Strategy weaving: Using HCCs, MACRA and readmission reduction requirements to strategize performance improvement

Nov. 20, 2019 / By Michael Malohifo’ou, RN, MBA, PhD

Far too often, healthcare organizations treat planning and execution as two separate processes which are intended to achieve a larger goal. Leadership makes plans and departments and workers are told to execute them. Meanwhile, those charged with execution don’t see the full vision of the plans, and planners have difficulty understanding why their plans failed to meet the vision. Frequently, people charged with execution of a set plan end up in silos, merrily performing their tasks, without knowing how their work impacts (or is impacted by) the work of others. Unfortunately, most individuals will never see how their work is woven into the greater picture. However, planning and execution should be threads which integrate into a seamless fabric. Planning must include execution, and execution must reference the underlying plans. Building execution into the planning, and including those who do it in the process, makes for a smoother transition from the theoretical to the practical. There is a chain reaction from vision to plan to strategy to action, that creates a picture of how each action contributes to the whole. When this cascade is shared with, and built in concert with, those tasked with execution, everyone has a common language and goal. The process of integrating a cascade of events across an enterprise may be referred to as “strategy weaving.”

In order to best illustrate the problem that the concept of strategy weaving may help address, I would like to offer an example. When consulting out in the field I often ask the question “Why do we silo individual X and individual Y from one another?” This question is particularly relevant when attempting to reconcile how a patient care activity, executed by clinicians, is then expected to transform into a billing and coding process which is ultimately intended to meet a specific organizational goal. In this example, I am typically asking this question because when analyzing an organizations’ outpatient and professional divisions I find that the patient care strategy formulated by administrators for clinicians is often planned with the intent to capture some form of revenue, or meet a larger organizational or enterprise-wide goal (i.e. capture charges, documented data points, obtain specific CPT’s or Diagnosis code types).  The answer I frequently get is “That is how it’s done here because we’re unique.” This answer of course underlies the problem which strategy weaving may be able to help address.

In health care, the individual silos that exist between clinicians, health information systems professionals, and administration have historically been put in place for specific reasons. Many of the reasons no longer exist in today’s healthcare environment. This is due to the fast pace at which technological advances and regulatory changes occur in the healthcare industry.  In most cases, past experiences influence and impact how an organization approaches these issues. Naturally, individuals directing these organizations have their own biases that direct their attention and lend to a directive approach to problem solving. Often in large organizations the old models are too deeply ingrained in people’s thinking. It takes time to understand, at a conceptual level, the kinds of intuitive insights healthcare consultants have been having for the last couple of decades. For a healthcare organization, any change management process which requires the removal of individual work silos can cause administrative and operational apoplexy. The apoplectic responses to change management is what we have been witnessing, in one form or another, since the slow change from activity and fee for service-based care to value-based care has begun. This has resulted in financial opportunity losses amongst a myriad of other barriers. I believe this is where strategy weaving comes in. 

Some have speculated that the recent push to value-based care through application of the financial incentives set forth by CMS (MACRA, Risk Sharing, readmission reduction) appears to be feeding an avaricious jump towards consolidating private practices into large enterprise-based healthcare systems. The truth is the move to a value-based system is an altruistic one. As a primary strategy, the financial incentive move has required incentivizing people within the industry to change deeply ingrained behavior. The financial strategy being applied today is multipronged, as it incentivizes individuals who are willing to change behavior and thereby withholds those same incentives from those unwilling to change the same targeted behavior. As discussed earlier, a weak part of this big picture strategy is that, as a result of the application of diverging planning and/or execution formulation, some of the targeted individuals may not see how their work impacts (or is impacted by) the work of others. In the healthcare consulting world, I often hear the common mantras “We need to change health care, this system is broken” and “How are these bureaucratic process making patients better?” This is evident when looking at the recent numbers coming out of organizations reporting less than stellar performance in one or many CMS driven value-based care changes, experiments, initiatives or programs.

For example, I recently worked with a large tri-state enterprise-based healthcare organization where I was tasked with advising the establishment on operationalizing appropriate enterprise-wide documentation and coding procedures to meet their risk assessment HCC goals at the executive level. When conducting the analysis, I found that the organizational systems were highly compartmentalized into silos. The individual silos were so highly compartmentalized that individuals working in the hospital coding apparatus (HB) had no idea that the physician coding apparatus (PB) had their own respective plans intended to address HCC coding that were, in fact, contradictory. Even worse, the CDI department had no idea that the HB and PB coding departments had any plan in place to address HCC coding. This description doesn’t even begin to scratch the surface in describing the compartmentalization, as the individuals working in the patient care arena (i.e. the document creators) had no idea that anyone was involved with their respective plans on addressing HCC coding, and how those plans would help meet any other financial initiatives they were currently involved in. When interviewing stakeholders within the organization, I found that the mere mention of change management around HCC current process operations—even in conversation—caused staff, administrative and overall derangement resulting in the stalling of further analysis. This was concerning because prior to my on-site stakeholder analysis, I received documentation around the risk assessment and HCC initiative planning which appeared to operationalize this process very neatly.

This client was an extreme example, which is important to note, as I found that in regard to multipronged initiatives like risk assessment scoring through HCC coding, the organization did not plan the risk management strategy with the overall goal in mind, i.e. assuring they were appropriately accounting for cost of care. Rather, I found that goals planned around risk assessment coding through HCCs were being executed and planned completely independent of one another and completely irrespective to other initiatives in play such as chronic care management (CCM), transitional care management (TCM), readmission reduction management (RRM), Comprehensive Primary Care (CPC) and annual wellness goals. Each of the above initiatives does address the same overall shared accountability and cost of care goals.

Needless to say, this particular organization required in-depth consultative recommendations to be translated across the enterprise in order to address the specific task I was assigned. However, when I did offer consultation recommendations, one of the most critical elements addressed was around the concept of weaving strategies together so that clinical care professionals (nurses, MD’s, and so on) were not unaware of what CDI, HIM or Medical Group coding departments were doing. I also had to assure that, moving forward, each of the plans being crafted included individuals from the respective groups which the plan was to be executed by. I had to reiterate, to many groups and many individuals’ stakeholders from administration to registration, that any plans made without regard to the individuals responsible for execution was contradictory to achieving the overall organizational goal.  I am happy to say that those recommendations have worked marvelously for this particular client and have helped me better understand healthcare enterprise challenges as a whole.

Michael Malohifo’ou, RN, is a Professional Consultant for 3M Health Information Systems.