ACOs, Unlikely Homes for Medical Homes - Part 3 of 3

Continued … see part 1 of this discussion, published Monday, August 20

OK, so you’re a skeptic and the numbers from last day look just too good to be true. Let’s take a more conservative view. While the above scenarios are supported by actual clinical tests and situations, let’s suppose they are best-case scenarios and therefore extreme. If the savings were only 15% of the above, the medical home provider could still see over $100,000. Let’s say then that the medical home decides to keep 50% of the shared savings and divide the other 50% among the other team members. This means adding only $50,000 to the income of the primary care physician. Current average PCP income = $135,000. Add $75,000 net for care coordination. Add $50,000 from shared savings. $260,000.  We now have a program that, even when viewed from the most conservative vantage point, is structured to bring the income of the primary care physician from $135,000 to $260,000. In essence, the program is designed to double the income of primary care physicians who decide to participate in medical home style delivery and reimbursement systems.  

We can start to understand now why payers are willing to work together to fund the coordination of care through pilot programs like the Comprehensive Primary Care Initiative (CPCI). We can also see why 200 primary care physicians attended the first organizational meeting of the CPCI in one small city in Ohio.  And we can also understand why ACOs would not embrace this process or why, in fact, they would put as many barriers as possible in place to prevent such a system from being implemented. As we have stated already, the regulations by which ACOs can be established are so complex that almost all ACOs are large health systems. These health systems primarily generate their income from specialty care while the savings are being generated through primary care, coordinated care and the medical home.  

It is clear to see that the maximum cost savings, and the biggest boost to improving quality of care is going to work when the medical home is a separate business entity from the health system.  Predictably, we would not expect to see ACOs embrace the medical home.  On the other hand, we would expect to see – and are seeing, in fact – huge popularity of the CPCI among independent primary care physicians. ACOs are resisting expansion of the medical home even publishing negative studies to resist the concept from being established as part of the new delivery system.  

Jim Grue, O.D.

Alistair Jackson, M.Ed.

ACOs, Unlikely Homes for Medical Homes - Part 2 of 3

Continued … see part 1 of this discussion, published Monday, August 20

When a new medical home is formed, a rather complex set of formulae is used to predict the cost of care in the traditional delivery system. Going forward, the actual cost of coordinated care is tracked, so eventually it is known whether the coordinated care or the traditional care was more expensive. The hypothesis is that coordinated care is able to deliver better quality at a lower cost, so let’s assume that the coordinated care, in fact, ends up less expensive. At least in these early years, the formula for shared savings dictates that the medical home gets paid 85% of the savings.  Yes, almost the complete amount saved through the medical home’s coordinated care approach is given back to the medical home.  This will no doubt change over time; a big return is intentionally structured as a major incentive in order to convert quickly to the new model, a similar approach to the EHRs incentive program – money speeds adoption.  

Now let’s look at the savings possible. Almost all providers, new to the medical home concept, are concerned that the primary care physician will act as a gatekeeper, preventing them from seeing the patient or doing the required tests. In reality, nothing could be further from the truth, which we’ll see below. Cost savings are not generated by reducing or eliminating necessary care. In fact, the maximum savings are generated when the coordinator ensures that the patient receives the very best care. It is difficult to think of an example where poor care is less expensive than the best care. If a patient isn’t properly diagnosed and treated then invariably there are more visits to eventually get it right. If the best surgery is not performed, the result is simply more after-care at higher expense.  So the first mandate of a care coordinator is to make sure all care received by every patient is the best available. This alone will generate savings.  

The next step is to eliminate duplication of care that doesn’t result in better outcomes. A familiar scenario will serve us well here:  in eye care, if an optometrist does specialty tests then has to refer the patient to an ophthalmologist, in almost all cases, the ophthalmologist repeats every specialized test.  In the case of ODs and retinal specialists co-following patients, both typically see the patient on an ongoing basis and both continue to perform the same specialty tests. This happens right now because the two specialists get to decide what tests they want, not to mention that it’s in the economic interests of both to perform the tests. If we were in a position to coordinate the care of this patient, we’d know exactly how to increase those shared savings! We’d make sure the appropriate tests were being done but by one provider only and we’d have the results shared by all providers seeing the patient. The only time a test would need to be repeated would be if there was a question of its accuracy, which then gives the coordinator the incentive to ensure that the office that performs the tests is the one that proves over time its ability to get the most consistent, accurate results. 

Scenarios like this one are replicated in different ways throughout medicine every day. So, the care coordinator has two simple tasks that create huge savings: ensure every patient receives the best available care at every visit; identify and reduce or eliminate redundant costs which do not improve the quality of care.

Studies have shown that these two things alone have the potential to reduce the total cost of care by as much as 30%. Those are big dollar amounts. When we consider that the cost of health care in the United States is approximately $7,000 per person per year, we start to see the potential shared savings. Using this figure, a medical home coordinating the care of 500 patients is coordinating $3.5 million dollars of care per year. If 30% can indeed be saved, the potential savings is over $1 million. The 85% rule tells us that the medical home could receive over $850,000 from shared savings. These are staggering numbers for PCPs whose average annual earnings are currently $135,000.  Do we dare think PCPs are not all over this opportunity? If in doubt, check out the website of the American Academy of Family Physicians and see what they’re doing about the PCMH initiative.

To be continued …

Jim Grue, O.D.

Alistair Jackson, M.Ed.

ACOs, Unlikely Homes for Medical Homes - Part 1 of 3

In the early days of Accountable Care Organizations, it seemed they would be the natural resting place for the patient-centered medical home (PCMH). That thinking has changed. While it appears ACOs may use some medical home concepts, there is growing doubt about the compatibility of the two entities. Let’s understand why. 

Why would ACOs would be resistant to medical homes?  First, the medical home concept promotes coordinated care and shared savings, core values in health care reform. Second and fundamentally, health care reform means a change in the financial positioning of primary care versus specialty care. In the current fee-for-service system, some would contest, primary care is underpaid while specialty care is overpaid. The balance is shifted by the core tenets of health care reform so that primary care becomes better paid, basically at the expense of specialty care. And hospitals and health systems, where ACOs typically reside, are predominantly specialist-oriented.

For the sake of simplicity in the following discussion, we’ll be viewing primary care and specialty care in separate business contexts even though we know that within hospitals, health systems and ACOs the two exist under one roof.

To begin, let’s use precise figures from the Ohio Comprehensive Primary Care Initiative (CPCI); it is modeled as a medical home and we know the numbers. Reimbursement for primary care physicians through the medical home model involves two key changes: the first is that the medical home gets paid a separate fee for coordinating the care of patients; secondly, the medical home gets to share in the savings created as a result of care coordination.  

What is the effect on PCP income of getting paid for coordinating the care of patients? Let’s assume that the office of a primary care physician can coordinate the care of 500 patients. This requires the medical home to hire an additional staff person at a cost of $50,000.  The CPCI in Ohio is paying $22.50 per head per month for care coordination. This generates $11,500 per month, or $138,000 per year, in additional revenue to the medical home. After the cost of the additional staff person, the new revenue leaves $88,000 for organizational profit.  Supposing that the medical home provider has some miscellaneous expenses, we’ll allocate $75,000 toward profit. The average income for a primary care physician in the USA today is $135,000.  Therefore, by becoming a medical home, a primary care physician practice increases its income to about $210,000.  So we can see how becoming a medical home, versus remaining simply an independent PCP practice, can significantly increase the income of the primary care physician. Yet, we haven’t begun to consider the real income-increasing potential of a medical home: shared savings accounts. This is where it gets interesting.

To be continued …

Jim Grue, O.D.

Alistair Jackson, M.Ed.

You asked about ACOs - Part 2, Team Delivery of Care

... continued from last day. For a brief discussion of ACOs and Communications, see Monday, August 13.

Team Delivery of Care

We clearly see a corollary in the development of team-based care delivery: the purists would like to see a system where all providers could form into teams to deliver care in the most efficient and cost-effective ways and in which all providers could participate in shared savings accounts. Large health systems want to maintain their dominance and even extend their control over the delivery system. What we are seeing arise is a number of programs that represent the gamut between these two extremes.  

On the one extreme are ACOs which revolve around a myriad of regulations to the point that it is difficult even to understand exactly what ACOs can and cannot do. The bottom line is that this complex set of regulations restricts ACOs to relatively large health systems in order to fulfill all the requirements. This, of course, favors health system domination and, in fact, was pushed as a complex system by the large health systems.

On the other end of the spectrum is the new Comprehensive Primary Care Initiative, which was effected largely by the designers of health care reform and pushed by the Office of the National Coordinator. These stakeholders want to see competition in the health care marketplace and access by providers at all levels.  

From an eye care perspective, we believe it is important for every eye care provider to have a general understanding of ACOs and health information exchanges, knowing that both are too complex and too diverse to be fully understood in terms of what they can and cannot do. Every eye care provider, on the other hand, should have an intimate knowledge of how DIRECT works and the significance of the Comprehensive Primary Care Initiative, as these are the two programs that most parallel the original goals of the health care reform movement. They also show how providers may work together, through coordinated care, to provide the highest level of care within a structure that openly communicates patient health information between providers. Seeing the significance of shared savings when controlled by primary care is a key to understanding the importance of team care delivery and reimbursement.  

Once again, we believe the way that independent eye care providers are going to be most successful is to understand ACOs and exchanges generally but DIRECT and the Comprehensive Primary Care Initiative specifically. The latter pair illustrate well how the emerging system is supposed to function. Then, being involved in the local community as the care delivery structures are being formed is the most important step.  To that end, the National Eye Care Communications Project, while sponsored by EMRlogic, is offered as a vendor-neutral gathering where providers can share their learnings, their experiences and assist all participants in understanding the cultural changes necessary for business success in health care reform.

Jim Grue, O.D.
Alistair Jackson, M.Ed.

More on ACOs is available in Archives. See Categories: Accountable Care Organizations.

You asked about ACOs - Part 1, Communications

One of the participating doctors in our National Eye Care Communications Project asked for more insight into ACOs, as what some have called "the real rising power" in health care reform.  

In our attempts to understand national-scale bills or movements, such as health care reform, we must acknowledge a conceptual level where the creators and influencers would like to see things go, and also a practical level involving the passing of regulations, legislation and policy.  These two levels rarely align.  And this was never more true than in the case of health care reform.  Let’s consider two parallel situations – communications and team delivery of care – in which we see clearly this difference between how a system is ideally designed and what was necessary to put it in place on a practical basis.

Communications

In the area of communications, we see two distinct programs emerging: the first is the health information exchanges being established in almost all states; the second is the national DIRECT communications network.

From a conceptual standpoint, the purists in health care reform would like to see a system in which every provider has equal and secure access to patient health information. From a practical standpoint, health systems see an advantage in being the central hub with information easily flowing in and where they have control over what flows out. The result is the first category of exchanges, repository-type HIEs, being developed by large health systems that tend to dominate the process in their states. The health systems share patient health information through the exchange, and independent providers send information into the exchange. Independent providers however, for the most part, only have access to view patient information through portals rather than easily receive information from the exchange.

In addition to the health information exchanges, we also see the emergence of the DIRECT system, which is being resisted in many states by the large health systems. DIRECT however is being pushed by the National Coordinator of Health Information Technology and also by some state HIE adminstrators as a way of granting to all providers equal access to patient health information. This is the system that gives independent eye care providers equal access to patient health information.

To be continued ... join us next day for part 2, Team Delivery of Care.

Jim Grue, O.D.
Alistair Jackson, M.Ed.

More on ACOs is available in Archives. See Categories: Accountable Care Organizations.

Bundled payments ... ubiquitous change!

I'm a big believer that trends flow to their logical conclusion. If we look at the initiatives under way today in coordinated care, it should be no surprise that changes in the delivery model will flow to changes in the reimbursement model.


Look at this background statement for the Bundled Payments for Care Improvement initiative, from the CMS Innovation website:

Medicare currently makes separate payments to providers for the services they furnish to beneficiaries for a single illness or course of treatment, leading to fragmented care with minimal coordination across providers and health care settings. Payment is based on how much a provider does, not how well the provider does in treating the patient. 

Research has shown that bundled payments can align incentives for providers – hospitals, post acute care providers, doctors, and other practitioners– to partner closely across all specialties and settings that a patient may encounter to improve the patient’s experience of care during a hospital stay in an acute care hospital, and during post-discharge recovery.

As expected, most health care reform initiatives are contextualized in the hospital setting and flow from there into ambulatory care settings. It's important, therefore, that you, as an independent health care provider recognize Accountable Care Organizations (ACOs) as the bridge between these two worlds.

ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.  

While the statement above comes from CMS, recognize that today there are more commercial ACOs than Medicare ACOs. It is a dangerous gamble to segregate CMS initiatives from those of other payers and pretend the trends don't matter because you don't see many Medicare or Medicaid patients.

In a similar vein, we still encounter the equally harmful gamble that "this is all going to go away" in the supposed defeat of Obamacare. Not so. While some aspects of payment reform (health insurance reform) will survive and others won't, health care reform is here to stay. It is not the object of the pending Supreme Court decision. For the well being of your business and private-practice profession, look back then look ahead. Ubiquitous change. Are you preparing for what it means to you? Are you participating alongside your colleagues to ensure that independent eye care providers have a place in the emerging models of health care, both delivery and reimbursement?

Alistair Jackson, M.Ed.

Coordinated care leads to bundled payments

Coordinated care is by no means a new concept or recent buzzword but it does flag some important developments in the ongoing transformation of health care. In our discussions with eye care providers it is not yet apparent that many have grasped the significance of press releases like the one on June 6 from CMS entitled, “CMS Announces Private-Sector Commitments to Improve Primary Care for Patients, Save Money for Medicare: Eight States will test unique investment in coordinated care”. 

“In a strong show of support for more effective, more affordable, higher quality health care, 45 commercial, federal and State insurers in seven markets today pledged to work with the Centers for Medicare & Medicaid Services (CMS) to give more Americans access to quality health care at lower cost.”

The announcement goes on to explain a new initiative that impacts the business of every eye care provider from coast to coast, even though it specifies pilot projects in only eight states. Why is this important to you as an ECP? Because pilot projects like these signal ubiquitous change. If we understand the big picture, we can see that coordinated care spells the eventual demise of fee-for-service care billed directly by you to CMS or any other payer. To the extent that you don’t bill much to CMS, look past Medicare and Medicaid. See the private-sector commitments and public-private partnerships. Ubiquitous change.

“Under the Comprehensive Primary Care initiative, CMS will pay primary care practices a care management fee, initially set at an average of $20 per beneficiary per month, to support enhanced, coordinated services. Simultaneously, participating commercial, State, and other federal insurance plans are also offering an enhanced payment to primary care practices that provide high-quality primary care. 

"We know that when we support primary care, we get healthier patients and lower costs," said Acting CMS Administrator Marilyn Tavenner, "This initiative shows that the public and private sectors can come together to meet the critical need for these services."

Insurers in Arkansas, Colorado, New Jersey, Oregon, New York’s Capital District-Hudson Valley Region, Ohio’s and Kentucky’s Cincinnati-Dayton Region, and greater Tulsa, Oklahoma signed agreements with CMS to participate in this initiative. The markets were selected based on a diverse pool of applicants from commercial health plans, State Medicaid agencies, and self-insured businesses who hoped to work alongside Medicare to support comprehensive primary care. 

In order to receive the new care management fee from CMS and insurers, primary care practices must agree to provide enhanced services for their patients, including offering longer and more flexible hours, using electronic health records; delivering preventive care; coordinating care with patients’ other health care providers; engaging patients and caregivers in managing their own care, and providing individualized, enhanced care for patients living with multiple chronic diseases and higher needs. 

Approximately 75 primary care practices will be selected to participate in the Comprehensive Primary Care initiative in each designated market ...

The Comprehensive Primary Care initiative is a four-year initiative administered by the Innovation Center. Applications will be accepted until July 20.

For more information, please go to: http://www.innovations.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/index.html”

Takeaways for you as an independent eye care provider:

1. Getting connected with primary care is imperative to the survival of your business.
2. Coordinated care management fees mean that qualified entities will take over the complete care of the patient, including assigning their eye care provider.
3. Enhanced services include using EHRs, delivering preventive care (that’s you!) and coordinating care with patients’ other health care providers (that’s team-based care).
4. Chronic care is defined as two back-to-back billings by a provider for the same condition or diagnosis (that’s everyone, all your patients in due course).
5. Coordinating care with other health care providers means electronic communications … exchanging CCDs and other forms of patient information.
6. The National Eye Care Communications Project is focused precisely on helping you meet these requirements. 
7. The CMS Innovation website is a tremendous resource for understanding where the transformation of healthcare is taking us. We strongly recommend that you go there and read up on ACOs, Bundled Payments and the Comprehensive Primary Care Initiative. Links to all three topics are available in the bottom section of the home page.
8. Join us next day for more on the logical conclusion of coordinated care ... bundled payments.

Alistair Jackson, M.Ed.

Jim Grue, O.D.

Communications, Connected Care and Medical Homes, Part 2

Continued from last day, "Communications, Connected Care and Medical Homes, Part 1"...


Why are Medical Homes relevant to the National Eye Care Communications Project? 

Joining the dots back through our recent posts in the Communications series, let’s understand the significance of the PCMH in its big-picture context. 

• Your patients are becoming accustomed to the new patient-centered medical home, through their family physicians. 
• As expectations change, patients will transfer them to all health care providers.
• Since the patient-centered medical home resides effectively in Accountable Care Organizations, you must participate in team-based care.
• Team-based care requires secure electronic communications, both to providers and patients.
• Your state HIE is the home base of your communications network.
• ONC Direct is the secure transmission standard required in every state and for national communications.  
• Beacon Communities are case studies where we can see clearly what the transformation of healthcare to a connected-care model, with the full range of certified EHR technology, is supposed to look like.

Alistair Jackson, M.Ed.

Jim Grue, O.D.

Communications, Connected Care and Medical Homes, Part 1

What are Medical Homes? 
In the previous post, we saw that ACOs are rapidly becoming the new status quo in healthcare delivery and reimbursement. Healthcare is becoming team-based and reimbursement likewise. Patient-Centered Medical Homes (PCMHs) are taking flight within ACOs. 


From the American Academy of Family Physicians (AAFP), here are four building blocks your local PCPs are using to build the practice as a Medical Home.   Note the significance of the patient experience. 


Building Your PCMH?


A truly patient-centered medical home is designed to enhance the patient experience – a fundamental, transformational shift from the practice designed to enhance physician workflow.


In a medical home, the practice is organized around the patient. Communication is based on trust, respect and shared decision-making. Patients want access to personalized, coordinated and comprehensive primary care when they need it, when it’s convenient for them. They also want convenient access to practice information.
• Provide convenient care. 
• Develop your practice's online presence. 
• Assess patient satisfaction. 


A patient-centered medical home automates business and clinical processes, depends on clinical decision support tools, and connects patients with the health care team.
• Connect and communicate: e-Prescribing, email and secure electronic messaging.
• Clinical data: capture and analyze. Medication histories, for starters. 

Two fundamentals for a patient-centered medical home: an engaged and productive staff and an organized and disciplined approach to finances.
• Build a productive and supporting environment 
• Put finances in order 
• Install a system to collect data.  
• Use the system to improve care. 


To be continued. Join us next to see why Medical Homes are relevant to the National Eye Care Communications Project.


Alistair Jackson, M.Ed.
Jim Grue, O.D.

Communications, Connected Care and ACOs, Part 2

Continued from last day, "Communications, Connected Care and ACOs, Part 1" ...


Why are ACOs relevant to Eye Care and the National Eye Care Communications project? 

Changing your practice to demonstrate the ability to be a productive team member is significant and helping you do this is one of the primary goals of the NECC Project.

In a nutshell, ACOs matter. They appear to be all about larger health systems, hospitals and group practices but as the health care reform game plays out ACOs are taking control of access to your patients, in the name of “shared savings”. Your patients still need eye care and if you're not involved in your local ACO, your patients will be awarded to others who are. Hospital-based EHRs don't do as good a job of eye care as your EHRs do, but they are nevertheless certified and meet Meaningful Use criteria. That means you can lose patients to those providers and systems. You owe it to yourself at least to be finding out if you have an ACO in your locality, or if any of the health systems in your area are working toward forming one. Since many ACO's are still at the formative stage, now is the perfect time for you to get involved. Once they're functioning, it may be too late to open the door for your participation.

ACO's are a good example of how health care reform doesn't apply only to providers who take Medicare. As seen in the link above to the list of 80 current ACOs, team-based care and reimbursement has already well surpassed the bounds of CMS. You may not be driven by the CMS EHRs Incentive Program and, certainly, your involvement in the National Eye Care Communications Project doesn’t require meaningful use attestation. But if, by virtue of the fact that you cannot communicate as required with other health care providers, you do not qualify to participate on a chronic care team, then your business consequences will far surpass any CMS penalties.

If you're not already aware of the ACOs being organized in your area, not already talking to "the powers that be", you may have an uphill battle to be included. We encourage all NECC Project participants to get on this now. It's critical that eye care providers be involved in chronic care teams. The question is not whether ACOs want to include eye care; it’s whether the ECP will be a hospital-based employee or potentially an independent eye care provider.


Alistair Jackson, M.Ed.
Jim Grue, O.D.

Communications, Connected Care and ACOs, Part 1

What are ACOs? 

Accountable Care Organizations (ACOs), in the opinion of most national authorities, are the direction healthcare care delivery and reimbursement is going. An ACO refers to a group of physicians, hospitals and other suppliers of services that work together to provide coordinated team-based care to insurance beneficiaries. Several groups of providers and suppliers are eligible to participate as an ACO:

• ACO professionals in group-practice arrangements. 
• Networks of individual practices of ACO professionals. 
• Partnerships or joint-venture arrangements between hospitals and ACO professionals. 
• Hospitals employing ACO professionals. 
• Such other groups of providers and suppliers as the Secretary determines appropriate. 

ACOs are popping up everywhere. CMS is not the only organization driving them. In fact, the majority of ACOs in existence today are commercial ACOs not tied into CMS initiatives such as the Shared Savings Program. See the CMS list of 27 ACOs and compare it against the other list of 80 ACOs. The lists show locations, so be sure to see which ones are in your back yard.

• CMS releases list of 27 ACOs  
• 80 Accountable Care Organizations to Know

Another group, estimated at 150, will begin getting bundled payments from Medicare on July 1, 2012, then another on Jan 1, 2013. 

How will ACOs affect my eye care practice?

It's important to understand the effect of this trend on your practice. There are two important points:

Reimbursement. The way providers get paid for patients covered through an ACO will change. The ACO will receive a “bundled” payment for the care of the patient and the ACO will pay the providers delivering the care. You will no longer be able to bill the insurance company under a fee-for-service payment system.

Access. Your access to patients covered by the ACO will be affected. A fundamental concept of the emerging healthcare delivery system is that outcomes for patients with chronic conditions is best delivered through teams of providers communicating closely about the patient, with the patient an integral part of the process, in order to determine the best management plan. Coordinating this team delivery of care is one of the main functions of the ACO. If you are not part of the team delivery system, you will likely lose access to these patients. As a part of the coordination of care, the ACO not the patient actually schedules the patient's routine appointments with team members. 

The ACO also is responsible for ensuring that every provider who sees the patient has the appropriate patient medical information. This is information shared among all team members. The ACO, as part of its reimbursement, gets a specific fee for doing this coordination. Thus, the ACO is becoming your new referral center.

There are three things you need to be doing before you'll be considered by an ACO to be part of a care team:

1. You must be using a certified EHR;
2. Your EHR must have the capabilities to communicate electronically with the ACO; 
3. Most likely, you will need to demonstrate a changing culture in your practice, that you are embracing the implications of being an effective team member versus a standalone practitioner, as is now the dominant model.

To be continued ...

Alistair Jackson, M.Ed.

From Anti-EHRs to Pro-ACOs: a Must-Read Story

Have I ever told you about what I call "Noah syndrome"? You've heard about the ark and the flood, right? Poor old Noah was told not only to build the ark but also to warn everyone about the coming flood. Given many years of drought, everyone thought he was crazy. They taunted him and laughed. I suspect you know how that story ended! Sometimes I feel like Noah. The transformation of health care has seemed a far-off reality, a bit of a joke in the minds of some. Many older doctors especially have sworn they'd rather retire than switch. 'Paper works fine thank you. The world can just go ahead and change without me.'


Meet Dr. Jeffrey Selwyn. His is a story you really must read! With thanks to Diana Manos, Senior Editor for Healthcare IT News, here is "Not retiring at 65: Physician goes from anti-EHR to pro-ACO".


Enjoy!


Alistair Jackson, M.Ed.


P.S. How about you? Do you have a similar story from our eye care world? If so, I'm extending an invitation to tell it. Two options:
1. Click on Comments and Reactions below this post. You'll be given a window in which to tell your story... or just respond to this one.
2. Contact me via email. I'd be happy to talk offline, hear more and discuss how best to tell your story.

A National Eye Care Communications Project

Why does eye care need a national eye care communications project?            

The changes under way presently in the delivery and reimbursement of health care are occurring outside the normal purview of independent eye care providers. Nevertheless, they will affect the success of your business. The infrastructure of the new system is being formed in every state, in preparation for going national. The National Eye Care Communications Project is a collaborative effort that allows you to work with other eye care providers to understand these changes, and to transform the culture of your businesses, engage effectively in connected care, and build better practices.

What’s driving the change?

CMS is driving a significant transition, one being followed by other payers, away from fee-for-service toward bundled payments. Accountable Care Organizations (ACOs) are now being reimbursed for providing packages of services. In order to retain access to your patients covered under bundled payments, you must gain entry into your local and regional ACOs.

Bundled payment means another subtle transition: away from individual providers to team delivery of care and shared savings. The predominant model is the patient-centered medical home, found within ACOs.  Medical Homes are starting by targeting treatment of chronic conditions such as diabetes and heart disease but are designed to eventually coordinate the care of all chronic conditions.

What does the ACO have to do with the HIE? Why both?

The ACO is a local organization through which team delivery of care and shared savings are offered. Since all chronic care will eventually take place through this group, you will need to be part of it in order to retain access to your patients and grow your business. Part of your eligibility to belong to an ACO is your ability to communicate electronically with other providers. That’s where the HIE comes in. The HIE is the communications network that lets you move protected health information securely from your office to those of other health care providers, whether in your local area or across the country. 

Why should I participate? What does my office have to do?

Ultimately, your success will depend on what you do in your local community. We can expect the process to vary somewhat by state, by ACO and by community. Your participation in the collaborative process of the National Eye Care Communications Project will bring the following benefits, and more:

• you’ll understand the general principles at work as ACOs and HIEs take shape
• you’ll collaborate with other ECPs going through the same process in their communities and see what works and doesn’t work
• you’ll learn how to ensure the local ACO understands what you as an eye care provider bring to the care team, and that it values and encompasses your contributions.

Want to know more about this project? Contact us here.

Alistair Jackson, M.Ed.

Looking "outside", seeing the road ahead

Our December 19, 2011 post was entitled, "To understand eye care, look outside!" We talked about the infamous crystal ball, which no one seems to have, and why it's not actually needed if we simply look outside eye care ... at the hospitals. If we follow hospital news, we'll see the road ahead for eye care, really for the domains of care of all independent practitioners.


Today's look at Becker's Hospital Review reveals yet another new healthcare model: the integrated care model, or network. Two have been announced in the last week, one in Central Georgia and the other in Western New York. Let's look at the one in New York since it involves a BCBS partnership. The bolded words are mine, for emphasis.

"BlueCross BlueShield of Western New York and Kaleida Health of Buffalo, N.Y., announced plans to partner and form an integrated care model, the first of its kind in the Buffalo region.

The model includes a network of Western New York physicians partnering with health system Kaleida and health insurer BCBS to create a physician-led organization. It's a first of its kind healthcare delivery model for the Buffalo region in that it combines a health plan, health system and group of physicians providing patient-centered care.

It's essentially a commercial accountable care organization. Kaleida Health refers to it as a "strategic partnership" intended to "assure accountability for both the clinical outcomes of the patients and the costs of the care delivery model."

Are we drifting off into aspects of health care reform that don't apply to ECPs? Absolutely not. Admittedly, we still feel the need to point to the evidence that says (a) health care is transforming, and (b) the very changes we're seeing today in the hospitals are the changes we'll see in your practice tomorrow. If we're harping on HIEs and ACOs, it's because these entities matter for you. This is not about stimulus money, neither grants nor penalties. It's about the survival of your business.


Action items for ECPs:

1. Find out about your state HIE and how you can get connected to it.
2. Inquire about local ACOs and what it takes to belong to a care team.
3. Ask your software vendor about their readiness to offer you ONC Direct. (We have written a number of posts recently on HISPs and ONC Direct. See those for more details.)
4. At the bottom of this post, see "Comments and Reactions". If you have a question, click on that title and type away. We'll be more than happy to respond.

Alistair Jackson, M.Ed.



  

ACOs, your new referral center

Accountable Care Organizations (ACOs), in the opinion of most national authorities, are the direction healthcare care delivery and reimbursement is going. It's important therefore that you understand the effect of this trend on your practice. There are two important points:

1.  Reimbursement. The way you will get paid for patients covered through an ACO will change. The ACO will receive a “bundled” payment for the care of the patient and the ACO will pay the providers delivering the care. You will no longer be able to bill the insurance company under a fee-for-service payment system.
2. Access. Your access to patients covered by the ACO will be affected.  A fundamental concept of the emerging health care delivery system is that outcomes for patients with chronic conditions is best delivered through teams of providers communicating closely about the patient, with the patient an integral part of the process, in order to determine the best management plan. Coordinating this team delivery of care is one of the main functions of the ACO. If you are not part of the team delivery system, you will likely lose access to these patients. As a part of the coordination of care, the ACO not the patient actually schedules the patient's routine appointments with team members.

The ACO also is responsible for ensuring that every provider who sees the patient has the appropriate patient medical information. (This is information shared among all team members.) The ACO, as part of its reimbursement, gets a specific fee for doing this coordination. This is why the ACO is becoming your new referral center.

There are three things you need to be doing before you'll be considered by an ACO to be part of a care team:

1. You must be using a certified EHR;
2. Your EHR must have the proper capabilities to communicate electronically with the ACO;
3. Most likely, you will need to demonstrate a changing culture in your practice, that you are embracing the implications of being an effective team member versus a standalone practitioner, as is now the dominant model.

Changing your practice to demonstrate the ability to be a productive team member is significant. Fortunately, there are now groups of eye care professionals collaborating to go through this process. We'll be sharing insights, on an ongoing basis, right here on EMRlogic Live. This is new territory for all. We hope you'll check back often and keep learning with us.

Jim Grue, O.D.

Are you too late for your local ACOs?

ACOs are popping up everywhere. Did you know? CMS is not the only organization driving them. In fact, the majority of ACOs in existence today are commercial ACOs not tied into CMS initiatives such as the Shared Savings Program. That says a couple of things:

1. That health care reform initiatives are growing beyond the bounds of Medicare. We all remember the days, I'm sure, when many protested, "Health care reform doesn't apply to me; I don't do enough Medicare to qualify for the stimulus funds."
2. That you can't follow only the CMS news for your region with regard to ACOs. You need to be following the hospital news as well. (See a good link below.)

Where does the rubber meet the road with ACOs? They're the organizations pulling health care providers into chronic care teams. Patient-centered medical homes are taking flight within ACOs. They're also the entities being reimbursed for team care and made responsible for provider payment.

But here's the real rub: if you're not already aware of the ACOs being organized in your area, not already talking to "the powers that be", you may have an uphill battle to be included. Get on this now. It's critical that eye care providers be involved in chronic care teams. I suppose the question is whether or not the ECP will always be a hospital-based ECP.

ACOs are taking over access to patients, including your patients. If you're not part of your local ACOs and their care teams, you will eventually struggle to retain your patients.

Below are two must-read articles on the topic of ACOs. See the CMS list of 27 ACOs and compare it against the other list of 80 ACOs. The lists show locations, so be sure to see which ones are in your back yard.

• CMS releases list of 27 ACOs
• 80 Accountable Care Organizations to Know

Also look here for that "hospital news" mentioned above. See especially the two articles (April 10 and April 12) on the Patient Centered Medical Home.

Alistair Jackson, M.Ed.

Reform at a glance

You may not have seen last week's April 10 press release from CMS entitled, "New Affordable Care Act program to improve care, control Medicare costs, off to a strong start ... Over 1.1 million beneficiaries now served by Accountable Care Organizations." I'm highlighting some excerpts not due to the message itself but because the press release touches on so many of Reform's key concepts. It's instructive to see them tied together and articulated for public consumption.

A new program that will help physicians, hospitals, and other health care providers work together to improve care for people with Medicare is off to a strong start, the Centers for Medicare & Medicaid Services (CMS) announced today.  

Under the new Medicare Shared Savings Program ... 27 Accountable Care Organizations (ACOs) have entered into agreements with CMS, taking responsibility for the quality of care furnished to people with Medicare in return for the opportunity to share in savings realized through improved care. The Shared Savings Program and other initiatives related to Accountable Care Organizations are made possible by the Affordable Care Act, the health care law of 2010. Participation in an ACO is purely voluntary for providers and beneficiaries and people with Medicare retain their current ability to seek treatment from any provider they wish.

The first 27 Shared Savings Program ACOs will serve an estimated 375,000 beneficiaries in 18 States. This brings the total number of organizations participating Medicare shared savings initiatives on April 1 to 65 ... 

Anyone who has multiple doctors may have experienced the frustration of fragmented and disconnected care: lost or unavailable medical charts, trouble scheduling an appointment or talking to a doctor, duplicated medical procedures, or having to share the same information over and over with different doctors.

Accountable Care Organizations are designed to lift this burden from patients, while improving care and reducing costs. The Shared Savings Program was created by the Affordable Care Act after a number of efforts in the private sector showed that improving care can lead to lower costs. The selected ACOs include more than 10,000 physicians, 10 hospitals, and 13 smaller physician-driven organizations in both urban and rural areas. Their models for coordinating care and improving quality vary in response to the needs of the beneficiaries in the areas they are serving. CMS is reviewing more than 150 applications from ACOs seeking to enter the program in July. 

To ensure that savings are achieved through improving and providing care that is appropriate, safe, and timely, an ACO must meet strict quality standards. For 2012, CMS has established 33 quality measures relating to care coordination and patient safety, appropriate use of preventive health services, improved care for at-risk populations, and the patient and caregiver experience of care.

CMS also announced today that five ACOs are participating in the Advance Payment ACO Model beginning April 1. This model will provide advance payment of expected shared savings to rural and physician-based ACOs participating in the Shared Savings Program that would benefit from additional start-up resources. These resources will help build the necessary care coordination infrastructure necessary to improve patient outcomes and reduce costs, such as new staff or information technology systems. CMS is reviewing more than 50 applications for Advance Payments that start in July.

To learn more about the ACOs announced on April 10, visit: http://www.cms.gov/apps/media/fact_sheets.asp

For more information on the Advanced Payment ACO Model, including the participating ACOs, visit: http://innovations.cms.gov/initiatives/ACO/Advance-Payment/.


As a reminder, care teams (to care for patients with chronic conditions) are being organized in Medical Home models, which fall under the umbrella of ACOs. ACOs, accountable care and shared savings are for eye care too.


Alistair Jackson, M.Ed.

Accountability: it cuts both ways

Accountability is a basic tenet of today's transformation of health care. Why? Perhaps because the lack of accountability inherent in a paper-based fee-for-service honor system is the root cause behind the near bankruptcy of Medicare.


Last week, we saw that accountability in health care reform is not just about Providers becoming accountable to low cost and high quality; Payers are also accountable. We've seen fraudulent providers get caught and penalized; now we're seeing unreasonable insurers stopped in their tracks. Secretary Sebelius called on two insurance companies to drop unreasonable rate hikes in nine states.

"Thanks to the Affordable Care Act consumers are no longer in the dark about their health insurance premiums," said Secretary Sebelius.  "Now, insurance companies are required to justify rate increases of 10 percent or higher.  It’s time for these companies to immediately rescind these unreasonable rate hikes, issue refunds to consumers or publicly explain their refusal to do so."

In these nine states, the insurers have requested rate increases as high as 24 percent. These increases were reviewed by independent experts to determine whether they are reasonable.  In this case, HHS determined that the rate increases were unreasonable, because the insurer would be spending a low percentage of premium dollars on actual medical care and quality improvements, and because the justifications were based on unreasonable assumptions.

In light of the March 19 HHS press release and this week's Supreme Court hearings on "health care reform", it's worth re-emphasizing that the Affordable Care Act and many other examples commonly cited in the media as health care reform are more accurately called "health insurance reform". Health care reform and key concepts like accountability, transparency, portability and interoperability are not up for discussion. Like EHRs and the new technology of health care, these basic tenets are here to stay. Expect to see them everywhere, including in your own back yard. And prepare your business for them accordingly.

Alistair Jackson, M.Ed.

Know Your Community: Accountable Care Organizations

My colleagues Dr. Chuck Haine and Alistair Jackson have written previously about Accountable Care Organizations. (See the Archives for Chuck's post from December 23, 2011 and Alistair's from February 17, 2012.) My question for you is, have you taken the time to see if there is an ACO in your area?  ACO’s represent a new patient referral and reimbursement system whereby the ACO receives a bundled payment for the care of the patient instead of each provider being able to bill fee-for-service to Medicare. The ACO then becomes responsible to distribute payments to the providers involved in the care of the patient. This in turn means two things: one, that the ACO chooses the participating providers and, two, that the ACO controls access to patients.

My point today is this: if you don’t learn how to become part of this new delivery system, it will affect your access to patients.  You owe it to yourself at least to be finding out if you have an ACO in your locality, or if any of the health systems in your area are working toward forming one.  


There are many ACO's functioning now already. Another group will begin getting bundled payments from Medicare on July 1, 2012, then another on Jan 1, 2013.  Since many ACO's are still at the formative stage, it's the perfect time for you to get involved.  Once they're functioning, it may be too late to open the door for your participation.


ACO's are a good example of how health care reform doesn't apply only to providers who take Medicare. You may not be concerned about stimulus incentives since, based on your current Medicare volume, your eligibility is low. Correspondingly, you may be even less concerned about  a small Medicare penalty. But what if, by virtue of the fact that you do not have certified EHRs and cannot communicate as required with other health care providers, you do not qualify to participate on a chronic care team? Losing access to patients is certainly a more serious matter than a 2% Medicare penalty. This is why we have maintained that the EHR Incentives program is really not about the money - it's about the survival of your business. Know your community and get involved in its healthcare programs. They're going to affect your business for better or for worse. It's within your grasp to make it for the better.


Jim Grue, O.D.