Essay Grade

Independent Physician Office Scenario
Partners in Health Care Associates (PHC) are a four-physician practice located in the
Midwestern United States. Three physicians are board certified in internal medicine and
a fourth is certified in geriatrics. The practice also has a full-time nurse practitioner,
three part-time nurses, two medical assistants, and two front desk staff. Due to changes
in physician leadership, the practice no longer has a functioning ambulatory electronic
health record. There is a legacy physician practice management system in place for
billing and scheduling which is no longer supported by the vendor but does process
electronic claims.
Current State
The practice has not been able to participate in the CMS Meaningful Use program and
is being assessed 5% reimbursement penalties on Medicare patient payments.
Likewise, two commercial payers are offering pay for performance incentives for
managing panels of patients with diabetes and asthma, but PHC cannot participate due
to their inability to produce the required health maintenance clinical reporting for the
program.
The practice has an existing practice management system that does patient scheduling
and automated claims submission via EDI (electronic data interfacing). This vendor
system is unsupported and must be replaced as part of the search for an electronic
health record. The goal of the practice is to be able to be financially and clinically viable
and compliant with the CMS Meaningful Use phase 1 and 2 programs and prepared for
Meaningful Use phase 3.
Software vendors who have sold products to other physicians in the area have
approached the medical director and administrator of the practice. These vendors
include Practice Fusion and Next Gen. Recently a colleague of the medical director who
has a practice in California is recommending that he examine a product called Athena.
In addition, the Chief Medical Officer of Green Valley Regional Health System has
approached PCH offering to implement and support Green Valley’s Epic Care product in
this practice under an affiliate agreement. There is also an option to run an MSO
(Management Services Option) of Green Valley’s Epic Practice Management suite for
billing and scheduling. While PHC is an independently owned physician practice they
refer about 65% of their patients to facilities and specialists of Green Valley.
Currently PCH’s practice management system is non-supported by the vendor. Front
desk office staffs have become very proficient in using this software to schedule
patients, submit claims and follow up on denials. Office IT operations such as email
printing and a basic website are run by a local information technology company who
provides the services to PCH for a monthly fee.
© 2016 Laureate Education, Inc.
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About 75 of the other approximately 100 independent primary care practices in the
region run either Next Gen or Practice Fusion as stand-alone systems. About 15
practices who have been approached by Green Valley are in the process of
implementing their affiliate version of Epic Care. Three of the other five practices are
divesting their practices due to financial hardships and two of them are in negotiations
with Athena.
Environmental Factors
When examining the patient mix for both Green Valley and the regional primary care
practices we see approximately 40% Medicare, 20% Medicaid, and 40% commercial
insurance patients. The main commercial insurance carriers are Aetna and CIGNA.
Green Valley is in final discussions with CMS in formulating an ACO organization that
includes their facilities, the physicians who are running on the affiliation agreement, and
a long-term care partner.
In terms of financial pressures both Aetna and CIGNA have launched aggressive payfor-performance programs in areas such as diabetes management, asthma
management, and medical management of congestive heart failure. For these
programs, physicians who produce regular health maintenance reports on panels of
commercially insured patients are receiving performance incentives. The reporting for
these performance incentives is very similar to the core measures reporting requirement
for the CMS program’s Meaningful Use phase 1.
Another factor affecting the region is the launch of the standalone urgent care option
called Doctors Care. These urgent care centers are open 12 hours a day, seven days a
week and offer highly convenient urgent care and online care services to patients for
non-urgent conditions. They have also recently begun doing campaigns to offer
vaccinations, school and employment physicals, and health risk assessments required
by Aetna and Cigna. Part of their overall customer campaign is a highly user-friendly
secure Internet presence in the form of a consumer health record where consumers can
do electronic visits and on-line chats with health coaches about common medical
issues.
What to Do?
PCH must make a vendor choice regarding both a patient management and ambulatory
electronic health record system. As the practice administrator you have been asked to
investigate vendor options and provide an objective analysis to the PCH medical
director. He has asked that this analysis include both standalone options and the Epic
affiliate option offered by Green Valley. He has asked you to investigate at least three
vendor partners and objectively document both the benefits and limitations of choosing
each of these options.
© 2016 Laureate Education, Inc.
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