Accountable Care Organizations

MMS Statement on the Release of Senate Payment Reform Legislation

Posted in Accountable Care Organizations, Global Payments, Payment Reform on May 9th, 2012 by MMS – Comments Off on MMS Statement on the Release of Senate Payment Reform Legislation

By Lynda M. Young, MD
MMS President

With the release of the Senate bill today, we now have two detailed legislative approaches to payment reform, along with the Governor’s legislation from last year.

We recognize the need to bend the cost curve in Massachusetts, and we will continue to work with the House, the Senate and the Governor for the remainder of the session to ensure that the final legislation aligns with the following principles.

We assert that the market is working, and has already been doing an effective job controlling the growth in the cost of health care over the last two years. The most responsible approach to continuing this trend would be to empower this market-led approach.

A market approach would afford us the best chance of ensuring that patients’ access to care is preserved; the delivery of quality health care is supported; that we continue to foster innovation; that we maintain the viability of physician practices, and protect the jobs of the many thousands of people who work in health care –without disruption or interruption.

We support an approach that establishes a reasonable cost control goal over a reasonable period of time. If these reasonable goals are not met, then a detailed review would be initiated, which would inform a set of targeted actions to fairly address the causes of the problem. Any benchmark below the annual growth in the state’s economy is too aggressive.

This is a very complex system. Massachusetts is already among the nation’s leaders in designing new models for the delivery of health care. State legislation should foster the innovations that are currently underway. It should allow us the opportunity to learn what works, and provide the flexibility to make corrections when needed. This is an imprecise science, and no one has done anything like this before. This must be a gradual learning process, conducted in a non-punitive environment.

We also need to be mindful of the risk that a new statutory framework could add administrative burdens on providers and payers who are already staggering under the weight of administrative mandates, many of which add no value to health care. We must simplify, not complicate the administration of health care.

We are pleased to see language modeled on the University of Michigan’s Disclosure, Apology and Offer approach to resolving patients’ claim of medical malpractice. This would lead to the faster resolution of cases, increase openness and honesty between patient and provider, allow for provider apologies, reduce the incidence of defensive medicine, and help control and reduce costs. We believe this model would vastly improve the experience of patients with an unanticipated medical outcome, and better foster a culture of safety in our health care system.

House Releases Payment Reform Legislation

Posted in Accountable Care Organizations, Defensive medicine, Global Payments, Payment Reform on May 4th, 2012 by MMS – Comments Off on House Releases Payment Reform Legislation

The Massachusetts House Friday released a comprehensive payment reform bill that seeks the cut $160 billion in health care spending in Massachusetts over the next 15 years.

House Speaker Robert DeLeo characterized the bill as an effort to balance the need to cut health care costs for employers and families with a desire to keep health care “a healthy part of our economy.”

Rep. Stephen Walsh, co-chair of the Joint Committee on Health Care Financing, said health care stakeholders “may not like everything [in the legislation], but you certainly will like something.”

The bill spans 178 pages and more than 3700 lines of text. Its provisions include:

  • There are firm targets to encourage health care providers to limit increases in health care costs. In Year 1, annual spending growth may not exceed the growth in the Gross State Product. In Year 3, that target is reduced to a half percentage point below the growth in the Gross State Product. If providers exceed these targets, the state is empowered to change payment methodologies, propose new legislation, require corrective action plans, or reopen providers’ contracts with insurers.
  • Providers whose costs exceed 120 percent of the comparable state median would be fined at 110 percent of their spending that exceeds that 120 percent level.
  • A comprehensive adoption of the so-called Michigan model of “disclosure, apology and offer” to resolve patients’ claim of medical malpractice. This includes the establishment of a 182-day waiting period upon the filing of a notice of a claim. It prohibits the introduction into evidence of a provider’s expression of apology or regret.
  • A powerful new independent agency, the Division of Health Care Cost and Quality, would consolidate the role of many existing agencies and oversee the implementation of the bill.
  • To improve transparency of prices and costs, there are new requirements on providers and insurers to publicly report costs and quality information, and patient cost-sharing.
  • It provides for loan forgiveness for primary care providers practicing in underserved or rural areas.
  • It seeks to simplify certain administrative procedures, and includes a requirement that all health plans must use the same two-page form for all prior authorization requests.
  • It requires that all patients have access to an interoperable electronic health record by 2017. The bill promises an unspecified amount of financial support to help providers develop their EHR systems.

MMS President Lynda M. Young, MD, applauded the inclusion of the Disclosure, Apology and Offer language in the legislation. “We’re very supportive of the approach outlined in the legislation, which we believe will vastly improve the experience of patients who experience an unanticipated medical outcome,” she said.

Dr. Young expressed concerns about the legislation’s cost control mechanisms. “While we certainly appreciate the need to make health care more affordable, we’re worried that the bill’s goal and timetables are too aggressive. We look forward to working with the House and Senate to develop mechanisms that address patients’ affordability concerns, without reducing their access to care, unduly restricting physicians’ ability to practice medicine, or putting a damper on our state’s culture of medical innovation.”

Dr. Young added, “We appreciate Rep. Walsh’s openness and diligence during this long process. He met with us many times, and listened carefully to everything he had to say. We look forward to working with him, and members of the state Senate, during the coming weeks and months.”

The full text of legislation is available here. We’re continuing to analyze its details and will publish the product of that analysis next week.

According to Speaker DeLeo, the House bill will remain in the Ways and Means Committee for further analysis. The Senate, for its part, is expected to release its version of payment reform next week.

Data Tracking and Analytics: No Longer Avoidable in Physician Practices

Posted in Accountable Care Organizations, Electronic health records, Health IT, meaningful use on March 29th, 2012 by MMS – Comments Off on Data Tracking and Analytics: No Longer Avoidable in Physician Practices

In an age where the federal government has settled on a total of 33 quality metrics in its final rule for accountable care organizations, figuring out how to track data and meet quality and performance benchmarks is becoming a critical part of a physician’s role in providing quality care to patients.

More practices in Massachusetts are focusing on data and analytics, because where risk-based contracts and accountable care delivery models are becoming increasingly prevalent. Understanding practice level and physician level data is a key to success, starting at the point of payer contract negotiation.

Many practices are challenged by where to start, which is not surprising given the alphabet soup that exists in terms of recognized metrics, HEDIS, NQF, NCQA, PQRI, PCPI to name only a few.

The good news is that while many are just beginning on this path, several practices have been operating in the data and analytics space for many years, and they are happy to share their lessons learned as well as the upside and downside of their experiences.

One such practice, South East Texas Medical Associates (SETMA), under the leadership of Dr. Larry Holly,  has worked to hone its data analytic capabilities to successfully manage their patient population, and has demonstrated success in improving metrics in areas such as diabetes management.

Of course, this is the result of years of evolution and a level of comfort with the metrics that are being tracked. That being said, SETMA has demonstrated success in working with the plans in risk based contracts as a result of their efforts.

Again, it took years for SETMA to perfect its strategy. One should not fear data tracking and analysis but embrace the initiative by starting with a few metrics that are important to the practice.  There is plenty of opportunity to tweak, improve and revise your processes over time.

As experienced practices such as SETMA will tell you, it’s about starting somewhere and perfecting your process over time.  On that note, why not start now?

If you’d like to learn more about how to approach data and how organizations like SETMA were able to successfully use data, join us at MMS on March 30th for the program titled “The Importance of Data in Physician Practice”.  Visit http://www.massmed.org/DataAnalytics2012
— Kerry Ann Hayon

ACOs Offer Physicians New Leadership Roles and Challenges

Posted in Accountable Care Organizations, State of the State: 2011 on November 7th, 2011 by Erica Noonan – Comments Off on ACOs Offer Physicians New Leadership Roles and Challenges

The new world of Accountable Care Organizations will focus on performance measurement, new payment models, and patient-doctor cooperation, according to Dartmouth Medical School professor Elliott S. Fisher, MD, MPH.

Dr. Fisher said ACOs are expected to dramatically shift old paradigms of health care.

“It’s not just a contract, but a journey. It’s not us versus them. It’s a partnership,” he told more than 200 physicians, legislators and industry leaders attending last week’s State of the State’s Health Care Forum, hosted by the Massachusetts Medical Society.

Unlike managed care systems that locked patients into rigid contracts, ACOs are expected to be  more flexible groups of care offering significant patient-doctor collaboration.

Ideally, they will embrace the idea that “the best fence is a good pasture,” said Dr. Fisher, in his talk, titled “How Will Accountable Care Organizations Change Cost and Quality?”

The forum, now in its 12th year, was titled “Health Care Reform: Quality, Cost, and Access – A New Paradigm.”

The challenges for physicians are formidable, as are the rewards, Dr. Fisher said.

The scope of social and technical change is enormous. New  systems will measure many aspects of physician performance and patient health in detailed ways.

Those measurements can’t be overly focused on cost,  he said.

“Consumers fear stinting (on care) and the model will be rejected if there are not measurements that are meaningful to consumers,” Dr. Fisher said.

Practices and hospitals will encounter significant technology infrastructure and organizational and training costs during the ACO transition.  The early phase of the process will be a time of failed experiments as doctors learn “what works and how to improve it,” he said.

However, physicians will have many new opportunities as they guide society through this approach to health care.

“Stewardship will become a core value,” said Dr. Fisher.  “Physicians will be partners in leadership.”

–  Erica Noonan

Coakley: Physician Perspectives Needed in Health Care Reform

Posted in Accountable Care Organizations, Health Reform, State of the State: 2011 on November 1st, 2011 by Erica Noonan – Comments Off on Coakley: Physician Perspectives Needed in Health Care Reform

Massachusetts Attorney General Martha Coakley on Monday called on the state’s physicians to become more involved in shaping major health care reform initiatives on the horizon.

Physician leadership and input is crucial to efforts to successfully implement new practice models, she said, such as accountable care organizations.

“You can make a difference when you come forward with information,” Coakley told physicians attending the State of the State’s Health Care Forum, hosted by the Massachusetts Medical Society.

The forum, now in its 12th year, was titled “Health Care Reform: Quality, Cost, and Access – A New Paradigm.”

Coakley said many physicians fear that new rules discouraging comprehensive medical testing or hospital stays will open them up to potential lawsuits or accusations of poor patient care.

“I hear from doctors, ‘How do we get medicine and judgment back to where it needs to be?’ ” Coakley said.

Collaboration between physicians, patients and legislators are a key to crafting solutions that will work for the complex and fast-changing health care landscape.

The 2008 payment reform legislation made it possible to start examining ways to bring down health care costs, but the process has just begun, said Coakley.

“There are many ways to fail and only a couple of ways it can succeed,” she said.

There is no quick fix to what Coakley termed a “dysfunctional marketplace.”

“We in Massachusetts have made the commitment to this and have the will and resources to make it work,” said the attorney general.  “When we break down silos we can get real results.”

–      Erica Noonan

One Size Does Not Fit All for Payment Reform

Posted in Accountable Care Organizations, Payment Reform on September 20th, 2011 by MMS – Comments Off on One Size Does Not Fit All for Payment Reform

“One size doesn’t fit all.”

Last week, during the MMS’ education program “A Path to Accountable Care Organizations: How Do We Get There From Here,” that concept for payment reform and ACO development was echoed repeatedly by several speakers.

The new paradigm that is emerging requires physicians and hospitals to cooperate and work together, taking advantage of each  entity’s unique factors.  Physicians provide a critical role in patient care as noted by our presenters, therefore their leadership remains essential to success.

Harold Miller, CEO of the Center for Health Care Quality and Payment Reform, cited examples from around the nation where small, independent practices are successfully collaborating to manage global payments.

He noted that various models of successful collaboration exist. He cited examples of small primary care practices, and independent primary care physicians and specialists, working together to manage global payments with full and partial risk contracts.  He also cited examples of joint contracting by physicians and hospitals for global payments.

Clearly, active engagement and participation of physicians, regardless of the size of their practice, IPA or medical group, is extremely important in the pursuit of better outcomes and lower cost.

Harold Miller  also stated that physician-hospital collaboration is not necessarily a zero-sum game:

To learn more about ACOs, accountable care delivery models and the things your practice can do to prepare please visit www.massmed.org/acsc for more information.

– By Kerry Ann Hayon
Manager, MMS Physician Practice Resource Center

Preserving the Concept of Physician-Led ACOs

Posted in Accountable Care Organizations, CME, Payment Reform on August 18th, 2011 by MMS – Comments Off on Preserving the Concept of Physician-Led ACOs

In the recent New England Journal of Medicine article Launching Accountable Care Organizations- The Proposed Rule for the Medicare Shared Savings Program, Dr. Donald Berwick noted that “a critical foundation of the proposed rule (on ACOs) is an unwavering focus on patients.”

The best way to focus on patients is to ensure that decisions are being made by those directing care – the physicians. It is undeniable that ACOs may be structured in various formats with group practices, networks of individual practices, hospitals or a combination there of. In order to uphold the patient centered focus it is important to preserve the physician led ACO construct.

Even with national trending showing that more and more physicians are moving towards employed organizational models, there is still the opportunity and necessity for physician leadership. Encouraging physicians to think outside the box in terms of partnerships will ultimately allow innovative models of ACO development.

To learn more about ACOs, accountable care delivery models and the things your practice can do to prepare join us on September 13 for our fall program, A Path to Accountable Care Organizations: How Do We Get There From Here? Visit www.massmed.org/aco2011 for more information.

– By Kerry Ann Hayon
Manager, MMS Physician Practice Resource Center

Do Accountable Care Organizations Have Staying Power?

Posted in Accountable Care Organizations, CME on August 4th, 2011 by MMS – Comments Off on Do Accountable Care Organizations Have Staying Power?

Recently, some physicians and health care administrators have expressed doubts about the viability of accountable care organizations (ACOs). Does this viewpoint stand up to scrutiny?

If you’re talking about the Medicare ACO program, as proposed by the Centers for Medicare and Medicaid Services this past spring, the naysayers probably have a point. The proposed regulations attracted lots of scrutiny, criticism and recommendations for improvement from entities including the American Medical Association, the Massachusetts Medical Society, industry thought leaders, physicians, administrators, and politicians.

By definition, an accountable care organization is an group of health care providers that agree to be accountable for the quality, cost, and overall care of assigned beneficiaries. Under this definition, there are already many entities in existence within Massachusetts and across the country that are already operating successfully as ACOs. Many organizations, physician groups and physicians are participating in enhanced risk based contracts with payers. In some cases, these groups have already improved their quality and financial results based on measured success in the area of cost and quality metrics.

These developments, combined with the CMS’ continued efforts to promote innovation through the Pioneer Program, provide evidence that the concept of integrated delivery organizations, like ACOs, are here to stay.

To learn more about ACOs, Accountable Care Delivery models and the things your practice can do to prepare join us on September 13 for our fall program A Path to Accountable Care Organizations: How Do We Get There From Here? Visit www.massmed.org/aco2011 for more information.

— By Kerry Ann Hayon
Manager, MMS Physician Practice Resource Center

ACOs as Food for Thought

Posted in Accountable Care Organizations, Payment Reform on July 26th, 2011 by MMS – Comments Off on ACOs as Food for Thought

The term Accountable Care Organization (ACO) seems to be everywhere these days.  It’s hard to pick up a health care journal, newsletter or newspaper that does not contain at least one reference to ACOs.

The one consistent thread is that ACOs are organizations of health care providers that agree to be accountable for the quality, cost, and overall care of ACO beneficiaries.  Industry thought leaders, physicians, administrators, and politicians are all buzzing about what the final CMS regulations on ACOs will look like.

Despite the fact that there has been a lot of concern voiced about the CMS proposed rule set, there has also been a lot of interesting discussion focused around using the ACO concept in innovative ways that ultimately promote CMS Administrator Don Berwick’s “Triple Aim” of better care, better health for populations and lower per capita cost.

A recent article in the New England Journal of Medicine, “A Model Health Care Delivery System for Medicaid,” by Dr. Richard Rieselbach and Dr. Arthur Kellermann, discussed the benefit of creating Community Health Center and Academic Medical Center Partnerships (CHAMPs) that would join together to form a CHAMP ACO.

The triple aim goal could be achieved for Medicaid patients by combining the strengths of teaching hospitals with those of community health centers, which would fundamentally be centers for the delivery of primary care.   Unfortunately, the proposed CMS rule set creates barriers for this type of ACO model.

If this phase between proposed and final rule making continues to stimulate innovative thought around models for high-quality, reduced-cost care, then perhaps release of the final rule should be delayed a bit longer.

To learn more about ACOs and the things your practice can do to prepare to become an ACO, join us on September 13 for our fall program A Path to Accountable Care Organizations: How Do We Get There From Here? Visit www.massmed.org/aco2011 for more information.

— Kerry Ann Hayon

State Cost Hearings Uncover Lots of Data, But Little Consensus

Posted in Accountable Care Organizations, Payment Reform on July 7th, 2011 by MMS – Comments Off on State Cost Hearings Uncover Lots of Data, But Little Consensus

By Lynda Young, MD, MMS President

During four days of public hearings last week, the Division of Health Care Finance and Policy heard providers, payers, researchers, and members of the public explain, under oath, what they think drives health care cost growth in Massachusetts and how provider prices affect insurance premiums.

Day one focused on trends in premiums and overall health costs. On Tuesday, the spotlight shone on health care price variations, with attention given to Attorney General Martha Coakley’s recent report that questioned whether a shift to global payment would really save money.

The big news coming out of Tuesday’s hearings was support for temporary government price controls from executives representing Lowell General Hospital, MetroWest Medical Center, and Tufts Medical Center.  Among Tuesday’s testifiers, only Dr. Gary Gottlieb, chief executive of Partners HealthCare, came out against government rate regulation. Many smaller providers claim Partners’ market clout hampers their ability to negotiate reasonable reimbursement rates with health plans.

The Wednesday hearings were dominated by pundits and public health officials discussing alternative payment methods and health resource planning. The theme for Thursday morning was care coordination, which is central to improved outcomes and lower costs — and a goal that alternative payment methods may advance. Thursday afternoon, panelists debated the role of government in containing health care costs.  Separately on Thursday, Health Care For All, a consumer health care advocacy group, called for a 2012 freeze on health insurance premium rates.

The diversity of the testimony last week demonstrates the complexity of the problem before us. We’re convinced that better integration and coordination of care is an important part of the solution – but not the only part.

Clearly, there’s a growing appetite for strong government regulation of health care prices. This greatly concerns us. Rate setting wasn’t very effective 20 years ago, and I doubt that it would be any more effective today.

The most comprehensive and realistic approach we’ve seen was produced by the Health Care Quality and Cost Council two years ago. The Council’s “Roadmap to Cost Containment” has been nearly forgotten. That’s unfortunate, because it recommended a focused, multi-faceted approach, in recognition of the fact that we’re dealing with a complex problem. That report is worth revisiting. If we had adopted that roadmap back in 2009, who knows how much progress we would have made by now?

Dr. Young is a pediatrician based in Worcester.