Payment Reform

Young to Mass. Doctors: Stay Involved, Be Heard on Payment Reforms

Posted in Health Policy, Interim Meeting 2011, Payment Reform on December 2nd, 2011 by Erica Noonan – Comments Off on Young to Mass. Doctors: Stay Involved, Be Heard on Payment Reforms

Massachusetts Medical Society President Lynda Young urged doctors to make themselves heard in the debate over health care costs, especially as the stakes rise in Washington D.C. over looming Medicare cuts

She spoke before the House of Delegates opening session at the MMS 2011 Interim Meeting, which began Friday, Dec. 2 at 9 a.m.

Dr. Young’s remarks focused on the “challenging times” in Massachusetts health care.  As pressures in Washington rise, closer to home increasing consolidation of hospitals and practices have left no part of the state untouched.

“Things are changing, and it’s happening very, very quickly,” said Dr. Young.

She recalled the historic day back in April 2006 at Faneuil Hall when the state’s health care reform bill was signed into law.  Five years later – it has exceeded the expectations of even its most enthusiastic supporters — less than 3 percent of the state’s population is uninsured.

But the job is by no means done, she said.

“This is what we have left for later – the relentless rise in the cost of health care – while the rest of the economy rose at a much slower rate, if at all,” said Dr. Young.

Massachusetts is making strides, however, she said. Health care premiums here are no longer the highest of fastest-growing in the country. Some 26 other states have seen their premiums rise faster than Massachusetts in recent years.

The Massachusetts medical community needs to keep up its advocacy work against efforts by government to impose rate setting, said Dr.Young.

Doctors must not walk away from this debate, although the politics and delays can be deeply frustrating.

“If you’re not at the table, you’re on the menu,” she said, drawing laughs from the more than 200 attendees at the morning session.

“We must stay at the table in all these discussions.  Everyone wants us there and we are making a difference.’’

Read more details about the  MMS Interim Meeting Dec. 2-3

— Erica Noonan

Physicians and ACOs: Skepticism Abounds

Posted in Payment Reform, workforce on October 7th, 2011 by MMS – 1 Comment

Last in a series of five articles on the 2011 MMS Physician Workforce Study

With global payment contracts and accountable care organizations becoming more prevalent in Massachusetts, we thought it would be important to ask physicians what they thought of these new practice arrangements.

About 57 percent of physicians said they were familiar with global payment contracts and 58 percent said they were familiar with ACOs. Forty two percent said they were willing to enter into a global payment contract, and 49 percent said they would join an ACO. Physicians who were familiar with the terms were only slightly more willing to participate than those were not familiar.

There is a strong divide between specialists and primary care physicians. Almost 72 percent primary care physicians said they were likely to join an ACO, compared to 50 percent of specialists. This correlates strongly to specialists’ long-stated worries that their referral patterns – the lifeblood of their practices – would be disrupted or diminished by ACOs.

The survey didn’t ask for the reasons behind their answers, but preliminary results from research that the Harvard School of Public Health is conducting for us may shed a light on that.

In that study, only 7 percent of all respondents said their practice has access to computer systems to manage clinical information, and only 29 percent said their group is ready to enter into a global payment contract. These are important preconditions to succeeding in a global payment environment.

Will implement global payment system achieve what its sponsors hope? Physicians are skeptical.

Fewer than half (44%) believe that medical spending will decrease. Even fewer, 19 percent, believe that quality will improve. Most believe that that global payments will reduce physician incentives to work (59%) and reduce the numbers of physicians willing to work in Massachusetts (76%).

Sponsors of a global payment system need two groups to believe it will work – physicians and patients. We don’t have data yet on patients, but the evidence suggests that physicians aren’t there yet.

Read the workforce study at

End of series. Read the other posts in this series here.

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 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 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 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.

Does Payment Reform Save Money? Comments on the Attorney General’s Report

Posted in Accountable Care Organizations, Capitation, Global Payments, Payment Reform on June 24th, 2011 by MMS – Comments Off on Does Payment Reform Save Money? Comments on the Attorney General’s Report

By Lynda Young, MD, MMS President

Attorney General Coakley’s new study this week on health care costs and payment reform has been generating a lot of discussion. Here are some thoughts from our corner.

We think it’s too early to declare payment reform a failure from a cost-cutting perspective. You can’t measure its effectiveness after just one year. Five years is a far more reasonable time frame to declare victory or defeat.

Further, the implied threat of more top-down rate regulation greatly concerns us. It hasn’t worked in the long run, because players always find a way around the rules and the unintended consequences are too great.

But we don’t want to be entirely negative. We applaud the attorney general’s observation that a variety of organization models can be effective, and that both physician-based and hospital-based groups can get the job done.

But perhaps the most important part of the report discusses risk management and risk adjustment.

As the attorney general noted, most physician groups are ill-equipped to handle significant financial risk today. To do so in the future, we will need much better data than we currently have. We will need a clear picture of who is in our practice group, their utilization patterns, and what they do when they seek care outside our group. Without this, it will be impossible to monitor our own efficiency or quality.

We also need good electronic health record systems that can communicate with physicians outside our practice. By and large, this is not possible today. Imagine how limited your cell phone would be if you couldn’t call someone who’s using a different cell phone provider. That’s pretty much what most EHR users face today.

We also need to ensure that physicians can stay in small practices if they want to, while enjoying the benefits of aligning with larger networks. To remain viable, most physicians will need to share IT costs, reinsurance costs, contracting expertise, and clinical information, while maintaining some measure of independence. Many patients would prefer that too.

The payment reform initiative has a laudable but challenging goal – to make care more affordable while fostering quality and innovation. We haven’t been able to do it yet, but if anyone can do it, it’s this health care community in Massachusetts.

Let’s keep trying.

Dr. Young is a pediatrician based in Worcester, Mass.

Risk Adjustment and Payment Reform: A New Webinar

Posted in Accountable Care Organizations, Global Payments, Health Policy, Payment Reform, webinar on June 15th, 2011 by MMS – Comments Off on Risk Adjustment and Payment Reform: A New Webinar

Every study of accountable care organizations recognizes that proper risk adjustment tools are critical to their success.

Without adjustments for case-mix severity and other issues, providers’ cost and quality measures can be simply wrong. For example, hospitals and physicians who treat a high number of seriously or chronically ill patients would unfairly have inappropriate funding, simply because they treat more people who are sick.

Last month, our House of Delegates declared that “proper risk adjustment” is an essential component of payment reform.

In order to take on a bundled, global payment or other related payment models, funding must be adequate, and adequate risk adjustment for patient panel sickness, socioeconomic status, and other factors is needed. Current risk adjustment tools have limitations, and payers must include physician input as tools evolve and provide enough flexibility regarding resources in order to ensure responsible approaches are implemented. In addition, ACOs and like entities must have the infrastructure in place and individuals with the skills to understand and manage risk.

On June 23, the MMS is hosting an important webinar on risk adjustment. It will cover why risk adjustment is important to your practice, its importance in the context of ACOs, global capitation, and medical home models. The webinar will also focus on a detailed description of the risk scoring and funds allocation processes.

The webinar content is particularly relevant to provider organizations that are about to enter into global payments, are already in such a program, or considering the creation of an ACO.

Click here for more information or to register.

MMS Calls for Changes in Medicare ACO Regulations

Posted in Accountable Care Organizations, Global Payments, Medicare, Payment Reform on June 6th, 2011 by MMS – Comments Off on MMS Calls for Changes in Medicare ACO Regulations

Today, the MMS submitted 20 pages of comments on the federal government’s proposed regulations for Medicare accountable care organizations (ACOs). Our comments were based on the principles for health care reform approved by our House of Delegates last month.

Our comments include:

  • Physician leadership, from both primary care and specialty care physicians, for the implementation of any new delivery system, including ACOs.
  • Medicare patients must have the freedom to choose their physician and ACO. The regulation proposes to assign patients based on where they have received most of their care in the recent past.
  • The 65 proposed quality measures are excessive and flawed, and will discourage many small practices from participating in a Medicare ACO. We stated that it’s “unnecessarily punitive” to require that practices meet every measure to qualify for the “shared savings” distributions at year’s end, particularly since many of the measures are hospital-based. We also believe the measures are inadequate for practices with a large number of senior patients.
  • The proposed financial withhold of 25% is too high and will hinder small practices from investing in IT and other infrastructure improvements. Financial withholds are funds set aside during the year to serve as an incentive to meet financial or quality benchmarks.

Last week, in similar comments, the American Medical Association recommended substantial changes in the regulations. Separately, leaders of the Mayo Clinic, Cleveland Clinic, Geisinger Health System and Intermountain Health criticized the regulations. One official at Mayo said, “There’d have to be substantial revisions for us to participate.”

Health Reform Principles Stress Balance Between Patient Choice and Economic Reality

Posted in Accountable Care Organizations, Annual Meeting 2011, Defensive medicine, Global Payments, Health Policy, Health Reform, Malpractice, medical liability reform, Payment Reform on May 22nd, 2011 by MMS – Comments Off on Health Reform Principles Stress Balance Between Patient Choice and Economic Reality

Spirited debate at the MMS House of Delegates Saturday led to the adoption of 18 principles on health care reform that the Society plans to share with local and national legislators.

The principle that dominated deliberations asserted that “health care reform must enable patient choice in access to physicians, hospitals, and other services while recognizing economic reality.”

Among the other principles adopted were the following:

  • Physicians must lead reform, keeping clinical decision-making in the hands of doctors and patients.
  • Reform must be flexible enough to account for different practice types and their variable readiness to change.
  • Fee-for-service payment should have a role in any system.
  • Physicians will need infrastructure support, especially for IT and hiring physician extenders.
  • Risk adjustment methods must incorporate physician input and account for illness burden and socioeconomic status of patients.
  • Transparency throughout the whole process is essential.
  • Patient education and accountability must be enhanced.
  • Professional liability and antitrust reform are crucial underpinnings to reform.

The complete principles are available at

Complete Annual Meeting coverage is available at