• April 2008 FEATURE ARTICLES •
Health Plans and Technology:
Case History
Planning For Productivity
A Michigan health plan leverages its PM and EMR systems to improve the bottom line and speed access to business intelligence.
By Pamela Lea Silva
Controlling costs and operating efficiently
while ensuring fair payment to provider employees are challenges
faced by many payers, including Grand Valley Health Plan (GVHP).
Located in Grand Rapids, Mich., and established in 1982, GVHP
owns six primary care practices, an obstetrics center, an urgent
care center, a radiology facility, a holistic health center and
two full-service pharmacies. All of our physicians are employees
of the plan, which covers 10,000 lives.
As a staff-model health maintenance
organization (HMO), GVHP needed solutions that would make claims
easier to process, hasten provider reimbursement and provide
coding support that accurately reflects the level of service
delivered. Our ultimate goals were to improve workflow processes
from patient check-in through charge capture, claims submission
and remittance processing that allows GVHP to extract critical
information about utilization and performance to improve
productivity and determine appropriate pricing for its products.
Problem
When GVHP was founded, we relied upon
paper-based processes throughout the enterprise. In 1994, we
converted to a single software solution, which was intended to
support both the patient care and insurance components of the
business. This was an improvement over manual processes, but not
an ideal solution. Because it was a middle-of-the-road hybrid,
the system did not offer "best practices" for care delivery or
insurance processes. In addition, since the software did not
completely fulfill needs on either side of the business, neither
our providers nor our insurance staff felt any ownership of the
system and, therefore, were not invested in maximizing its
value.
With the implementation of an EMR system with the PM system, documentation of care and coding has improved, allowing us to collect accurate quality data, enhance risk management efforts, and allow better reporting on Health Plan Employer Data and Information Set (HEDIS) measures that are necessary for the plan’s National Committee for Quality Assurance (NCQA) accreditation.
Once implemented, the system was static. We
were unable to reconfigure processes or make any changes to
content as GVHP grew and as the healthcare market evolved.
Likewise, we found it difficult to obtain reports and analysis
from the system. Leadership was unable to extract scheduling
information, encounter data or even demographic detail about
special patient populations. With no access to vital business
intelligence, we were handcuffed as we attempted to make
decisions in a dynamic and constantly changing environment.
Solution
Leadership at GVHP determined we needed to
implement a practice management (PM) system as well as a
separate, more sophisticated insurance system throughout the
organization. In 2002, we hired a consultant to gather
information on available options. A committee representing
various internal stakeholders then began to evaluate options,
narrowing the list to three vendors for each system. Committee
members included group practice managers, nurses, medical
assistants and IT staff from Grand Valley Technology Services,
as well as representatives from central billing, claims
processing and contracting.
Following demonstrations and extensive
reference checking, GVHP representatives attended each
candidate’s user-group meeting to solicit candid feedback from
current users. We later discussed what we learned from the user
group meetings — the good, bad and ugly — and reviewed the
strengths and weaknesses of each system.
After an 18-month evaluation process, we
selected the NextGen Enterprise Practice Management (PM) system
in 2003. Extensive coding support is automatically generated
from our providers’ documentation and is scrubbed by a
comprehensive edits engine to speed electronic claim submission.
We are able to generate customized reports based on select
information we need, such as analyzing the types of visits
scheduled by provider or provider location. In addition, tasking
capabilities streamline work processes and interaction with our
new insurance system is essentially seamless. Plus, NextGen
offers a companion electronic medical records (EMR) system,
which we implemented in 2006.
Implementation
We found implementation of the PM system in
2004 to be relatively painless. At the heart of our efforts was
the formation of an implementation work group, with
representation from each practice. The work group’s first
assignment was to review all of our current processes, and
determine what was working well and what could be improved. The
work group also looked at the functionality of the PM system so
we could modify procedures and work habits in order to make best
use of this new technology. Documentation of the modified work
processes and use of the system was distributed to all users for
ongoing training and support.
The work group then attended vendor-sponsored
training and was subsequently awarded the daunting task of
determining the best way to roll out the PM system among all of
our providers and locations. Our solution was to install the
system in one practice at a time. When the first practice was up
and running, staff members from the second practice visited the
first, and observed the system in use. Observational staff
members then returned to their own site and helped drive
adoption. This leapfrog process was followed at all locations,
until implementation was complete by the end of the year.
Challenges
The biggest hurdle took the form of human
resistance to change. While we wanted to complete the transition
as quickly as possible, GVHP leadership also recognized that if
we pushed too hard, we might create additional barriers.
Instead, we made an effort to ensure that users understood the
"whys" and "what fors" of the new PM system, not just the "whos"
and "whats."
The only significant problem we encountered
related to hardware. We had initially installed a wireless
platform that proved unreliable — users would become aggravated
because they lost connectivity on a regular basis. The only
solution was to remove the initial hardware and install a better
system, which delayed rollout by approximately a month.
With no access to vital business intelligence, we were handcuffed as we attempted to
make decisions in a dynamic and constantly changing environment.
Of course, we subsequently took on an even
bigger project: the adoption of the EMR. Our success with
implementing the PM system smoothed the path and reassured our
clinical staff that their efforts would pay off during this
period of change. They recognized the benefits that integration
of the two systems would offer. Better documentation increases
coding accuracy, which facilitates our efforts to report quality
and business data. This, in turn, impacts compensation and
performance bonuses.
Results
Since converting to the new PM system, both
the health plan and our providers have realized a number of
benefits. Among the most significant is improved scheduling and
timely response to patient requests for appointments. To
determine performance in this area, GVHP measures the "days to
appointment" for planned encounters and for urgent visits, and
conducts analysis of each practice and category of patient to
measure compliance. GVHP has decreased average days to
appointment for preventive and routine care from 15 days to 10
days. Likewise, when patients call for urgent appointments, the
days to appointment rate is 0.3 days, whereas prior to
implementation it was 0.89 days.
We also generate automated reminders to
patients regarding scheduled appointments. Besides being viewed
as a valuable customer service, this functionality has also
caused our no-show rate to drop, which saves the plan money and
decreases provider frustration when patients fail to arrive for
visits.
With the implementation of an EMR system with
the PM system, documentation of care and coding has improved,
allowing us to collect accurate quality data. This, in turn,
enhances risk management efforts and allows better reporting on
HEDIS measures that are necessary for the plan’s NCQA
accreditation.
Leadership is likewise able to generate
reports with information vital to the health plan’s business
stability; improved utilization and quality data helps GVHP
better understand costs. We, therefore, are able to more
effectively price our products and appropriately determine rates
the insurance company must charge.
We have also been able to decrease referrals
to non-plan specialty providers. Quality data reporting allows
the health plan to identify which of our own staff provides
superior care in specific areas (e.g., diabetes). We have set up
a hold in the system giving all GVHP providers a consultation
time window from 2:00 p.m. to 2:30 p.m. daily, when no
appointments are scheduled. Whenever possible and appropriate,
plan physicians consult with one another instead of referring
patients elsewhere. This has generated a reduction in specialty
care costs of 14.52 percent.
A New Attitude
GVHP providers have maximized their use of
workflow tasking and appreciate the convenience it provides.
Fewer details fall through the cracks since assignments are
forwarded electronically and then monitored automatically. This
is especially convenient for several of our providers who
practice from multiple locations, as they are able to forward
work assignments to any staff member from any location. Workflow
tasking likewise supports the GVHP preceptor program. Mentors
oversee new providers for six months. Chart and documentation
review can be completed in real-time, thanks to automation.
With virtually no exceptions, our staff
members are delighted with the benefits of our PM system. It has
improved efficiency and productivity, and made everyone’s job
easier. Because it provides easy access to a wealth of data, we
have been able to improve business and clinical operations, as
well as respond to changes in the healthcare and insurance
marketplace.
Pamela Lea Silva is vice president of
operations for Grand Valley Health Plan. Contact her at
silvap@gvhp.com.