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Opportunities for Specialties

May 10, 2013

As this is being written responses are being formed with regards the release of hospital charge information by Medicare (CMS).  In the major cities in Alabama, competing hospital’s fees for specific illnesses have been printed for the general public to see.  Of course, few patients get hit with the full fee but the question does come up about why one hospital has a fee structure over twice the rate than another, similar hospital in the same city.  Particularly in cases where the same medical groups involved with the diagnosis goes to both hospitals which is not an unusual event.  The big numbers get the headlines but the details require careful review. 


The issue in the past, and present, is how we measure quality (immediate outcome, long term outcome, best case scenario, etc.) and costs, on a patient specific / large volume of patient’s basis.  These points continue to be debated with the answer often having been, it costs more to take care of my patients because they are sicker.  Then it becomes the argument of proving that “sicker” definition.  Today the best we can do is look at the number of diagnoses reported on a claim form and develop some type of Co- Morbidity Index (CMI).  That is then a function of how many diagnoses spaces are there on a claim form and how do we identify which ones to use.  That creates a daunting, and often imprecise, task.  However, it is one a physician must deal with.


The opportunities for specialists all revolve around understanding this data and improving on their data input process.  If a specialist can “prove” their patients are sicker and that they, and their hospital, have a lower cost to the system, they can argue they are the ones who should be treating those patients.  If their data does not support their position, they have the opportunity to find out why and fix it.  In the new world of shared savings and ACO’s, this becomes a true marketing advantage.


In addition, like the Patient Centered Medical Home (PCMH) concept, the NCQA is preparing to release the guidelines for Specialty Centered Medical Homes (SCMH).  The details are still in the works but it is likely that, like those groups attaining PCMH status, there will be financial incentives for those groups who meeting the quality and operational measures being developed.  That qualifies as an opportunity that is really based on what most groups are already doing, it’s just the documentation / formality process that has to be met. We are in an information driven world and the opportunities are there for those who grasp them.

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