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Volume 3, Number 5 May, 2012
Published by Health Policy Publishing, LLC ● 209-577-4888 ● www.AccountableCareNews.com
Patient-Centered Medicine and ACOs – It’s Not Just about Primary Care By James B. Rickert, MD
atient-centered medicine is a specific physician behavior or skill set that helps doctors improve their patients' clinical outcomes and health care experience. Practitioners employ good communication, show empathy, and develop a
personal relationship with their patients. They also provide collaborative care, working as a team with other physicians and the patient and requesting input from their patients regarding their communication and similar skills. These physician behaviors have all been shown to improve clinical outcomes while reducing unnecessary interventions, and they integrate well within accountable care organizations.
Accountable care organizations, or ACOs, are designed to provide high quality patient care while reducing costs. Cost reduction is achieved by reducing unnecessary or duplicative care, while quality is assured by continual measurement of quality care indicators and assessment of patient satisfaction rates. This dual focus on both quality and cost dovetails nicely with the skills of physicians who employ patient centered medicine. Physicians practicing patient-centered care improve their patients’ clinical outcomes and satisfaction rates by improving the quality of the doctor-patient relationship, while at the same time decreasing the utilization of diagnostic testing, prescriptions, hospitalizations, and referrals.1 This type of care can be employed by physicians in any specialty, including my own specialty of orthopedics, and it is effective across disease types. 1 http://healthaffairs.org/blog/2012/01/24/patient-centered-care-what-it-means-and-how-to-get-there
continued on page 4
Home Health Care and Predictive Modeling: Reducing Unplanned Rehospitalizations By Tessie Ganzsarto and Dan Hogan
ome health care is changing. A galaxy of powerful new technologies is redefining the home care experience for patients, providers, and families alike. Home care agencies must strive to put this new technology to meaningful use. Data and analytics are not just immovable numbers and statistics on a page – they hold the key to
reducing patient hospital readmissions, improving patient outcomes, and crossing the threshold into a higher quality of care. Across the health care sector, the sweeping changes of a new era of Federal mandates for improved patient outcomes, reduced reimbursements, and shared risk are forcing hospital systems and home care agencies to build stronger partnerships in ACO and ACO-like models and in initiatives specific to reducing unwarranted readmissions.
With the imminent retirement of the Baby Boomers over the next 15 years, the number of patients needing home health services will grow at an exponential rate. And because these patients will be Baby Boomers – defined by their expectations of aging with amenities – they will demand and expect to be cared for in their homes instead of a nursing facility. Home health care services are patient-centered, after all. It is natural for a patient to prefer to be in his or her own home, where care can be personalized and consistently monitored.
The tech firm Medalogix, a Nashville-based company, emerged from the idea that homebound patients would benefit from a more in-depth analysis of the risks associated with their conditions and medications, and that home care agencies – when armed with that information – would be better able to remediate that risk. A litany of studies has shown that patient outcomes are far better at home than anywhere else for a variety of clinical conditions.
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In This Issue
1 Patient-Centered Medicine and ACOs – It’s Not Just About Primary Care
1 Home Health Care and Predictive Modeling: Reducing Unplanned Rehospitalizations 2 Editor’s Corner Report from the Field: What’s the Difference between ACOs and “AC-Like” Arrangements?
3 Nurturing e-Patients in the Medical Home and the ACO
7 Thought Leader’s Corner
9 Industry News
12 Catching Up with…. Douglas A. Hastings
2 Accountable Care News May, 2012
Published by Health Policy Publishing, LLC ● 209-577-4888 ● www.AccountableCareNews.com
Accountable Care News May 2012 – Volume 4, Issue 5 ISSN 2166-2770 (Electronic) ISSN 2166-2738 (Print) National Advisory Board
Peter Boland, PhD Managing Partner, Polakoff Boland, Berkeley, CA.
Lawrence P. Casalino, MD, PhD, MPH Livingston Farrand Associate Professor of Public Health, Weill Cornell Medical College, New York, NY
Wes Champion Senior Vice President, Premier Consulting Solutions , Charlotte, NC
Charles A. Coleman, PhD, CMPH Worldwide Healthcare Solutions Senior Executive -- Providers/ACO/Bio- Surveillance/Clinical Research AMRC IBM, Research Triangle Park, NC
Don Crane, JD President and Chief Executive Officer, California Association of Physician Groups, Los Angeles, CA
Duane Davis, MD Vice President, Chief Medical Officer, Geisinger Health Plan, Danville, PA
William DeMarco President and Chief Executive Officer, Pendulum Healthcare, Rockford, IL
Jill H. Gordon, JD, MHA Partner and Co chair, Health Law Group, Davis Wright Tremaine LLP, Los Angeles, CA
Douglas A. Hastings, JD Chair, Board of Directors, Epstein Becker & Green, PC , Washington, DC
Bruce Perkins SVO, Healthcare Delivery Systems, Humana, Louisville, KY
Ann Robinow President, Robinow Health Care Consulting, Minneapolis, MN
Mark Werner, MD, CPE, FACPE Chief Clinical Integration Officer, Fairview Health Services, Minneapolis, MN
________________________________
Publisher Clive Riddle, President, MCOL Senior Editor Raymond Carter Accountable Care News is published monthly by Health Policy Publishing, LLC. Newsletter publication administration is provided by MCOL. Accountable Care News 1101 Standiford Avenue, Suite C-3 Modesto, CA 95350 Phone: 209.577.4888 Fax: 209.577.3557 [email protected] www.AccountableCareNews.com
Editor’s Corner Raymond Carter, Senior Editor, Accountable Care News
We continue our 2012 ACO “Reports from the Field” on ACO issues and developments with a post from Vince Kuraitis at Better Health Technologies, LLC.
Vince Kuraitis Principal Better Health Technologies, LLC Boise, ID
What’s the Difference Between ACOs and “AC-Like” Arrangements? A lot. AC-Like arrangements will be MUCH simpler to create and maintain. The health care market is moving toward accountable care. There are at least two broad paths forward: (1) formal Accountable Care Organizations (ACOs), by which care providers contract with Medicare; and (2) informal Accountable Care-Like (AC-Like) arrangements between care providers and commercial health plans What are the differences between these routes? I see at least six factors at play: (1) Transaction costs, (2) Timing, (3) Incrementalism, (4) Flexibility, (5) Capital cost, and (6) Visibility. Let’s take a look at each: 1. Transaction Costs. ACO? Everyone needs their own attorney, including one for the new yet-to-be-created ACO entity. Expect to pay people during months of negotiations. Anticipate formal board meetings, minutes, white china. But want to form an AC-Like arrangement? Gather people in a room and have a meeting. Paper plates and plastic cups. Yes, you’ll still need the lawyers to write up a contract. 2. Timing. ACO? Anticipate months of negotiation with partners to form the ACO. Anticipate months of negotiation with Medicare to hammer out a contract. AC-Like arrangement? Theoretically it could all be done in an afternoon. 3. Incrementalism. ACO? Want to start small with an experiment? Sorry, Medicare has a long list of take-it-or-leave-it conditions in all their ACO models. AC-Like arrangement? Want to start with an experiment, e.g., putting nurse care managers in primary care physician offices? Pick up the phone and start negotiating. 4. Flexibility. ACO? Want to change something about your ACO internal structure? Start digging into the ACO by-laws. Want to change your contract with Medicare? Sorry, your deal runs for 3 years. AC-Like arrangement? Pick up the phone and start renegotiating. 5. Capital Costs. ACO? The American Hospital Association estimated that capital costs could range from $11–26 million. AC-Like arrangement? It won’t be cheap, but it will depend greatly on what you plan to do. 6. Visibility. ACO? Formal ACOs will be visible from miles away -- think elephants on the Serengeti. An ACO that wants to contract with Medicare must establish itself as a corporation. The Medicare ACO models have substantial disclosure and reporting requirements. We won’t know everything about formal ACOs, but we will know a lot. ACOs cannot hide. AC-Like arrangements? AC-Like arrangements between care providers and commercial payers could be much more difficult to spot and categorize -- think chameleons in the jungle. These informal arrangements can be made through private contracts — therefore not necessarily publicly identifiable. Some AC-Like arrangements have been visible and have been announced with press releases and confetti -- but it’s also foreseeable that there will be circumstances where deals will be quietly negotiated without fanfare. Chameleons can choose to blend in, or they can change their colors. The bottom line? AC-Like arrangements between commercial health plans and care providers will be MUCH simpler to create and maintain
Originally posted by Vince Kuraitis on his e-CareManagement blog on March 9, 2012, with the visibility addendum posted on March 15, 2012. Vince can be reached at [email protected].
May, 2012 Accountable Care News 3
© 2012, Health Policy Publishing, LLC. All rights reserved. No reproduction or electronic forwarding without permission. page 3
The engaged patient is a cornerstone of the PCMH
and, like Alice, is part of the care team that also includes
specialists, therapists, pharmacists, social workers,
nutritionists, practice managers, home health
workers and other healthcare professionals as needed.
Nurturing e-Patients in the Medical Home and the ACO By Nancy B. Finn
lice is a 72- year- old retired teacher who suffers from diabetes and, hypertension. Several times a year she was rushed to the local ER outside of Kansas City for crises caused by diabetes and elevated blood pressure. A year ago Alice switched from a local primary care physician to a group practice that had established a patient-centered
medical home (PCMH). The group has a portal where Alice can view her digital health record, check her labs, request referrals, review her medication lists, renew prescriptions and communicate daily with the nurse practitioner. Each day Alice uploads her blood sugar and blood pressure to the portal using a telephone hook-up that is provided by the practice. The nurse practitioner checks to see if there are any problems or changes. If so, she contacts Alice, either by phone or email, and Alice is invited to have an e-visit with her primary care doctor, the nurse practitioner, and the diabetes educator, where they discuss treatment options and work together to decide on a plan of action.
This use of secure patient portals and the team approach to care that includes the patient as a full member of the team are ways that the patient-centered medical home nurtures and protects patients and provides ongoing continuity of care. The engaged patient is a cornerstone of the PCMH and, like Alice, is part of the care team that also includes specialists, therapists, pharmacists, social workers, nutritionists, practice managers, home health workers and other healthcare professionals as needed.
The technology that enables the PCMH to function and take special care of patients is part of the formula. It is a given, in a PCMH, that doctors and other healthcare professionals in the group communicate via email and engage patients with e-visits for non-emergency issues between face to face office visits. At the PCMH, there is also generally a shared digital health record that is available to all members of the care team, including the patient. Patients are encouraged to create their own personal health record as well, because full patient information should always be available at the point of care to eliminate redundant testing and procedures.
The PCMH care team also strives to find the appropriate Internet resources that help educate and enhance patients’ knowledge regarding their medical issues. They encourage patients to engage with social networks to find other individuals to talk with who may be facing the same medical issues and who have ideas and suggestions that the team may not have covered. The PCMH is one way that primary care practices are able to coordinate their patients’ care across multiple locations and settings while striving for cost reductions and using quality of outcome incentives to reward the healthcare professionals rather than standard compensation based on the volume of services provided through fee.
The other new model of care -- the Accountable Care Organization (ACO) – shares a similar mission of effectively nurturing and taking care of Medicare patients and keeping them healthy, while controlling costs through the provision of effective medical care. The ACO can do this by providing global payments with opportunities for additional bonus incentives for those healthcare providers who closely monitor chronic conditions and keep their patients well and out of the hospital. The ACO also gives patients full access to information, including digital health records and lab results, allowing them to become more involved in their own care. In this model of care, patients and doctors are encouraged to communicate frequently via email, telephone, or by using telemedicine and remote monitoring. Providers engage patient populations in a variety of settings, facilitating collaboration and care coordination among a distributed care team that uses advanced decision support tools, shared decision making, and analytics to help the patient assess the merits of various treatment options and choose those that are right for them.
Mount Auburn Hospital in Cambridge, Mass., and the Mount Auburn Cambridge Independent Practice Association (MACIPA) were among only 32 healthcare institutions across the country chosen by the Centers for Medicaid and Medicare Services (CMS) as Pioneer ACO providers. Mount Auburn Hospital is a community/tertiary care facility that includes Obstetrics, Medical Surgical, and Psychiatric. The hospital provides comprehensive inpatient, outpatient, and specialty services at its main campus and 25 off-site locations.
MACIPA is an independent practice association established in 1985 and composed of more than 500 physicians in Cambridge, Arlington, Watertown, Belmont, Somerville, Lexington, Waltham, and Medford, Massachusetts. Physician members of MACIPA include doctors in private practice and those employed by Mount Auburn Hospital and the Cambridge Health Alliance. Practices range from solo physicians to groups of approximately 25. MACIPA has always worked in collaboration with Mount Auburn Hospital, and together they have a long history of innovation in healthcare, quality improvement and patient care coordination. According to Medical Director Dr. Robert Janett, MACIPA has been working on providing value and quality while maintaining efficiency via a global payment system for more than 20 years. This has been central to the success of MACIPA, the hospital, and the Cambridge Health Alliance (which serves the uninsured populations) and all of their patients.
continued on page 4
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4 Accountable Care News May, 2012
Published by Health Policy Publishing, LLC ● 209-577-4888 ● www.AccountableCareNews.com
Patient-centered practitioners, on the other hand, continually ask their
patients to rate their satisfaction with their care
in general and with specific physician skills such as communication.
A recent study by Kaiser Permanente confirmed the hypotheses that patients who are provided with a
secure messaging capability had better outcomes for
cholesterol, blood pressure and blood sugar, than other patients who did not have
this access.
Nurturing e-Patients…continued “We know that patients over the age of 65 need more health services than other patients,” said Dr. Janett. “As a pioneer ACO, and even before we received that designation, we have been striving to provide our patients with opportunities for ongoing communication with their providers via our patient portal and using e-visits. As enhancements to the system of electronic records that we have been deploying during the past few years, we are working with individual physician offices to provide speedier access time. We have also built a registry that will help our practices manage their patient populations and schedule outreach communications. To address some of the social determinants of health and thereby help insure that our patients are getting the proper care and assist them in obtaining needed services, we are also building a department of social workers,” Dr. Janett said. A recent study by Kaiser Permanente confirmed the hypotheses that patients who are provided with a secure messaging capability had better outcomes for cholesterol, blood pressure and blood sugar than other patients who did not have this access. Kaiser studied over 35,000 patients with diabetes and hypertension over a period of several months and found that those who engaged in secure messaging with their providers had better cholesterol and blood pressure levels than those who were not engaged. The Kaiser study was published in the July issue of Health Affairs and reported that the use of secure patient-physician messaging in any two-month period was associated with statistically significant improvements in HEDIS (Healthcare Effectiveness Data and Information Set) care measurements. Results included 2% to 6.5% improvements in glycemic, cholesterol, and blood pressure screening and control. More than 556,000 secure patient-physician e-mail threads, containing more than 630,000 messages, were logged throughout the study. Patients initiated 85% of those threads, which researchers say indicates that health IT is empowering patients to manage their healthcare better. This study is one of the first to show that electronic communications have a measurable positive effect on a patient’s outcome, in addition to improving efficiency. Patient-centered medical homes and ACO models of care have a way to go before they become ubiquitous. It would seem, however, that these models of care have huge potential to change health delivery and elevate it to a place where patients are nurtured in new ways, where doctors and patients communicate as equals and everyone is working toward the common goal of keeping the population healthy while reducing the cost of care.
Nancy B. Finn is the author of e-Patients Live Longer the complete Guide to Managing Health Care Using Technology, published by iUniverse, and available on www.amazon.com . She also writes the blog www.healthcarebasics.blogspot.com, is a frequent contributor to the Journal of Participatory Medicine and epatients.net. She can be reached at [email protected] .
Patient-Centered Medicine and ACOs…continued Both ACOs and practitioners of patient-centered care work to improve coordination of care both between patients and their doctors and between physicians caring for the same patients. This has been shown to improve patients’ quality of care while reducing costs.2 Patients in such arrangements assume greater responsibility for their care and hear the same instructions and messages of support from multiple doctors: for example, orthopedic patients hear from many providers within the ACO the same encouragement to keep performing physical therapy to regain function after surgery or complimentary messages from different providers on the need to continue with medication for osteoporosis or arthritis. This type of reinforcement improves clinical results rewarding both the surgeon and the patient. Furthermore, the ability to reinforce medical information also helps patients better understand the significance of surgical procedures like total knee or
hip replacements and the need to follow instructions to lower the risk of complications such as surgical site infections or DVTs. Care coordination requires specialists, such as orthopedic surgeons, to communicate their diagnostic findings and treatment plans with primary care doctors more thoroughly and effectively than is currently often done. Specialists should send PCPs and other care team members not only their initial consultation notes, but also progress notes, operative notes, and the results of diagnostic testing. The use of shared electronic medical records greatly eases this process. Another important component of both patient-centered care and ACOs is quality and patient satisfaction measurement. Orthopedic surgeons are taught and are familiar with
physician-centered measurement tools like the Harris Hip Score for hip replacement; it, like most such tools, answers questions important to doctors but does not ask patients to rate their satisfaction, leaving physicians who use such tools to guess their patients’ satisfaction rates. Patient-centered practitioners, on the other hand, continually ask their patients to rate their satisfaction with their care in general and with specific physician skills such as communication.3 This type of patient-centered measurement system is often new to orthopedists, but it is essential for improved outcomes and should be added to more routine measurement systems that include such skills as appropriate perioperative antibiotic use or DVT prophylaxis. It should also be included in financial reward systems. __________________________ 2 http://www.annfammed.org/content/6/4/361.full 3 http://www.aafp.org/fpm/2007/0900/p20.html continued on page 5
May, 2012 Accountable Care News 5
© 2012, Health Policy Publishing, LLC. All rights reserved. No reproduction or electronic forwarding without permission. page 5
It has been shown that good communication skills allow
physicians to tell their patients "no" without disrupting the patient-
physician bond. … Thus, patient centered physicians are much more likely to be able to avoid unnecessary
care and keep their patients happy and feeling well cared
for than other physicians.
An orthopedist who is empathic and
personally connected to his patients will
have better outcomes and happier patients
than a more detached surgeon who does equivalent work.
Patient-Centered Medicine and ACOs…continued Furthermore, orthopedists along with all physicians within the ACO should ask their patients whether they feel a personal connection with their doctor and whether they feel their doctor understands their emotional needs. These questions are central to patient-centered medicine, and are particularly important in the setting of ACOs. It's been well demonstrated that patient satisfaction rates are highly dependent on the quality of patient-physician relationships, and clinical outcomes are partly dependent on a physician's ability to convey empathy and develop such a relationship with patients. 4 Little et. al. studied 865 consecutive patient encounters and found that a patient-centered practice approach reduced the symptom burden in patients so treated. 5 Henbest and Stewart also showed better symptom resolution in patients who felt they had a personal relationship with their doctor,6 and Kim has shown the positive effect of physician empathy on patient compliance and satisfaction. 7 In ACOs, this is crucial for serving the twin purposes for which ACOs are created. First, such physician behaviors improve patient satisfaction and increase clinical success. An orthopedist who is empathic and personally connected to his patients will have better outcomes and happier patients than a more detached surgeon who does equivalent work. Therefore, a patient-centered approach serves an ACO well by improving patient outcomes and satisfaction rates. Furthermore, these improvements are based on patients’ relationship with their doctors and occur without the need to acquire new operating room equipment, more powerful MRI magnets, or any other costly equipment. Second, patient-centered techniques allow physicians to prescribe only the care that patients really need while maintaining patient trust and a high satisfaction rate. It has been shown that good communication skills allow physicians to tell their patients "no" without disrupting the patient-physician bond.8 Orthopedic surgeons often feel patient pressure to order more tests, including costly advanced diagnostic imaging, or prescribe more medicine than they feel is clinically necessary. Paternini and his colleagues have shown that good physician communication is more likely to satisfy patients than such expensive, and often unnecessary, testing.9 Thus, patient-centered physicians are much more likely to be able to avoid unnecessary care and keep their patients happy and feeling well cared for than other physicians. Of course, by avoiding unnecessary procedures and all of their attendant costs, patient-centered orthopedic surgeons are in a position to greatly improve the cost control efforts of the ACOs in which they participate. Many resources, such as the Dartmouth Atlas, suggest surgery rates which sometimes cannot be clinically justified.10 It must be remembered that unnecessary medical interventions are both costly and decrease quality of care due to their concomitant risks, complications, and the perioperative morbidity that they cause. A patient-centered orthopedic group functioning within an ACO should result in a procedure rate below the mean for their practice area, resulting in both cost savings and a higher
quality of care for the patients of the ACO. Furthermore, patient-centered orthopedists should gravitate toward participation in ACOs due to the expected financial rewards of practicing within such a group. In private practice, patient- centered orthopedic surgeons must accept the lower income that fewer procedures or imaging tests bring the practice, but ACOs offer the opportunity for some financial reward for practicing in a manner where patient interests are always paramount regardless of financial considerations. Accountable care organizations, due to both their structure and goals, make excellent practice partners for patient-centered physicians of any type, including orthopedic surgeons. Both the patient-centered medicine model and ACOs rely on collaborative care between physicians and their patients. They both encourage regular feedback from their patients to assess patient satisfaction rates and the quality of the care provided. Finally, both are interested in attaining the highest quality care at the lowest cost possible by relying on patient-physician
interactions instead of expensive tests, prescriptions, or procedures. Patient centered medicine and ACOs, therefore, complement each other, and together they provide an excellent opportunity for care improvement and cost reduction.
Dr. James Rickert practices orthopedic surgery in southern Indiana and also serves as an Assistant Clinical Professor of Orthopedic Surgery at the Indiana University School of Medicine. He is president of The Society for Patient Centered Orthopedics, a group of orthopedic surgeons dedicated to expanding the patient centered care model. He can be reached at [email protected]. ________________ 4 http://www.ncbi.nlm.nih.gov/pubmed/15217167 5 http://www.bmj.com/content/323/7318/908 6 htttp://fampra.oxfordjournals.org/content/7/1/28?ijkey=9aa7f6c1b34529f59b5797c4381d8939be843996&keytype2=tf_ipsecsha &linkType=ABST&journalCode=fampract&resid=7/1/28 7 http://fampra.oxfordjournals.org/content/7/1/28?ijkey=9aa7f6c1b34529f59b5797c4381d8939be843996&keytype2=tf_ipsecsha &linkType=ABST&journalCode=fampract&resid=7/1/28 8 http://www.medscape.com/medline/abstract/20177043 9 http://www.medscape.com/viewarticle/720725_2 10 http://www.dartmouthatlas.org/data/topic/topic.aspx?cat=22
6 Accountable Care News May, 2012
Published by Health Policy Publishing, LLC ● 209-577-4888 ● www.AccountableCareNews.com
According to the National Association of Home Care and Hospice, a
reduction of readmission rates by just two percent
among home care patients would help
928,000 people avoid rehospitalization and save upwards of $500
million in costs.
The Medalogix toolset enables home care agencies to provide
enhanced care through a focus on the two most significant factors in
predicting geriatric patient re-hospitalization:
medication and geography.
Home Health Care and Predictive Modeling:…continued Keeping patients at home means keeping them out of the hospital, and the goal of Medalogix is to assist home care agencies in identifying patients who are most at risk of requiring unplanned hospital care. To meet this goal, Medalogix combined its knowledge of medication risk with clinical data from home care agencies to build a powerful predictive modeling toolset. Ohio-based Alternate Solutions Healthcare System, founded in1999, began a partnership with Medalogix in January of 2012 in order to address the biggest problem facing home care agencies today: unplanned hospital readmissions. According to the National Association of Home Care and Hospice, a reduction of readmission rates by just two percent among home care patients would help 928,000 people avoid rehospitalization and save upwards of $500 million in costs. New provisions of the Affordable Care Act that penalize hospitals when a patient is readmitted under the same diagnosis within 30 days of his or her discharge go into effect in October 2012. The “30-day window” readmission rate at Alternate Solutions has vacillated between nine and 10 percent (significantly lower than most agencies in Ohio, where readmission rates are in the 13-15 percent range), and reducing that rate further is the number one priority. Hospitals that re-admit too many patients will look to home health services as a means to ensure quality follow-up care, monitoring, and communication because patients who have some help at home are less likely to return to the hospital shortly after being discharged. In an ACO model, the savings can be significant. Medalogix is helping Alternate Solutions identify and direct resources to those patients most likely to require rehospitalization. Hospitals want to have confidence that the patients they send to Alternate Solutions are less likely to be readmitted. The Medalogix toolset enables home care agencies to provide enhanced care through a focus on the two most significant factors in predicting geriatric patient re-hospitalization: medication and geography. Up to a third of all geriatric patient rehospitalizations are related to medication risk. This is why Medalogix places an emphasis upon medication risk as the primary driver of unplanned hospital care. Factoring a Medication Risk Quotient – a scored number representing a patient’s medication risk – into its proprietary algorithm, Medalogix has correctly predicted patient risk with an accuracy exceeding 74 percent, using historical data.
A sizeable body of research supports the idea that factoring in the specific geography of a patient population is necessary for accurate predictive modeling. The Medalogix algorithms take into account the patient’s specific geographic location as a determining factor in calculating the patient’s risk level. This localized accounting of patient data provides more accurate and attuned pictures of patient risk levels. At this stage of the partnership, Alternate Solutions and Medalogix are working to refine the tool. The efforts have focused on teaching Alternate Solutions home care staff how to combine the mathematically verifiable risk analysis Medalogix provides with the more traditional elements from clinical records, which nurses use to assess patient risk. It is understood that the full implementation of the Medalogix toolset will take time, but Alternate Solutions is confident that – once fully integrated into the daily
rhythms of the agency – it will emerge a stronger agency, equipped with the advanced tools necessary for providing efficient and accountable care in the future.
Tessie Ganzsarto is President and Chief Development Officer of Alternate Solutions HomeCare, which she founded in 1999 with her husband David Ganzsarto, and which has strategic partnerships with health care systems in Ohio, Illinois, Wisconsin and West Virginia. The company was ranked by HomeCare Elite™ in the top one percent of home health care agencies in the U.S. based on quality of care, quality improvement and financial performance. She may be reached at [email protected]. Dan Hogan founded Medalogix in 2009 to address the medication complications he saw occurring among geriatric patients at Doctor’s Associates Home Health, the Manchester, Tenn. home health agency he owned and operated from 2005 to 2010. He may be reached at [email protected].
REGISTER NOW! Special Sessions on Medicaid ACOs at the
SEVENTH NATIONAL MEDICAID CONGRESS Medicaid ACO and Shared Savings Model in New Jersey – Dr. Jeff Brenner, Camden Coalition
Medicaid CCOs in Oregon – Dr. Bruce Goldberg, Oregon Health Authority Half-Day Preconference on Emerging Medicaid ACOs – Tricia McGinnis, CHCS (Chair)
May 30 – June 1, 2012 -- Hyatt Regency Crystal City at Reagan Airport, Washington, D.C.
www.MedcicaidSummit.com
May, 2012 Accountable Care News 7
© 2012, Health Policy Publishing, LLC. All rights reserved. No reproduction or electronic forwarding without permission. page 7
Thought Leader’s Corner
Each month, Accountable Care News asks a panel of industry experts to discuss a topic of interest to the accountable care community.
Q. The controversial piece by Ezekiel Emanuel in the New York Times predicted the “extinction” of health plans because of delivery system re-structuring, especially ACOs. Even if they aren’t extinct, how will health plans look and act differently over the next five to ten years?
“I think that Dr. Emmanuel was being intentionally provocative rather than making an actual prediction. Health plans will need to evolve and change to be successful in the accountable care era, just as will providers. The years ahead will provide an opportunity for both to collaborate to achieve better clinical outcomes, patient satisfaction and cost efficiency—and a healthier population. Toward the end of the piece, Dr. Emanuel points out one step that some payers and providers may take together -- to structurally integrate. Others will integrate and better align their incentives through new contractual arrangements and joint ventures. According to recent reports, there already are over 200 pilot programs around the country taking place between provider-based ACOs and payers, both private and public. Health plans have much to continue to bring to the table -- experience in financial risk management, sophisticated administrative systems and infrastructure to pay claims, and clinical data and systems to analyze the data for quality improvement, among others. Those functions will remain necessary and will not be fully absorbed by current provider organizations. Accountable care will cause organizations in each sector to take on attributes of the other, which is good. The adversarial environment between payers and providers of the last couple of decades will not best serve the U.S. health care system in the future. In my view, successful payers and providers will develop innovative programs on a cooperative basis. It will take such joint efforts to align the complex, multi-faceted interests not only of payers and providers, but also purchasers, consumers and regulators. The opportunity is there. Failure to collaborate effectively will lead to efforts by outside parties, especially government, to control the pricing of both and to regulate the contracts between them.”
Doug Hastings Chair of the Board of Directors Epstein, Becker & Green, P.C. Washington, D.C.
“While it is a leap to suggest extinction, it is clear that payors are embarking on a new era in the way care is managed and will need to change business operations accordingly to manage the shift. If done properly, the payor of the future should be more aligned with providers, as opposed to today’s adversarial relationships, and be able to share risk, rather than assume it all on their own. Today, a number of progressive payors are already engaged in this type of cooperative work and are working with providers to develop care management systems and payments that align with more high value care. The end result should be decreased costs for both payors and consumers. In an ACO type environment, payors are equal partners with providers, and their participation in accountability is critical in order to ensure that payment aligns with value.”
Wes Champion Senior Vice President of Premier Consulting Solutions Premier Healthcare Alliance Charlotte, NC
“The American Medical Group Association (AMGA) supports efforts to develop a payment structure for physician services that is based on value and is encouraged by payment models emerging in the private sector that promote accountable care. In these models, many driven by commercial insurers, the health plan and the medical group or health system work as partners to lift the standard of care to the patient, rewarding evidence-based treatment and efficiency. The insurance industry for decades engaged in various reimbursement and financial recognition incentive programs in pursuit of effective and efficient health care delivery, and we applaud the efforts of the industry to move from volume-based to value-based care. When health plans and providers work together for better care, all stakeholders benefit -- most importantly, patients.”
Donald W. Fisher, PhD, CAE President and Chief Executive Officer AMGA Alexandria, VA
8 Accountable Care News May, 2012
Published by Health Policy Publishing, LLC ● 209-577-4888 ● www.AccountableCareNews.com
Thought Leader’s Corner
“This editorial really got my blood boiling. It’s irresponsible and naive. Irresponsible: Provoking and demonizing health plans might have had populist appeal and political value in 2009, but in 2012 it’s an unnecessary attack on a constituency that has the potential to be one of the Administration’s best allies in advancing accountable care. Prior to the ACA, health plans had the wrong economic incentives -- they had incentives to AVOID risk, not manage risk, and they had minimal incentives to CONTROL systemic costs -- they could pass them on in the form of premium increases. The ACA, however, has changed incentives and disrupted the payer business model: plans must accept all comers and must MANAGE, not avoid, costs. Almost all health plans are embracing the vision of accountable care and shifting the system from Volume to Value. They could be the Administration’s biggest friend. Naïve: Emanuel mislabels the trend that is occurring. It’s not about Accountable Care Organizations, it’s about incentivizing and promoting “accountable care.” He seems also not to have noticed that care providers have a lot of hesitations about the ACO model -- at best we have some early adopters trying them out. There is no stampede. Provocation as a tactic might have some political value when stakeholders are dragging their feet and resisting change. Provocation as a tactic when industry stakeholders are lining up to help you achieve Administration objectives -- well, that’s just plain dumb. Emanuel would be much wiser to take credit and praise health plans, not bury them.”
Vince Kuraitis Principal Better Health Technologies, LLC Boise, ID
“Savvy health plans can become what I call ‘market makers’. They can use their market power to be champions for quality and lead the rest of the health care industry toward a system of value-based care. Just as plans can be market makers for health care as a whole, Exchanges can be market makers among plans. Which providers a plan includes in its network, how much cost-sharing the plan charges, how the plan raises its own quality and consumer scores…all these things should matter in an Exchange.
Insurers that point people to the most effective parts of the delivery system and encourage effective care should be rewarded by getting more members. That’s a win for the plan, a win for the patients, and a win for society. If Exchanges are structured so that insurers are competing on value instead of on price, I know that plans will step up. The key is to align incentives so that it’s in everyone’s interest for health plans to deliver value, not just low premiums.”
Margaret E. O’Kane President National Committee for Quality Assurance (NCQA) Washington, D.C.
“Accountable care organizations (ACOs) have alternately been predicted to replace health plans and become leaders in delivering high-quality, cost effective healthcare, or to not produce anticipated results and become a failed experiment. Because delivery systems do vary by community, a complete success or blanket failure of the ACO model is unlikely. In some communities, such as inner-city urban areas, ACOs may not have enough geographic disbursement or size to manage population risk. Health plans will remain relevant if they continue to provide meaningful value to the evolving delivery system. This might be through creative partnerships which provide support in areas where they excel, such as marketing and spreading insurance risk over populations. To forge these successful partnerships, health plans must approach the delivery system in a much different way than they have historically. Relationships between health plans and ACOs may vary according to the market, but closer cooperation on areas such as product design and pricing is one way to foster accountability. This collaboration should not leave out the employers who have a large stake In the success of more accountable and affordable healthcare.”
Jennifer Jackman Senior Vice President, Accountable Care Monarch HealthCare Irvine, CA
Subscribers’ Corner Subscribers can access an archive of current and past issues of Accountable Care News, view added features, change account information, and more from the Subscriber web site at www.AccountableCareNews.com. Subscribers can also network and discuss ACO issues with other health care professionals, review job opportunities, and more in the LinkedIn Accountable Care News Group. To join, go to http://www.linkedin.com/groups?gid=3066715 .
May, 2012 Accountable Care News 9
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Thought Leader’s Corner
“Will ACOs replace insurers? After reading the Emanuel piece in the New York Times where he surmises that insurance companies can be replaced by ACOs, I am thinking much of this has already happened around the country. In Florida and California, physicians have taken full risk contracts from health plans like Humana and Blue Cross. The insurer is basically holding the actuarial risk, keeping 15% for administration and profit and delegating hospital, drug, and physician components to physicians as a group or IPA for the service risk. In California this delegated risk model became so popular that many health plans had a hard time pulling the risk back into the health plan when rules changed. In both Florida and California we see ACOs stepping up to the plate as the next version of an IPA or group without walls. The Monarch IPA MSO in California is a good example of an IPA that qualified as a Pioneer ACO. Subsequently bought by United Healthcare, the United folks now have a captive MSO that they can load up with product and eventually create a staff model without walls. Of the 23 ACOs announced, seven of them have 51% ownership management contracts with Universal American, an insurance company in south Florida specializing in Medicare Advantage. The same opportunity could play out for Universal to open shop in several states and consolidate physicians and then grow Medicare Advantage as well as non-Medicare Advantage members through the ACO. Probably the largest play on this area is the alliance of three Blue Cross plans (New Jersey, Highmark, and Independence Blues in Pennsylvania) with Lumeris, a technology company, purchasing Navinet. Navinet touches 75% of all physicians nationwide, and Lumeris has a proven track record in building a series of portals and information exchanges with physician offices to offer utilization and quality reporting. This Blue Cross alliance can offer a digestible ACO solution for physicians on a regional and national basis. The original HMO legislation of 1973 was intended to help form medical groups that would compete in many areas around the country where there was little competition and yet great variance in outcome and quality. This was the original theme of a quality driven, physician owned HMO. This may still be the goal, and several recent acquisitions prove this point. Inspiris being bought by United, Senior Bridge being bought by Humana, and Health Spring being bought by Cigna all point out that the market for medical management is heating up and is the missing link that physician groups can provide and that most insurers can not. So when Dr. Emanuel and others say insurance companies can be replaced by ACOs (or in our opinion physician driven HMOs), he has a good point. Insurers need to offer exclusive products and lock in physicians through acquisition or joint venture on one side of the ledger, then invest heavily in building or acquiring those companies with the skill to actually apply technology to improve the care process. In fact this is what several Wall Street investment firms are recommending. The alternative of trying to build a business exclusively on premium management that is now regulated with new Medical Loss Ratios and not to exceed percentages for rate increases seems futile. Anything insurers can do to delegate risk down to providers through sticks and carrots -- and then on down to consumers via bigger deductibles and copays -- will help the profit margin during this period of transformation in the American health system. Once physicians understand that this is the new business model for insurance companies, they can better organize into medical home networks, build joint venture agreements with insurers to share in savings created by physicians, and then reinvest in practice technology and share overhead to make their risk of operation scalable. All of these mean more reimbursement and savings bonuses that go to the bottom line. Keeping all options open is no longer possible, but being SELECTIVE with partners including management services companies, equity investors (yes, this is the new market opening), and insurance companies may offer an alternative to being bought by hospitals or other practices. It is a time of great opportunity for physicians to leverage creativity and innovation while strengthening their practice asset.”
William DeMarco, MA, CMC President & Chief Executive Officer Pendulum HealthCare Development Corporation and DeMarco & Associates, Inc., Rockford, IL
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and Related Delivery System and Payment Reform
Produced by the Engelberg Center for Health Care Reform at Brookings and The Dartmouth Institute for Health Policy & Clinical Practice
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10 Accountable Care News May, 2012
Published by Health Policy Publishing, LLC ● 209-577-4888 ● www.AccountableCareNews.com
INDUSTRY NEWS
CMS Announces First Group of 27 MSSP ACOs On April 10 CMS announced the selection of the first 27 ACOs to participate in the Medicare Shared Savings Program. The ACOs are relatively small, accounting in total for just under 375,000 beneficiaries in eighteen states. Two have elected for a shared risk arrangement and five are participating in the Advance Payment ACO Model designed to encourage rural and physician-owned ACOs. CMS has 150 more applicants for a July 1 start date, including 50 interested in the Advanced Payment Model.
CMMI Comprehensive Primary Care Initiative A day after the MSSP ACO announcement, the CMS Innovation Center announced the selection of the seven geographic markets that will carry out the Comprehensive Primary Care initiative. Four are statewide markets -- Arkansas, Colorado, New Jersey, and Oregon -- joined by regional efforts in New York’s capital district and Hudson Valley, the Cincinnati-Dayton region, and the Tulsa area region. Roughly 75 primary care practices will be selected to participate in the initiative in each designated market, where multiple payers have already agreed to support comprehensive primary care in partnership with Medicare. Additional information on the initiative may be found at www.innovation.cms.gov..
Michigan Pioneer ACO Offers Home Care Program
The Michigan Pioneer ACO in affiliation with the Detroit Medical Center is offering physicians a way to enhance care for patients between appointments and after hospitalizations. By partnering with a personalized home care program called @HOMe Support™ the ACO can ensure that patients remain connected with a case manager who serves as liaison between the patient, the primary care physician, and other providers so that appointments are kept and treatment plans followed.
@HOMe Support™ was established in 2000 to provide supportive care for patients living with chronic illnesses. A recent research study demonstrated that the medical costs of caring for patients enrolled in this model were more than 30% lower than those not enrolled in the model.
Hospitals/Systems See ACA Reducing Revenue A survey of Employee Benefit Practices in hospitals and health systems performed by HighRoads and SullivanCotter between November 2011 and January 2012 found that 55 percent of respondents are anticipating a drop in revenue as a result of the Affordable Care Act. Only 12 percent projected an increase, and 28 percent said they did not know yet what the impact will be. The survey received responses from 178 participants, including 126 health systems, which had an average employee range of between 3,000 and 9,500.
Physicians Views on ACO Impact, Cost of Care The annual Physician Compensation Report for 2012 from WebMD’s Medscape found that 52% of physicians surveyed believe that ACOs will cause a decline in income, with 12% believing they will see revenue increase. Only 3 percent reported being involved currently in an ACO. The goal of reducing unnecessary care faces an uphill battle, with two thirds of physicians saying they won't reduce the amount of tests, procedures, and treatments they perform, either because the guidelines aren't in their patients' best interests or because of the need to practice defensive medicine. Only about a quarter of doctors (27%) said they would reduce the number of tests and procedures because the guidelines were valid. And only 38 percent of physicians regularly discuss the cost of care with patients, with 46 percent saying they do only if patients raise the subject.
Cigna Expands ACO Initiatives -- 10 New Partners Cigna has expanded its collaborative ACO program through 10 new initiatives with physician groups in seven states - Colorado, Maine, New York, North Carolina, Tennessee, Texas and Virginia. The plan now has 22 collaborative accountable care programs in 13 states covering more than 270,000 customers, toward a goal of 100 initiatives for one million customers by 2014. Cigna compensates physicians for the medical and care coordination services they provide. The physician groups are also rewarded through a "pay for performance" structure if they meet targets for improving quality and lowering medical costs.
May, 2012 Accountable Care News 11
© 2012, Health Policy Publishing, LLC. All rights reserved. No reproduction or electronic forwarding without permission. page 11
INDUSTRY NEWS
Paying More for Primary Care Bends the Cost Curve The ACA increased Medicare payments for PCP visits by 10 percent for five years. A new Commonwealth Fund supported issue brief by researchers at the Center for Studying Health System Change estimates that a permanent increase would increase visit costs by 17 percent but produce a six-fold return in reduced inpatient and post-acute costs, resulting in a net decrease in overall Medicare costs of two percent.
New Florida ACO Formed Florida Blue health plan, the Baptist Health South Florida system, and Advanced Medical Specialties, a Miami-Dade oncology group, have announced the formation of an ACO serving cancer patients in Florida Blue’s commercial plan. If successful, it may be extended to Medicare Advantage and even downstream result in reduced premiums for enrollees if savings are achieved. Better care coordination, bundled payments, and reducing unplanned hospital readmissions of cancer patients are all part of the ACO game plan.
PRMA Opens First of 50 ACOs Peer Review Mediation & Arbitration Inc. (PRMA, a multi-faceted medical services business development company, and its wholly owned subsidiary ProMed Alliance have formed an ACO in Dade County, FL. This is the first of some 50 ACOs that PRMA plans to establish over the next five years. The company has more than 17,500 physicians in its network of medical consultants The new ACO comprises 10-15 primary care physicians and 15-20 specialists together with an advanced diagnostics and surgery center and will serve about twenty-five thousand patients.
New ACO Partnership Launched in Iowa The University of Iowa Health Care in Iowa City and Mercy Medical Center in Cedar Rapids are partnering in an accountable care arrangement. Their initial focus will be on patients being treated for end stage renal failure. Both organizations will remain independent, but Mercy will convert to the University of Iowa Health Care’s medical records system.
Catching Up With…continued from page 12
Accountable Care News: Last month’s Thought Leader question was about the adequacy of the anti-trust guidance for ACOs – too rigid, too lenient, about right? How do you come out on that? Doug Hastings: Back in 1996, the Federal Trade Commission and Department of Justice, in providing antitrust guidance for multi-provider networks, considered financial integration and clinical integration as separate pathways for such networks to avoid per se violations of the antitrust laws and, instead, to be treated under the rule of reason, allowing for an assessment of their procompetitive vs. anticompetitive effects. Sixteen years later, in the context of accountable care, we can see how clinical and financial integration in fact go hand in hand. Under the various accountable care arrangements evolving under Medicare and in the commercial market, multi-provider ACOs are required to demonstrate both quality (featuring clinical integration) and cost efficiency (featuring financial integration). In the antitrust arena, there remain difficult issues to work through, particularly where the providers in an ACO have a high market share. But the recognition by the antitrust agencies in connection with the ACO final rule that legitimate ACO activities will be treated under the rule of reason and the identification of activities that may cause the agencies concern are helpful. The regulatory dialogue that has taken place around Medicare ACOs – i.e., how to distinguish “good” collaboration from “bad” – advances the related goals of achieving a more effective and efficient health system while also maintaining a legally compliant environment. Only time will tell whether common ownership and employment models will be more effective than network models in ACO development or whether some of each will succeed. Antitrust enforcers will continue to challenge mergers deemed to be anticompetitive. There is the potential that new forms of contracting (rather than mergers) among providers -- including in some cases high market-share providers -- working with payers (public and private) to accomplish accountable care goals through value-based payment arrangements can create antitrust-acceptable pathways — i.e., if payment is based on measurable value (Quality
Cost), where is the harm? The integration of financial and clinical integration
means that successful provider organizations in the future should be able to “do well by doing good.” Accountable Care News: Finally, tell us something about yourself that few people would know. Doug Hastings: I compete regionally and nationally in track and field in masters meets and the Senior Olympics. My best events are the sprints (50, 100, 200 meters) and jumps (high jump, long jump and triple jump). Competition among folks over 50 in these settings can be pretty intense, but in the end there is incredible collective satisfaction among the participants for “still being able to do this.”
12
Published by Health Policy Publishing, LLC ● 209-577-4888 ● www.AccountableCareNews.com
Accountable Care News: You’ve been an observer of the health care scene for a long time. Are ACOs really the “new new thing” or just a fad that will produce a few successes and a lot of failures? Doug Hastings: While ACOs are not a fad, only time will tell how successful they will be at improving health care outcomes and patient satisfaction, while also improving the cost efficiency of care. The concepts underlying accountable care as the keystone of the current drive for payment and delivery reform are not new, but they have evolved based on experience with earlier efforts and our increasing understanding of evidence-based medicine. It is important to view this period we are in now as one of continued testing and experimentation. We are making progress to a higher performing health care system, and ACOs are part of that progress. The challenge will be to move far enough and fast enough – and to prove it – to the satisfaction of purchasers, consumers, and public officials. Accountable Care News: A good governance structure is critical for an ACO. Any chance the board meetings are going to get prickly when the hospitals realize they are no longer in charge? Doug Hastings: Board governance is a hot-button issue in corporate America, and no less so in the ACO setting. Good ACO governance will require combining best practices in the fiduciary duty of care, in the board’s oversight of quality, and in balancing multiple stakeholder interests. ACO boards and ACO sponsoring organization boards will need to ensure that appropriate and effective management and clinical personnel and protocols are in place to meet CMS, NCQA, and other requirements and to achieve the ACO’s quality and financial goals. Health systems will need to consider how to coordinate the ACO board with other boards within the system. Successful hospitals will understand the need to collaborate effectively with physicians and other providers at the board level. ACO boards will need to balance stakeholder representation required by CMS or NCQA with IRS requirements related to community representation, as well as with both IRS and good governance recommendations related to the need for a reasonable number of “independent” directors on boards. Ultimately, directors should not view their job as representing factions or constituencies in exercising their oversight; rather, they must act in the overall best interest of the organization for which they are a fiduciary. ACO sponsoring organization board members who also serve as ACO board members will need to clearly understand the respective missions, visions, and goals of both entities as well as the differences between the two. Accountable Care News: There’s a school of thought that health plans will be wary of contracting with ACOs because they have more control when they contract individually with hospitals and medical groups. And yet there are some genuine partnerships emerging. How do you see the health plan-ACO relationship playing out over time? Doug Hastings: There is a huge opportunity for providers and payers to succeed through collaboration in the accountable care era. The adversarial environment of the last couple of decades is not good for the U.S. health care system as a whole or for the purchasers or consumers of health care. It may have been deemed necessary by individual payers or providers to treat each other with suspicion and as adversaries, but, in my view, successful payors and providers in the future will develop innovative programs on a cooperative basis. There will be innovation both contractually and through joint ventures and other integrating combinations. It will take such joint efforts to align the complex multi-faceted interests not only of providers and payers, but also purchasers, consumers and regulators. The opportunity is there. Failure to collaborate effectively will lead to efforts by outside parties, especially government, to control the pricing of both payers and providers, and to regulate the contacts between them. Accountable Care News: Dr. Terry McGeeney from TransforMED has said that patient engagement is the Achilles heel of the patient-centered medical home. What do you think the Achilles heel is for ACOs? Doug Hastings: Patient engagement. Dr. McGeeney is right in his concern. One of the three prongs of the Triple Aim is better health. One of the six aims of health care quality set forth in Crossing the Quality Chasm is patient-centeredness. Patient satisfaction measures will be a factor in whether ACOs earn a share of savings. Avoiding the backlash that managed care experienced in the 1990s will be critical to ACO success. A comment sometimes heard at conferences discussing ACOs is that amid all the discussion of structures, governance, payment models, measures and regulatory concerns, little is said about the patient. That is a valid concern. continued on page 11
Douglas A. Hastings • Chair of the Board of Directors of Epstein, Becker & Green, P.C., Washington, DC • Past President and Fellow, American health Lawyers Association • Member, Board on Health Care Services, Institute of Medicine (2003-2011) • National Advisory Board, Accountable Care News; Advisory Board, BNA's Health Law Reporter • Among many awards, most recently The National Law Journal's list of "Most Influential Lawyers" (2011); the David J.
Greenburg Service Award from the American Health Lawyers Association (2010); Best Lawyers "Washington, DC Health Care Lawyer of the Year” (2010)
• BA degree Duke University, Phi Beta Kappa; JD, University of Virginia, Order of the Coif
Catching Up With … Douglas A. Hastings is Chair of the Board of Directors of Epstein, Becker & Green, P.C. in Washington, D.C. As a member of the firm's Health Care and Life Sciences Practice there, his clients cover the entire health care spectrum: hospitals and health systems, physician organizations, health plans, post-acute facilities, and venture firms. He is recognized as one of the nation's leading resources on accountable care, value-based payment, and health care delivery system reform. He talks about ACO staying power, governance, health plan relationships, anti-trust, the ACO Achilles heel, and himself.
