Darrel Morrison, RN, FNP-BC, CEN, VP of Revenue Cycle, Summit Medical Group of Wyoming
The recent relationship between ED provider groups and managed care companies has been an adversarial one. But the passage of the No Surprises Act in December 2020 carries with it the potential to change that relationship into one of mutual interest and cooperation. For this to happen, however, ED groups must not only start to view their relationships with insurers differently—they must also look inward.
ED groups with an established internal culture of collaboration, who bring that alignment to the negotiating table have the best opportunity to improve their managed care contracts. Conversely, groups with a hierarchical, top-down leadership structure or align around solely around cost will have a difficult not bringing the adversarial relationships they have with their own physicians and APPs to their external contract negotiations.
THE NO SURPRISES ACT AS A CATALYST FOR CHANGE
The failure of ED provider groups and commercial insurers to establish mutually beneficial relationships led directly to regulation being imposed from without, both by state governments and now, in the form of federal legislation passed in December 2020. The No Surprises Act effectively bans balance billing by ED groups.
The law takes effect in January 2022, and before that time there is much still to do in terms of the federal rulemaking process (see our previous post for a detailed look at what independent ED groups should know about the No Surprises Act). In the meantime, the new law is a wakeup call for independent ED groups to examine their own internal practices.
ELEMENTS OF A COLLABORATIVE CULTURE
The biggest key to having a well-aligned managed care contract is to have a fundamental culture shift within your own group, from an adversarial mindset between leaders and providers, to a culture of collaboration. When everyone feels they are competing—against each other, against other groups, and against the hospital partner—that culture spills over into the relationship with payors and, even worse, with patients.
Shifting that attitude to one where leaders consider themselves to be servants, where core values are shared by everyone, and where there is open communication and a positive team environment, is essential to getting the level of engagement necessary to really deliver on the promise of quality care and profitable contracts.
There are three essential elements to this culture shift:
Ultimately, every healthcare organization should have a patient-centered culture, where the real reasons people entered the field of medicine and patient care in the first place are emphasized and rewarded.
ED groups which want to move the needle on door to doc times, or improve sepsis mortality, or embark on any quality initiative, can only truly do so if their clinical providers are truly bought into the mission of the group. And providers are usually only bought in if they really understand and believe deep down that the organizing principles are aligned with why they got into medicine in the first place.
Groups can reinforce that culture of service not only in their daily actions with patients, but also within the communities they serve. Providers can, and should, get into their community, volunteer, organize clothing or food drives, or find whatever motivates them to get outside the four walls of the ED.
Independent, democratic groups thrive when internal processes are built on collaboration. Even the mission, vision, and values themselves can be the result of a deliberative process with all the clinicians involved and contributing their ideas from the start (as ours were).
A culture of collaboration includes opportunities for education and peer review, leadership development and mentoring, and, importantly, an interdisciplinary process for improvement efforts.
Finally, no culture will truly be collaborative unless leadership views themselves as servants, rather than taskmasters or bosses. Real servant leadership takes the view that leaders are there to serve their clinicians, not the other way around.
What does a servant leader do, exactly? It starts with the words they choose in their daily interactions, going from, “I think you should do X” to “What can I do to help you be a better physician,” or “How can I make your practice environment more conducive to quality care?” A servant leader listens to their team, empowers them to solve problems, and takes feedback seriously. They encourage and coach other leaders, and they practice what they preach.
THE BENEFITS OF A COLLABORATIVE CULTURE
ED groups which are able to apply the three elements above will recognize numerous benefits, improved communication and clinician engagement, to higher patient satisfaction scores, increased quality, and improved community perception.
All these benefits will reflect on the group when they come to the table with payors and managed care providers. A group focused on its mission of patient care and with buy-in and engagement from its physicians will be able to better deliver on quality improvement metrics. By bringing that kind of quality and engagement to the table, ED groups will earn credibility and find a more receptive payor on the other end. They may even find not an adversary, but a collaborator with a shared goal: more efficient, better care, and improved outcomes for patients.