Industry Shift Towards Ambulatory Care Pushes Physicians to Prove Quality


Motivated by convenience, efficiency and cost, patients are attracted to ambulatory care

The healthcare landscape is rapidly changing as patient needs evolve and a variety of care settings have emerged, providing patients with many options. Motivated by convenience, efficiency and cost, ambulatory care is becoming extremely attractive to patients.

Healthcare organizations are increasingly carving out specialized outpatient services and looking for physicians to help manage the spike in volume, all while successfully adapting to consumerism, where an enabled patient population makes informed decisions about their care. Because of this increased patient engagement, the need for proper clinical documentation improvement (CDI) driving quality outcome scores has never been more important. At the same time, the shift in the settings of care is creating headaches for CFOs’ who are managing a far more complex puzzle focused on reimbursement and optimizing the revenue cycle.

CFO discussions at the 2016 HFMA ANI conference centered on helping align all aspects around the patient in order to prove the best care was delivered. This is especially critical this year when 85% of all Medicare fee-for-service payments will be tied to quality and value. We’ve seen this trend where CDI is on the rise among hospital administrators and physician leaders who are looking for help in linking care with analytics and outcomes to support the consumerism of healthcare and shift to value-based payments (VBP).

Jeff Hurst, former SVP and senior finance officer at Florida Hospital, used CDI to improve quality and to gain $72.5 million in increased appropriate reimbursement for inpatient care across eight different hospital sites. “We believe we’re now at a point where we need to expand that into both the outpatient space, as well as the physician space,” he recently said. “All providers going forward are truly moving to a fee-for-value payment stream and that includes both the hospitals as well as our physician partners.”

The complex ecosystem of hospitals, clinics, medical offices and other ambulatory services can cause difficulties in keeping care running smoothly, managing several patient conditions in tandem and streamlining documentation between inpatient and outpatient providers. When reimbursement fees migrate from traditional inpatient settings to the outpatient care settings, the result is lower inpatient admissions for services traditionally provided as inpatient services. This shift is likely to have a lowering effect on case mix index (CMI) resulting in reduced reimbursement cash flow for the hospital.  As a result, one of the biggest concerns among CFOs and CDI leaders is an ineffective process to properly document patients’ conditions in order to drive an optimized level of care and reimbursement. Added to this complexity is a shift in payment methodology creating a different perspective relative to how outpatient patient care is documented, particularly when treating the chronically ill members of a patient population. Because of this shift, CDI in this space has never been more important.

CDI programs that blend technology and expertise help solve this issue. Expanding CDI to the outpatient setting will enable the optimization of care, including the treatment of chronic conditions and all possible complications regardless of setting. Those who do it best will drive higher reimbursement and enable physicians to document correctly, accurately and distinctively for the care they are providing. Working to extend continuity of care into the community is still a work in progress, as is the administration and reporting of that care.

CDI Helps Organizations Adhere to Federal Regulations

Ambulatory settings, like acute care counterparts must meet federal regulations and adhere to value-based care requirements. The biggest unknown centers on details needed in patient notes that help track risk of patients and provide insight into the most severe and costly patient medical conditions. CDI programs can help accurately capture and report information such as the Hierarchal Condition Categories (HCC) and risk adjustment factors from CMS, as well as the new and growing ICD-10 codes. This will help clinicians optimize reimbursement for chronic conditions, while also better capturing the care delivered. These categories and principles are not well understood, and have widespread implications on reimbursement and population health management. Complete clinical documentation is a critical link between an individual’s health risk profile in a health plan and reimbursement.

Most recently, CFOs and CDI leaders are facing the ambiguity surrounding MACRA and MIPs, and the impact that these will have on the industry in the next few years. It is still far enough in the horizon that very few realize how these laws will change their processes throughout the healthcare ecosystem, especially when it involves reimbursement revenue. Those who have started the education process are realizing its impact will be significant. While it is starting to inform their way of thinking, most are not sure how to transform their understanding into action that will be meaningful in the future once these regulations take effect. Although hospitals are just starting to see this problem as a small light at the end of the tunnel, they will need to start understanding the effects of these new regulations now, because that small light is actually a freight train and is coming faster than they think.

Since quality will be rewarded and reimbursed regardless of where care is delivered, everyone needs to know what is really happening with the patient from both a clinical and business perspective. Penalties for readmissions coupled with variances in length of stay will have huge impacts. Severity of illness and risk of mortality driving expected to observed scores are coming into focus now more than ever. And once again, physicians are in the cross hairs trying to focus on patients with a swirl of changes surrounding them. And since consumerism is on the rise, patients are more informed than ever about their healthcare choices.

Quality rankings are taking a front seat and should be on the mind of every physician. Right now, it is not a high-priority because they are being compensated for their service – not their care. But as this shift happens, and it starts to hit them in the pocket book, they will have to adapt. The winners will be physicians and caregivers who cooperate and communicate well, maintain efficient care and top the charts of quality rankings already. The CFOs that win will have a comprehensive CDI strategy to span both the inpatient and outpatient settings ensuring optimized and accurate care for patients while ensuring accurate reimbursement for the quality of the services provided.

Don’t Go It Alone

Healthcare institutions facing the uncertainties of increased outpatient care will find solutions in partnerships. Hospitals are merging and acquiring physician practices in order to keep a grasp on consistency for patients and deliver well executed integration as they manage populations. Margins are so thin in healthcare that in order for a hospital to remain solvent, they will need tight partnerships with both a healthcare delivery component and an operational component. In addition, physicians themselves become partners in healthcare more than they ever have before. The most successful ones will reorganize their processes, gain clinical buy-in and create an environment where physicians and patients can interact as part of a connected care network where documentation dovetails nicely to support quality care.

However, with partnerships comes fragmentation. As hospitals acquire large medical practices, they come in with disparate systems and methodologies for how they are completing documentation. There is a huge opportunity for select third-party organizations to work as enablers between disparate architecture, system competency and actual specificity of level of care and documentation. The vendors that are best able to maneuver, adapt and work in diverse environments to drive optimization of documentation when there are highly variable technologies will come out ahead.

As outpatient facilities become increasingly popular, clinicians are tasked with maintaining patient satisfaction and quality care, but not without some concerns. Through efficient documentation and collaboration between inpatient and outpatient organizations, the patient experience is improved. These intricate healthcare ecosystems will succeed through strong partnerships and with thoughtful reorganization of processes that continue to keep the patient at the center of focus.


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About Author


Patrick Gardner is the vice president and general manager of the Clintegrity line of solutions for Nuance Healthcare, which includes coding, quality and clinical documentation improvement products and services. In this role, Patrick develops and executes market-driven strategies that support growth of the business, sales and implementations. Before joining Nuance in 2015, Patrick served as the vice president and solutions line manager at McKesson where he successfully managed the development of a strategic product portfolio and integrated additional lines of business. Patrick is a senior leader with more than 20 years in healthcare information technology and health information management with positions ranging from healthcare sales, sales management, marketing and product management. Patrick attended the University of South Carolina-Columbia where he earned a B.S in Business Administration.

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