinical Integration and VBP?
• Today’s volume-based, fee-for-service system is
based on independence: each provider is paid for
providing a discrete service, without regard to
others performance.
• Tomorrow’s value-based payment systems,
however, will demand interdependence: providers
will be rewarded for quality and efficiency achieved
through collaborative care

17. Page 16June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Questions?

18. Page 17June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Thank You!
Nancy McConnell
Principal
Pershing Yoakley & Associates, P.C.
(404) 266-9876
nmcconnell@pyapc.com
www.pyapc.com

19. Page 18June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Hospital-Physician Transaction –
The Compliance Wheel
The Alabama Hospital Association – Annual Meeting
June 12, 2014

20. Page 19June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Alignment Perspectives: Physicians
• Financially squeezed
• Decline in reimbursement and loss of income
• Obtaining malpractice coverage at reasonable rates
• Inability or unwillingness to recruit to level that hospitals demand
• Quality of life
• Increasingly complex government oversight
• Overhead and working capital requirements
• Quality pressures
• Healthcare reform

21. Page 20June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Alignment Perspectives: Hospitals
• Increasing payer and public emphasis on standardization, integration,
and consolidation of services in order to drive quality initiatives through
outcomes and evidence- based medicine
• Seeking efficiencies
• Diversifying and focusing on outpatient and wellness care
• Expanding into rural communities where there are not enough primary
care and key specialist physicians to service the community’s healthcare
needs
• Experiencing physician shortages in key specialties
• Competition from physician owned outpatient centers

22. Page 21June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Alignment Perspectives: Hospitals
• Healthcare reform and potential for global reimbursement
• Increase ability to recruit and retain high quality physicians to
the community
• Fill gaps in areas such as call coverage, where physicians are
increasingly unwilling (due to lifestyle demands and/or practice
economics) or unable (due to subspecialization) to provide
emergency room call
• Negotiate better rates with commercial payers

23. Page 22June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Alignment Perspectives: Payers and
Healthcare Reform
Payers
• Consumers more aware of price and quality.
• Baby boomers moving to the Medicare program.
• Medicare and other payers expecting “value” for payment.
• Commercial insurers under pressure from employers to reduce cost.
• Consumers picking up more of the healthcare “tab.”
Healthcare Reform
• Reimbursement changes accelerating alignment of hospitals and physicians.
• Tightening of resources requiring new approaches to the medical staff model.
• Quality, safety, and transparency will affect strategic and operational decisions.
• Capital and IT investments will be dictated by availability of capital resources
and government incentives.

24. Page 23June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Multiple Models for Collaboration
• Contracts
– Physician employment
– Recruitment agreements
– Professional service agreements (PSA)
– Practice acquisition agreements
– Practice support agreements
– Clinical research agreements
• Non-Clinical Joint Ventures
– Facility development/MOB ventures
– Space & equipment leasing companies
– Management companies
– HIT ventures
• Contractual Venture Models
– Service line co-management
– Pay for quality/pay for performance
– Block leasing
– Foundation model
– Centers of Excellence models
– Modified under arrangements models
• Clinical Joint Ventures
– ASCs
– Ambulatory facilities

25. Page 24June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Multiple Models for Collaboration
Physician
Advisory
Council
Extent of Physician Integration
High
High
Costs
Lease
Agreement
Low
Recruitment
Assistance
Clinical
JV
Professional
Services
Agreement Co-
Management
Arrangements
ED Call
Pay
Medical
Director
Management
Services
Agreement
Employment
Foundation
Model

26. Page 25June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
The Compliance Wheel
Physician-Hospital
Alignment
 Strategic/Business Planning
 Physician needs assessments
 Community health needs assessments
 Programmatic
 Legal and Regulatory
 Transaction structure
 Legal opinion
 Term sheet/contracts
 Due Diligence
 Financial
 Operational
 Regulatory compliance
 Documentation
 FMV
 Commercial Reasonableness
 Agreements
 Need
 Regular Audit & Monitoring
 Agreements
 FMV
 Need

27. Page 26June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Questions?

28. Page 27June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Thank You!
Tynan Olechny
Principal
Pershing Yoakley & Associates, P.C.
(404) 266-9876
tolechny@pyapc.com
www.pyapc.com

29. Page 28June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
The Osler Circle:
Differentiating Physicians for
Competitive Advantage
The Alabama Hospital Association – Annual Meeting
June 12, 2014

30. Page 29June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Today’s Discussion
1. Strategic Coherence – what is it
and why does it matter?
2. Current context and limiting
factors.
3. Coherence to what end?
(Differentiation)
4. Sir William and the Five “A”s.
5. Putting it all together – The Osler
Circle.
6. Wrap Up and Questions.

31. Page 30June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Strategic Coherence
(And What’s Holding Us Back?)
Limiting Factors
• In Place: EAs, Non-Competes, Comp
Plans, EHR – We’re Done! Wait…we’re
not?
• Clarity on what remains = continued
default defensive strategy.
• Demonstrating the Value-Add.
Strategic Coherence:
“Organization-wide collaboration, coordination and allocation of
resources to create unique, valuable and sustainable advantages.”
The ability to accomplish as a group, things not possible to
accomplish as individuals.
The Story of the Blind Men and the Elephant

32. Page 31June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Strategic Coherence (contd.)
Coherence Differentiation
Value
Generation
Competitive
Advantage
STRATEGY
Coherence to what end and along what path?
• Answer: Differentiation that creates value
• Competing to be different as a conscious strategy
• If this sounds familiar…it is

33. Page 32June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Competitive Physician
Differentiation
“Over time, if someone is taking your market share overall, or in a particular
specialty…You’ll find there is always a good reason. Most likely it is your poor service,
your bad results, or delayed access.” - Fred Loop, Former CEO of the Cleveland Clinic

34. Page 33June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
The “5 A”s of Physician
Differentiation
1. Availability
- Time vs. patient appointment, vs. waiting room vs. specialist
follow up with PCP.
- Secure Patient Portal and Next Day Appointment availability.
2. Affability
- “When I am your doctor, I try to imagine the kind of doctor I’d like
if I were you. Then I try to be that kind of doctor.” – Charles
Mayo
3. Ability
- Collectively represented by the physician’s experience, training,
outcomes, and reputation and extends to and is impacted by
perception of institutional reputation.
Sir William Osler, 1849 – 1919
Considered by many to be “The
Father of Modern Medicine” and
creator of the medical
residency.
Success in practice depends on: “Availability, affability, and ability, in
that order” – Sir William Osler

35. Page 34June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
The “5 A”s of Physician
Differentiation Contd.
4. Affordability
- The cost of care remains obscure and fragmented and
healthcare consumers have been insulated from the realities of
price for generations.
- However, price sensitivity and transparency is increasing on all
fronts and organizations are beginning to position physicians on
affordability.
5. Accountability
- Accountability is not new to medicine, however two new forms
are emerging:
1) Accountability on “value” of care delivered (combination of
outcome and costs).
2) For hospital sponsored/affiliated physicians, accountability to
organization mission, values, and vision.
Sir William Osler, 1849 – 1919
Considered by many to be “The
Father of Modern Medicine” and
creator of the medical
residency.
A couple of humble suggestions for 2014:

36. Page 35June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Putting it All Together:
The Osler Circle

37. Page 36June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Wrap Up and Take-Aways
• Ultimately, no hospital asset is as valuable as
physician differentiation.
• Competitive differentiation of the physician
enterprise (employed and independent) ought
to be a major strategic consideration.
• Osler’s circle can help define where to focus
that time and attention.
• Only by addressing the creation of unique value
will the investments of time, talent and treasure
in the physician enterprise provide sustainable
returns.
* A full article on this subject to be published in Hospitals and Health Networks Online in June 2014.

38. Page 37June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Questions?

39. Page 38June 12, 2014
Prepared for The Alabama Hospital Association Annual Meeting
Thank You!
Chris Beckham
Senior Manager
Pershing Yoakley & Associates, P.C.
(706) 248-6131
cbeckham@pyapc.com
www.pyapc.com