Accountable Care Organizations

After the ACA: Some Successes, and Lots More Work to Do

Posted in Accountable Care Organizations, Affordable Care Act, Health Policy, Health Reform, State of the State: 2014 on October 8th, 2014 by MMS – Comments Off on After the ACA: Some Successes, and Lots More Work to Do


David Blumenthal, MD, president of The Commonwealth Fund, told attendees of the MMS State of the State conference yesterday that while federal health reform has fostered many important improvements in our health care system, there are still big gaps in access to care, affordability, and health status.

Dr. Blumenthal said the U.S. is still “Two Americas,” where on the most metrics, the northern half of the country is generally much better off than the southern half. For example, he asserted that middle income people in the South are in no better a situation than low-income people in the Northeast.

However, the Affordable Care Act has been the primary reason for “historic” improvements on several fronts. In the attached video clip, he outlines some of those changes. Then he reviews the experience so far in Massachusetts.

Transforming Health: The Need for an Innovation Ecosystem

Posted in Accountable Care Organizations, Health Policy, Health Reform, State of the State: 2014 on October 7th, 2014 by MMS – Comments Off on Transforming Health: The Need for an Innovation Ecosystem


How do you transform the health care system in mid-flight?

Victor J. Dzau, MD, recently named president of the Institute of Medicine, argues that health care organizations have the ability to create an ecosystem that encourages the creation of ideas, nurtures them through experimentation, and then disseminates them to the rest of the health care system – up to and include commercialization.

His video clip begins with the wry observation that “innovation was not invented in the United States,” and can arise from anywhere.

His comments today were part of the 15th annual MMS  State of the State of Healthcare Leadership Forum.

Cleveland Clinic’s Lessons for Health Care Transformation

Posted in Accountable Care Organizations, Affordable Care Act, Health Policy, Health Reform, State of the State: 2014 on October 7th, 2014 by MMS – Comments Off on Cleveland Clinic’s Lessons for Health Care Transformation


The CEO of the Cleveland Clinic provided a persuasive and moving case study today of how a health care organization can tackle the transformation of health care.

Delos M. Cosgrove, MD, said the Cleveland Clinic has made significant improvements in the areas of affordability, access and quality.

But he noted that none of these are important if a fourth critical item is missing: empathy.

Dr. Cosgrove’s presentation was part of the MMS’ 15th annual State of the State’s Healthcare Leadership Forum.

View video clips from the conference’s other presentations.

Interim Meeting Ethics Forum: Ethics in ACOs

Posted in Accountable Care Organizations, Ethics Forum, Global Payments, Health Policy, Health Reform, Interim Meeting 2013, Payment Reform on December 6th, 2013 by MMS Communications – 2 Comments
Susan Dorr Goold, MD

Susan Dorr Goold, MD

The accountable care organization (ACO), loosely defined as a group of providers that accepts responsibility for the total care of a patient and is accountable for high quality care and the cost of care, is a rapidly growing concept whose aim is to reduce the rising costs of care and improve quality.

While the emphasis on ACOs has focused on cost and outcomes, less attention has been paid to the ethical considerations of delivering care within such a structure.  As the ACO continues to evolve, what are the ethical issues that physicians might face as they practice medicine?  Do healthcare institutions, as well as individual providers, face ethical issues as organizations? And how might ethical considerations influence payment structures?

These are some of the issues discussed at the Ethics Forum, held on the first day of the 2013 MMS Interim Meeting of the House of Delegates.

Presenting were Susan Dorr Goold, MD, professor at the University of Michigan and Chair of the American Medical Association’s Council on Ethical and Judicial Affairs, and Philip F. Gaziano, MD, chairman and CEO of Accountable Care Associates, a Springfield-Mass. based healthcare management company.

In two presentations over two hours, delegates heard perspectives on the practical and ethical challenges in making a transition to an ACO, who providers are accountable to and for what within an ACO while maintaining their first loyalty to the patient, conflicts of interest that may arise, and ways to protect patient autonomy while practicing in an ACO.

Some highlights from the presenters:

Dr. Goold, in a presentation entitled Strengthening Patient-Physician Trust in Accountable Care Organization, examined the elements of personal and organizational accountability that lead to strong physician-patient relationships.  Professionals, organizations and patients all have a responsibility in strengthening trust, she said: professionals with a duty to “seek trust from patients” based on openness and honesty, patients by being truthful and to trust wisely, and organizations as “moral characters” in modern society.

Dr. Gould also outlined the challenges to trust in physicians (patient expectations, requests, and demands) and health care institutions such as hospitals and payers (safety of personal information, treatment decisions, fair and prudent use of resources). She concluded with the notion that physicians and healthcare institutions have “moral responsibilities in health care” to include advocacy, competence, fairness, and honesty, among others.

Dr. Gaziano’s Ethical Considerations in Accountable Care Organizations focused on the payment considerations with ACOs, comparing fee-for-service to global payments (payments based on Relative Value Units) to Quality Value Units, a new designation created by his firm that provides the advantages of tracking and reporting in real time, predictive value, and the tracking of quality and budgets. He also addressed physician concerns: why ACOs are different from earlier cost-saving attempts like HMOs and opportunities within the new system of ACOs such as payments and managing budgets.

The presentations of both physicians are available on the MMS website here.


MMS Forum Spotlights the Past, Present and Future of Health Reform

Posted in Accountable Care Organizations, Affordable Care Act, Health Reform, Payment Reform on October 30th, 2013 by MMS – 1 Comment
David Gergen

David Gergen

On the same day that President Obama spoke at Faneuil Hall to defend and promote the Affordable Care Act, the Massachusetts Medical Society’s 14th annual forum on the State of the State’s Health Care focused on the consequences and future of state and federal health reform.

Calling the ACA “both a triumph and a tragedy,” veteran White House advisor David Gergen said the political firestorm currently surrounding ACA implementation – reports of consumers furious that their private insurance policies face cancellation – has seriously jeopardized the future of President Obama’s signature legislation.

Gergen, currently director of the Center for Public Leadership at Harvard’s Kennedy School of Government, recommended a major public information campaign and more transparency from President Obama to rally public support for the beleaguered law.

Stuart Altman

Stuart Altman

Stuart Altman,  chair of the Massachusetts Health Policy Commission, spoke about the need for states to become more aggressive about reining in total health care spending – not  just  the amount public money spent to care for low-income or elderly patients.

Because health care costs are disproportionately pushed onto the privately insured, the long-running cost-shifting model is unsustainable.  “It is simply impossible for private insurance to make up for shortfalls in Medicare and Medicaid rates,” said Altman, a Brandeis professor who currently chairs the state’s Health Policy Commission.

He predicted a noticeable decline in medical care nationwide if costs are not more quickly brought under control and tightly connected to quality and outcome data. “Not a `lights-out,’ but more like a `lights flickering,’” he said.

Altman, a supporter of physician-led ACOs and bundled payment systems in Massachusetts, said the state’s new innovated approaches strive to avoid the “mistakes” of 1990s-era managed care systems, such as micromanaging doctors, dumping too much financial risk on providers, and forcing unwilling consumers to join plans.

Control of post-acute care spending and an effective primary care system will be keys to the future success of Massachusetts ACOs, Altman said.

John Noseworthy, MD

John Noseworthy, MD

Mayo Clinic CEO John Noseworthy, MD, spoke about his system’s culture of teamwork and patient-centered care.  He said more work is needed in most other health care systems nationwide to reduce fragmented and uneven care – factors that drive up the costs of care dramatically.

The Mayo system struggles with downward pressure on Medicare reimbursement rates, and Dr. Noseworthy said he expected the ACA would likely cut them an additional 15 to 25 percent.

While Mayo has six campuses nationwide, Dr. Noseworthy said his system’s survival lies not in acquisitions or consolidation, but in scaling its practice knowledge and experience to affiliates at independent practices and hospitals.  “We hope that our network can be an integrator for groups without the culture of an integrated practice,” he said.

The program also featured a panel of Massachusetts health care executives: Tufts Health Plan CEO James Roosevelt Jr., Boston Medical Center CEO Kate Walsh, and Stuart A. Rosenberg, MD, CEO of the Harvard Medical Faculty Physicians at BIDMC.

Dr. Rosenberg said he felt one of the most pressing problems was a failure to use IT to transform health care and help patients manage chronic health issues in their own homes.

Roosevelt urged more collaboration between providers and payers to control costs, and said the state must be vigilant in monitoring provider consolidation to ensure better care for patients is the result.

In her comments, Walsh focused on BMC’s dramatic financial turnaround in the wake of major state funding cuts.

But, Walsh warned, the state must stay vigilant in monitoring the needs of its poorest citizens “or access will be slaughtered on the altar of costs.”

—     Erica Noonan

The President’s Podium: Primary Care Competition

Posted in Accountable Care Organizations, Health, Health Policy, Health Reform, medical homes, Primary Care, Retail Clinics on October 15th, 2013 by MMS Communications – 1 Comment

by Ronald Dunlap, M.D., President, Massachusetts Medical Society DSC_0003 Dunlap 4x6 color 300 ppi_edited

The shortage of primary care physicians, besides creating longer wait times for both new and existing patients, is also changing how care is being delivered.

National pharmacy chains are seeking bigger roles in patient care, like managing chronic diseases, and they’re developing partnerships with medical groups large and small across the country.

Non-physician health professionals are also pressing for more opportunities. Nurse practitioners, for example, encouraged by a 2010 Institute of Medicine report, are engaged in advocacy and legislative efforts to establish independent practice, unburdened by physician supervision. Chapter 224 of Massachusetts General Laws, passed last year, included a new definition of primary care and expanded authority for NPs to sign documents once limited to physicians. This has given some NPs the impetus to set up independent practice.

What effects will these efforts have on primary care? Let’s take a closer look.

Retail clinics:  How often and for what purposes patients will visit retail clinics remain open questions, as these clinics are just now expanding their services from basic offerings to more complex endeavors such as lab services and managing chronic diseases. Unlike many other states, Massachusetts health officials have established a long list of regulations that these limited service clinics must follow.  However, Chapter 224 also requires the Department of Public Health to promote these clinics to the full extent of the scope of practice of NPs (who generally run these operations), but not to classify the clinics as primary care providers.

Research shows that patients like the convenience of retail clinics, particularly when they have difficulty getting to their primary care provider. Given the limited resources and no onsite physicians, most patients may not regard them, at least for now, as a place for primary care. As they add more sites, services, alliances, and advertising, however, they are likely to play a bigger role in health care – a prediction already being made by health care analysts.

Nurse practitioners: NPs play a vital role in health care. They always have, and they will play an even larger role as the team approach to care becomes more prevalent with medical homes and accountable care organizations.

The idea, however, that independent practice by NPs can fill the physician gap falls short. For one, a nursing shortage exists alongside the physician shortage, and nurses, like physicians, are an aging part of the healthcare workforce, with more than half of nurses approaching retirement.  The difficulty in recruiting nursing school faculty to teach a new generation adds to the problem.

Independent practice by NPs isn’t likely to increase the number of primary care providers; at best it might redistribute some to underserved areas. Most now work in urban areas, as physicians do, and most hospitals will not allow NPs on staff without physician supervision.

Further, with an emphasis on cost containment, replacing high-salaried providers (physicians) with lower ones (NPs) with less training will likely not result in savings. We have seen that less-experienced providers tend to order more tests and procedures, raising costs. Cost control will result best from the team approach of coordinating care and avoiding unnecessary referrals, testing, and procedures.

Finally, as independent or solo practice by physicians is becoming less and less viable with the growth of medical homes and accountable care organizations, the same is likely to happen with nurse practitioners.

While retail clinics and independent practices may have their place, continuity and coordination of care is much preferred over fragmented care from multiple providers. I believe the basis of good health care remains within the physician-patient relationship, supported by nurse practitioners, physician assistants, and other allied health professionals in a team approach. Patients will benefit most from this kind of an approach.

The President’s Podium appears regularly on the MMS Blog, offering Dr. Dunlap’s commentary on a range of issues in health and medicine.



New: (Almost) Everything Physicians Need to Know About ACOs

Posted in Accountable Care Organizations on August 21st, 2013 by MMS – Comments Off on New: (Almost) Everything Physicians Need to Know About ACOs

Today, we released a new online publication, MMS Guide to Accountable Care Organizations: What Physicians Need to Know.

We’ve published many white papers on ACOs and practice integration before, but none as comprehensive as this. The document has been designed to be the first place to go for physicians who are:

  • Currently participating in an ACO and want to optimize their performance
  • Forming an ACO
  • Joining an ACO
  • Evaluating other kinds of clinical integration agreements

There’s lots of wisdom packed into these 49 pages. Topics include:

  • Is your practice ready to join an ACO?
  • How do you choose the right ACO?
  • Technology considerations
  • Legal and governance issues
  • Finances
  • Achieving clinical integration

It’s available online for free to MMS members. Printed versions will be available next month.

The Legislature’s Ambitious Health Care Bill: Steps Forward, and Concerns

Posted in Accountable Care Organizations, Global Payments, Health Reform, Mass. Legislature, Payment Reform on July 31st, 2012 by MMS – 5 Comments

By Richard V. Aghababian, MD
MMS President

(Update: The House and Senate passed the legislation today by overwhelming margins. Gov. Patrick is expected to sign the bill.)

The Legislature has produced an ambitious health care roadmap for our Commonwealth. It seeks to make health care affordable for the residents, businesses and government of Massachusetts, while fostering quality, access and innovation.

In many cases, the legislation strikes a responsible balance between the role of government as oversight entity, with the rights of private sector entities to operate responsibly. However, there are several areas where we have concerns.

Steps Forward

  • We are pleased that providers will be free to decide whether they want to participate in alternative payment methodologies. Global payments aren’t for everyone, and fee for service still has a vital role to play in our system.
  • The cost benchmarks locate a middle ground between the House and Senate proposals. We have advocated for higher benchmarks than the bill provides, and we have our doubts about sustainability of these benchmarks. We are pleased, however, that the legislation provides the opportunity for adjustments and corrections in future years.
  • We support the legislation’s decision to use a corrective action plan as the mechanism to hold providers accountable for their costs – as opposed to the more punitive measures outlined in previous proposals. In addressing payment disparities among providers, the bill fairly recognizes the real progress that the private sector has achieved over the last two years.
  • We are extremely pleased that the bill includes the Disclosure, Apology and Offer model of medical liability reform that we have championed for many years. We believe that implementing this alternative to traditional litigation will foster a climate of safety and openness in all health care settings, especially when a patient is harmed by an adverse medical outcome.
  • The commitment to full parity of mental health and behavioral health with other areas of medicine is most welcome.
  • We strongly support the proposals to address shortages in the health care workforce.
  • The initiatives to foster transparency of reliable cost and quality information will not only benefit patients, but will also assist providers in recommending the most effective and affordable tests, drugs and procedures for their patients.
  • We are pleased to support the wellness programs that are outlined in the legislation; prevention is the best medicine of all.


  • We are concerned about the impact of the bill’s very stringent reporting requirements on the smaller medical practices in the Commonwealth.  We will look to clarify how small practices will be impacted by the costs and burdens associated with reporting to new entities established by the legislation. The state must ensure that such efforts avoid duplication and provide a true net benefit to our Commonwealth.
  • We are concerned that the bill goes too far expanding the practice prerogatives of some groups of providers. In particular, we find that the favored status granted to limited service clinics to be unwarranted, and thinly supported by research or facts.  The classification of physician assistants as primary care providers also raises questions. We will monitor these developments closely and will be prepared to advocate for corrective measures if there are unintended consequences.

Clearly, the transformation of health care is only beginning. There is still much more work to be done.  The Massachusetts Medical Society remains committed to working with all stakeholders, as we strive for a health care system that is effective, affordable and accessible to all.

First Look at Payment Reform Legislation

Posted in Accountable Care Organizations, Global Payments, Health Policy, Health Reform, Mass. Legislature, Payment Reform on July 31st, 2012 by MMS – Comments Off on First Look at Payment Reform Legislation

349 pages.

7,489 lines.

The Legislature’s House-Senate conference committee finally released its consensus payment reform bill last night. The House and Senate are scheduled to vote on it today – just in time for the end of formal sessions at midnight tonight.

If you want to take a look at it yourself, here’s the full text and the Legislature’s own summary of the bill.

We’re analyzing the fine print and will comment later.

Key Similarities and Differences Between the House and Senate Payment Reform Bills

Posted in Accountable Care Organizations, Defensive medicine, Electronic health records, Electronic Medical Records, Health IT, Health Reform, Malpractice, Mass. Legislature, medical liability reform, Payment Reform on June 8th, 2012 by MMS – 1 Comment

After two years of discussion and debate, the Massachusetts Legislature must now deal with two huge pieces of payment reform and cost control legislation.

Earlier this week, the House passed its legislation by a wide margin, following eight hours of deciding which of 275 amendments it would accept. The Senate passed a separate bill on May 17.

During the House debate this week, the MMS sought to protect most small and medium physician groups from the House’s very rigorous reporting requirements. The original House bill exempted groups with fewer than 10 physicians. Due to MMS advocacy, the House agreed to increase the exemption to 25, which we will try to increase further during the conference committee’s deliberations.

When the members of the conference committee are appointed, they will have until adjournment on July 31 to agree on a single bill and get it passed by both chambers.

Despite their many similarities, reconciliation and consolidation of the bills is not expected to be an easy task.

Key Similarities

  • Cost containment: Each bill states that overall health care costs should rise in concert with the growth in the state’s economy. (Differences noted below.)
  • State oversight: Each creates a new state agency to certify provider groups, and collect volumes of information on quality measures and costs. The House agency is placed inside the executive branch, under the Executive Office of Health and Human Services. The Senate agency is an independent entity.
  • Market power: Both bills require payers to negotiate separate contracts for each hospital facility, with some exceptions.
  • Alternative payment models: The bills define ACOs and their requirements. They provide a 2 percent bonus in Medicaid payments to providers starting in July 2013, if they move to alternative payment methodologies.
  • Electronic Health Records: Each requires physicians to be proficient in the use of electronic medical records. (Differences noted below.)
  • Medical liability: Both mandate waiting periods for civil suits brought against health care providers. They require disclosure of case information to patients and providers; protect statements of apology from being admissible as evidence; provide for early payments to patients without prejudice. They reduce the prejudgment interest rate in malpractice cases from 4 percent to 2 percent. No contract may prohibit a physician from serving as an expert witness.
  • Determination of Need: They expand the Determination of Need process to include more new technologies, transfers of ownership and site expansions.
  • Administrative simplification: Both bills require standards forms for utilization review.
  • Peer review: Both bills expand the peer review statute. The House specifically provides ACOs with peer review protection; the Senate provides such protections to any provider group that conducts peer review activities.
  • Charitable immunity: They raise the charitable immunity cap from $20,000 to $100,000 (affects most hospitals in Massachusetts).
  • Physician assistants and nurse practitioners: Each bill provides more independence to physician assistants and nurse practitioners.
  • Limited service clinics: Both bills eliminate some existing regulations for the operation limited service clinics, such as those located in pharmacies; however their approaches differ.

Key Differences

Cost Containment

  • The House’s benchmark is 3.6 percent for 2012 and 2013. In 2014 and 2015, it would be equal to the growth rate projected in the Governor’s budget submissions. From 2016 to 2026, it would be equal to a half percentage point below the Gross State Product (GSP) from 2016 to 2026, and equal to one point above GSP after 2027.
  • The Senate’s cost benchmark is a half point above GSP through 2015, and equal to GSP from 2016 to 2026.
  • The House imposes a penalty on providers who costs are 20 percent higher than the benchmark. It establishes rate setting for governmental units. The House gives the state the ability to force providers to reopen contracts that it considers contributing to excessive spending. The House gives the attorney general to block unreasonable increases in rates, and block changes that adversely affect patient access and the quality of care. In the Senate bill, groups that exceed the benchmark must file improvement plans.

Market power

  • The House subjects provider groups of 10 or more physicians to a market impact review.
  •  The Senate gives the attorney general the power to prevent excess consolidation and collusion.


  • The House requires any physician group with 25 or more physicians to be certified by the Department of Public Health.
  • The Senate requires certification for all providers entering into alternative contracts. It exempts groups with less than $500,000 in annual net patient service revenue and fewer than five affiliated physicians, if the group does not accept risk.

Electronic Health Records

  • The House requires providers to adopt EHRs that are fully interoperable and connect to the statewide health information exchange.
  • The Senate updates existing the requirement for EHR proficiency by 2015 by requiring physicians must demonstrate the skills to comply with the federal government’s meaningful use requirements. It creates an institute to facilitate the implementation of interoperable records statewide, and promote the use of other health information technologies.