Archive
ACOs are not for Sissies
This is the title of a presentation I gave to the Tampa Bay MGMA on July 12.
Many have touted ACOs as one of the most critical reforms in the Affordable Care Actbecause of its focus on realigning healthcare provider financial incentives to patient-centered and preventive care and away from procedure/volume based care. I agree with that assessment. Unfortunately, the proposed regulations (which have been justifiably bashed by many in the healthcare industry) have done much to derail ACOs.
The final regulations will hopefully incorporate many of the criticisms so that the movement toward ACOs can continue. According to two industry leaders, ACOs must be successful:
“The Accountable Care Organization: Whatever Its Growing Pains, The Concept Is Too Vitally Important To Fail” — Health Affairs, 30, no. 7 (2011):1250-1255
HIT, Small Physician Practices, and IPAs
In its June 2011 Research Brief, the National Institute for Health Care Reform reports that “lessons from independent practice associations (IPAs) — net-works of small medical practices — can offer guidance about overcoming barriers to HIT adoption and use” in small physician practices. The study found that IPAs, as local networks of independent physician practices, promoted the development of HIT-knowledgeable physician leaders who were able to gain the trust of their less HIT experienced colleagues in coordinating efforts to deal with risk-based managed care contracts.
The study concludes that “IPA experiences with HIT adoption can offer insights for other entities charged with helping physicians in small practices overcome barriers to HIT adoption and use.”
(The study may also provide critical insights to, and hope in, dealing effectively with the even greater hurdles that physician groups are facing in their coming together to form accountable care organizations, where HIT will be critical to success.)
Compliance Oversight for Healthcare Leaders and Compliance Plans
In a new seven minute video presentation, OIG Inspector General Daniel Levinson and Chief Counsel Lewis Morris discuss the role of compliance and its importance to the health care industry.
By now, I think we all know that compliance with healthcare laws and regulations is good, and that noncompliance can be very bad. There is nothing much to learn in seven minutes. However, there is an important reminder in the video that the OIG wants providers to have effective compliance plans in place.
Nursing homes are required by the healthcare reform law to have such plans, and the law gives the OIG the power to require other healthcare industry groups to have compliance plans.
It is only a matter of time before this requirement is imposed on physicians. The OIG published guidance for physician compliance plans over 10 years ago. That guidance is worth reading again. Similar compliance guidance can be found at the OIG website for other kinds of healthcare providers.
This is something that healthcare providers should not put off any longer.
NEW TECHNOLOGY TO HELP FIGHT MEDICARE FRAUD
Predictive modeling once was used to help pick stocks on the rise and now is going to be used to identify Medicare cheats.
CMS announced in a press release on June 17, 2011 that it will be using new technology to track down healthcare fraud. CMS states in its press release that this technology is similar to tools used by credit card companies. This is part of the White House’s continuing campaign to cut waste in the Medicare program.
You can learn more about this technology at this CMS Factsheet.
Better Care and the Bottom Line
According to a survey of health leaders published in a HealthLeaders Media Intelligence Report, “Better Care and the Bottom Line” (June 2011), best practices for chronic care and evidence-based medicine are needed to overcome drivers of waste such as overutilized services and a lack of integration.
- 52% of the survey respondents put overutilization of services in their top 3 drivers of waste in the healthcare system
- 67% say a realistic goal for readmission rates is 1% to 3%, but only 40% have achieved that goal
- The top three tools cited to address medical cost escalation are chronic care management, evidence-based medicine, and medical liability reform.
Healthcare providers are being presented with numerous avenues for achieving better quality and more cost effective medical care — ACOs, consolidation of practices, and affiliation with hospitals, to name just a few.
If you would like to get a copy of the Report, click here.
ACOs — Savior of Physician-Based Healthcare?
I met with a large group of unaffiliated physicians last night who were worried about how to survive in this era of tightened budgets and schizophrenic healthcare reform. They had decided to form a large multi-specialty group, and be their own ACO, in the hope of controlling their care of their patients.
It is necessary for physicians to come together to form new delivery systems for patient care. It is exciting. It is also scary. Healthcare is not for sissies.
Read this article and download this special report about ACOs from HealthLeaders Media.
Physicians have an opportunity that will not last long to retake the healthcare delivery system for their benefit and for the benefit of their patients.
We all know that patients want physicians who care about them and will take care of them. Economics are important, but no one wants his or her healthcare to be so managed and so strained through insurance company and regulatory filters that it looks like the only thing that matters are the economics.
The heartbreak for so many physicians is that they cannot do what they went to med school to do — take care of people. Physicians have been forced to deliver the minimum amount of care, in the shortest time, to the maximum number of patients. The comfort of a trusted physician is what patients want.
ACOs may provide the mechanism by which physicians can reclaim the practice of medicine as a calling. Or, they can let the actuaries, accountants, and lawyers make the important decisions about healthcare.
Being proactive, being smart, and being cautious are critical to suviving as an independent healthcare provider.
Buckle Up: Proposed CMS ACO Regs, OIG Notice of Waiver, and FTC/DOJ Announcement
A lot happened this morning in the area of ACOs.
Whether any of the hundreds of pages of paper will be sufficient guidance to meaningfully assist healthcare providers and their advisors on how to proceed, only time will tell.
- CMS published its proposed regulations implementing Section 3022 of the Health Care Reform Act relating to payments to providers and suppliers participating in Accountable Care Organizations (ACOs).
- The OIG published its notice relating to the application (and waiver) of certain fraud and abuse laws in connection with ACOs.
- The FTC and DOJ published their proposed statement of antitrust enforcement policy relating to ACOs.
These are only proposed at this stage, and there is time to comment on the practicalities and difficulties of the proposals.
I suspect that we are going to see things start moving fast. There will be fear of being left behind.
So, it is time for physicians (if they haven’t already — which they should have been) to get educated about ACOs and what they mean to their practice of medicine. ACOs can provide a method for physician practices to remain independent. ACOs can also promote the consolidation of physician practices into larger single-specialty and multi-specialty groups. ACOs can also lead to the employment of physicians by hospitals and other large integrated healthcare delivery systems.
Standing still is an option for only the very short term.
Akerman Senterfitt’s brief summary of the proposed regulations can be found here.
Alternatives for Physicians
Physician practices are dealing with increased demands from the government, from managed care companies, from employers, and from patients to provide higher quality and better access to health care at cheaper costs. While these demands existed before health law reform, health law reform has exacerbated the pressures and the uncertainties on physicians and their advisors. Most of the alternatives for responding to these demands have been around for some time, but the need for more decisive action has greatly intensified. Some of the intensity is artificial, fueled by the fear of being left behind. In some cases, it is too early to do anything, because so much is still in flux. Newspapers, magazines, professional websites, and blogs are reporting on these issues more and more. This is likely to add to the confusion of what to do and when to do it.
Nevertheless, neither opportunities nor threats can be ignored. Physicians and their advisors must be alert and be prepared to act when the time is appropriate. Premature action may be as hurtful as delay. Staying informed is critical.
Here is a list of practice alternatives that I am seeing, and my physician clients are experiencing (and, in some cases, adopting). The list is not meant to be exhaustive, and I would like to hear what any of you or your clients are experiencing in this time of professional, economic, and legal uncertainty.
- Internal improvement of practice management — e.g., better billing and collection procedures, adoption of EHRs, employing more skilled administrative support staff
- Expansion of healthcare services being offered — e.g., adding nontraditional healthcare services, employing specialists
- Engaging outside practice management companies
- Consolidation/merger of solo and small practices with larger, same specialty practice groups
- Consolidation/merger/affiliation with multi-specialty practice groups
- Affiliation with IPAs, PHOs, and now ACOs
- Sale of practice to national practice management, single specialty, and multi-specialty corporations
- Sale to, affiliation with, or employment by hospital organizations
- Opting out of Medicare and managed care plans and establishing a concierge practice for selected patients
Over the next several postings, I will review these alternatives and discuss the issues involved.
Priorities
The recent Federal District Court holding that Obamacare is unconstitutional is another distraction to the real problem, which is, in case it has been drowned out by all of the static, how to improve health care for Americans in the context of the current economic situation.
I do not see how the issues of health care and health care reform can be solved without a shared view of our priorities.
What is the correct balance between entitlement programs directed to the elderly, disabled, and poor Americans, including the newly poor, unemployed, and uninsured, on the one hand, and a crippling federal debt, fighting wars to protect our security, and increasingly economically strapped individuals, businesses, cities, and states, on the other. Is access to health care a right? Is it more important than education, security, or economic and social freedom?
All these things are important to us as Americans.
So, what do we do first? In my opinion, we must do two seemingly incompatible things simultaneously — improve the quality of the care given (that includes allowing more creative and alternative modalities and providing more preventive care free of insurmountable regulatory obstacles) and reduce the overall costs of the care (that includes eliminating unnecessary, defensive, and fraudulent care).
We cannot talk about how much we should spend on health care without knowing how much it actually costs.
Obamacare is sensitive to these issues, but, at the same time, it is insensitive to the regulatory and economic burdens it places on Americans.
How do we talk about priorities in health care? We start with answering the question of “What would an ideal designed-from-the-ground-up health care delivery system look like?” If we don’t even try to understand what the ideal is, how can we know how to rank our priorities? In the endless process of legislating and adopting regulations, and incessant political bickering, has anyone taken the time to think about the question of how should health care delivery work in America? That would be a good place for a bipartisan effort.
This is not hopeless. Americans are finding ways to address our health care crisis on their own. Read the article, “The Hot Spotters,” by Dr. Atul Gawande in the January 24th issue of The New Yorker. President Obama is correct when he says “Yes, we can!” He is also correct when he said in his remarks on the State of the Union last month that “We do big things” in America.
It’s time.
Are ACOs Destined to Fail?
HealthLeadersMedia published today an article titled “5 Reasons Why ACOs Could Fail.” There is nothing new about these five reasons. They are the ones all of us are aware of that haunt any effort these days to put together an integrated group of healthcare providers. Nevertheless, it is good to be reminded of these issues, because if not confronted and conquered, no group of providers will be anything more than a confederation of solo practitioners.
Here are the five reasons:
1. EHR — Without EHR, there can be no integrated healthcare. Many physician practices still do not have any form of electronic record system. The recent CMS roll out of the EHR incentive program registration may spur some activity.
2. Income Redistribution — ACOs must have a system for distributing the savings that are earned as a result of quality and utilization controls. The problem is that the rewards are based on a paradigm shift from the current system that pays more for doing more.
3. Lack of Patient Incentives — There are no economic reasons for patients to join an ACO or to cooperate in reducing costs relating to their care.
4. Cost Management Confusion — Providers will need assistance from actuarial and insurance consultants in order to set up an ACO.
5. Cost Shifting — The physician practice industry is consolidating through hospital acquisitions and mergers, and this may force increases in private insurance costs through cost shifting.
The above five reasons are from the HealthLeadersMedia article.
Here’s a sixth reason from me:
6. Out of Pocket Costs — Related to some of the reasons listed above is the cost and time to establish a viable ACO. Who will pay or reimburse the costs incurred by physician leaders who see longterm value in setting up an ACO?
Leadership, early planning, and a willingness to invest in the future are needed to overcome these obstacles. Can physicians do this on their own or will they wait for the hospitals and insurance companies to do it for them. If they wait, physicians stand to lose much.
Joseph Rugg's Health Law Blog 