Where Are We
Headed and What
Will Get Us There?
If what we have is not working, we need to think of what will work. e premise of
this book is all about transforming the practice and engaging the traditional physi-
cians practice in a manner that will complement the future contracting models that
are now under development. e process is akin to the idea of forming a team that
can go “where the puck is going” rather than where it has been.
e other challenge is to be able to serve the increased demand that will be
coming from all fronts through the Patient Protection and Aﬀordable Care Act
(PPACA). Some estimates are placed at or around an additional 40 million people
moving from some kind of uninsured or underinsured state to coverage plans that
will be mandatory. ese are people who are going to be entering an already over-
crowded health care system. Managing access and triage will become a critical part
of each administrator’s job description.
e questions may not be, “When can the doctor see me?” but “Can I get in?”
e answer may soon depend upon how the contracts with the doctors have been
arranged and how eﬀectively the medical staﬀ has been deployed (Figure 5.1).
Health care is going to a version of quality contracting combined with a dose
of consumerism and more precise networks. is means that things like narrow
networks and value-based networks will emerge. is is the form that must be
Hopefully, the reader will recognize this saying as a quote from Wayne Gretzky, who stated
such when he was asked what made him such a great hockey player.
36 ◾ Medical Staff Integration
anticipated by hospitals and doctors that are combining forces to face the new mar-
ketplace. e “narrow network” is a “select network,” and it is deﬁned by a group
that is a subset of some other form of employee-wide, contact-wide, all-inclusive
preferred provider organization (PPO) or managed care network of physicians and
providers that has been precontracted to accept health care consumers at a negoti-
ated fee structure. e selection of a subset of providers can be based upon several
Quality or reputation of the provider
A guarantee of timely access
Adherence to deﬁned access protocols for the population
Integration with the central medical record system
Involvement (credentialing) of the medical staﬀ of the select hospitals in the system
Compliance with “care management” or other protocols
Utilization of other care resources related to the network, such as imaging and
Coordination of oﬀ-hours services with established call coverage groups
e idea that this is all about cost is missing the points related to access, value,
and patient satisfaction. A case could be made that the specialist involved in this
type of a program could actually be paid more if he or she assisted with ready
access and monitored duplicative diagnostics and avoided wasteful duplicative
events. Best practices in this arena could have a substantial positive eﬀect on the
projected cost savings or cost avoidance, but this program has to be developed,
managed, and maintained in order to be eﬀective. When the hospital enters into
Figure 5.1 Is this the health care marketplace under an additional 40 million
citizens with health coverage?