Last week (January 7, 2016), as we reviewed the details of what we expected in December of 2014 to accomplish in 2015, we were reminded of other years in which we had specific, stated goals.  The following are other examples of goal setting with a subsequent review of success at the end of the year. 

• December 31, 2009 2010 - SETMA and the Future
• December 30, 2010 A Review of 2010 and a Projection for 2011
• December 31, 2014 A Review of 2014 and What We Expect for 2015

We could go back to 1995 at the founding of SETMA and through the years show the progress we made in team organization and development, electronic medical records (EMR), electronic patient management (EPM), the development of the SETMA Model of Care, business intelligence (BI) with analytics and auditing, patient-centered medical home (PC-MH), clinical decision support (CDS), chronic disease management (CDM) and many other initiatives. 

With a clear picture of where we were at a given time and a clear vision for the future - where we wanted to be after a period of time - SETMA moved forward steadily.  The pressures on healthcare providers and healthcare organizations are such that without the juxtaposition of “where you are” (current reality) and “where you want to be” (vision for the future); and, without a projection of the latter (vision) and a review of the former (reality of where you are at the end of a period), it is possible to busy one’s self with the immediate such that no significant progress and/or transformation occurs.  

Therefore, projections and reviews are more than academic exercises; they are imperative for organizational growth, development and success.

For one who was born in 1943 and who completed medical school in 1973, the thought of establishing practice goals and expectations for the year beginning after he turns 73 years-of-age is daunting.  So it is with a degree of humility and sobriety that I write the words, “in January, 2017, what will SETMA hoped to have achieved in the previous twelve months, which from our current perspective is the next twelve months.

First - Renewing the Old as Part of the New

SETMA is never forgetful that our greatest goal is the fulfillment of our promise and for the continuing improvement of our performance.  We started things such as the LESS Initiative over fifteen years ago.  We started the building of our healthcare team over twenty years ago.  We adopted electronic patient management seventeen years ago.  The future will never be so bright that the failure to maintain these and hundreds of other transformative initiatives will be obscured by new projects.  The complexity of our goals is like the man who thrills us with the spinning of numerous china plates; it is the continual spinning of the first plate, while adding more and more plates that is so marvelous. So we must never sacrifice the foundation of our success; we must not sacrifice out first innovations, in order to “make room” for what we want to accomplish in the coming twelve months.  We must continue to “spin” those early pieces of china as we add other functions and tasks to our repertoire. 

How will we do that?  In our last provider training session for 2015, which took place December 15th, we realized that we needed a training center where providers new and old could go to sharpen their skills and improve their use of the many tools which have been designed over the past twenty years.  By January 15, 2016, this training center will be in place.  It will be a fixed addition to SETMA.  It will be important at the end of 2016 to evaluate the impact this center will have had on SETMA and SETMA providers’ performance.

Second - Financial Pressures

No one wants to talk about financial considerations but as we discovered last June during a brief time of cash flow pressure, those who are committed to SETMA’s vision and who have made that vision their own, can be trusted with reality.  It is a reality that healthcare changes are bringing financial pressures on those who have made the change from fee-for-service to a value-base model of reimbursement, as SETMA has. 

The Affordable Care Act brought new taxes to healthcare. The Independent Physician Organization (IPA) in which SETMA participates pays a significant tax on the revenue we and other physicians are paid.   Annually, beginning in 2014 and 2015, that tax has been over $1,600,000 per year.  There is no increase in reimbursement to pay that tax.  It is paid out of revenue which formerly was used to pay for patient care and provider compensation. 

2016 will be a year where the full impact and weight of this financial pressure will be felt.  As costs increase and revenue decreases, we will be challenged to sustain the sound fiscal position which SETMA has enjoyed.  As if this were not enough, CMS has announced that it is expanding the Recovery Audit Contractor (RAC) program to include Medicare Advantage.  Previously, this principally applied to fee-for-service Medicare and seeks to recover overpayments to healthcare providers.  Some of those overpayments are due to fraud; some are due to mistakes.   Either way, it is intended to bring money back to CMS and the contractors are “rewarded” with a percentage of the amount “recovered.”  (“CMS to launch RACs for Medicare Advantage,” See complete article at the following link: http://www.modernhealthcare.com/artic.../20151228/.../151229937...

SETMA has been involved with Medicare Advantage since 1997 and with Patient-Centered Medical Home and Accountable Care Organization since 2009.  All utilize HCC/RxHCC for reimbursement purposes. The link to the complete tutorial for SETMA’s HCC/RxHCC tool can be found at: HCC/RxHCC Risk Tutorial.  We believe that our program is sound and that we will be fine in such an audit but no one ever knows for sure.

SETMA’s hospital partners are experiencing many of the same fiscal challenges as many of their payments are now tied to quality measures.  Often physicians are not accustomed to performing some of those functions and it causes problems for the hospitals.  Rather than finding “work-arounds,” SETMA wants to contribute to a “real” solution to these challenges.

Here is the real challenge.  Do we become discouraged and “give up,” or do we become more resourceful and innovative?  In June, 2015, we chose this latter course and that is our goal for the coming year.  We designed a solution and it worked.  Steps had been put in place years ago to respond to such challenges; they worked.  Some of those steps were painful.  Partners had their salaries reduced.  And, they remain reduced.  But, no employee had a salary reduction.  We think that the plans put in place last year will make us successful in the coming year.

Third - New Initiatives

Many of the following have been discussed in recent Your Life Your Health articles so they will only be mentioned here, but our “audit” of our performance for 2016 will include an evaluation of these initiatives.

1. TCPI - CMS’ Transformation of Clinical Practice Initiative will be a major focus of SETMA this year. Details can be found at: CMS Transforming Clinical Practice Initiative SETMA's Offer to CMS and at the articles linked to this one.
2. CCM Codes - the Chronic Care Management Codes were initiated in 2015, but SETMA’s tools was designed toward the end of the year.  This will be a major focus for 2016; see: An Example of Value-Based Payment: Chronic Care Management.
3. Collaboration with Australia, China and others - SETMA’s unspoken goal is to help change how healthcare is delivered in America.  And, as we engaged in training medical students and graduate medical students, it never occurred to us that we could or would have an international influence.  However, that influence would be judged or measured, it is very gratifying to us.  For more information see:  SETMA's Collaboration with Delegations from Mainland China
4. ePCS - Electronic Prescribing of Controlled Substances has been a major advance in quality and safety for patients.  All of SETMA’s providers, including nurse practitioners are participating in this program and SETMA is working with the Texas section of Medicaid- CHIP Health Information Technology Health and Human Services Commission to expand the usage of this tool across Texas.  (see:  ePCS and High Intensity Drug Trafficking Areas (HIDTA) Program)
5. Hospital Reimbursement - SETMA will work with any of the local hospitals who so desire to help design transformative methods for achieving the performance levels necessary to maximize legitimate reimbursement.  Meetings for that purpose have already been set up. (see:  Hospital Medical Staffs Being Asked to Comply with Recognized Standards)
6. Physicians and/or Nurse Practitioners the in Hospital 24 hours a day - SETMA’s solution for the efficient and effective treatment of patients in the hospital will continue in 2016.  Sustaining this program will be a challenge.  An extensive discussion of this project can be seen at the following link and at the multiple links documented at the end of this article:  November 3, 2015 - An Opportunity for growth, remembering and learning - out of conflict comes creativity
7. Seven Years and Counting - SETMA has completed seven years of the pubic reporting of performance measures by provider name.  This can be reviewed at:  Public Reporting - Reporting by Type.  We will continue this process. 
8. Renewal of NCQA, AAAHC, URAC and Joint Commission - Beginning in April, 2016 and continuing through June, 2017, SETMA will renew the 10 categories of accreditations by national bodies in Diabetes, Stroke/Heart, Ambulatory Care, Laboratory and PC-MH.  The currently held accreditations can be reviewed at:  SETMA's Accreditation, NCQA, AAAHC, TMF Health Quality Institute, URAC and Joint Commission.
9. I-Care and Hospital Care Team - During 2016, SETMA will actively work to improve and to expand the services SETMA provides in long-term residential care, indigent care and unassigned ER care. 
10. Urine Drug Screens and Texas Medical Board - The Texas Medical Board’s evolving scrutiny of provider prescribing of controlled substances will continue to guide SETMA’s monitoring, auditing and guidance of our compliance with the Board’s standards and our pursuit of quality and safety in patient care.  (see:  SETMA Tools for e-prescribing controlled substances, pain management policy and Urine Drug Screens

In late December, 2016, we will review this list and see “how we have done.”