Friday, June 3, 2011

Long Island Business News: Doctors cautiously join IPAs

After decades in which patient privacy concerns, a culture of independence and antitrust issues divided doctors, physicians are banding together in groups, largely due to encouragement from insurers and the federal government.

The idea is that they can provide better care by sharing data and adhering to shared standards.

"It's like herding cats," said Michael Guarino, who is organizing the Nassau/Suffolk County Independent Physician Association, of efforts to overcome a culture of independence and isolation. "They've all been trained to be independent and think that way. They're the captain of the ship in the OR. Now someone's trying to put them in a group."

The result is the equivalent of bulldozing the Berlin Wall as doctors continue to run their practice, while participating in entities that set standards and procedures and help negotiate contracts and group purchasing.

On Long Island, The Beacon Independent Physician Association and East End Physician Hospital Organization formed recently. The North Shore-Long Island Jewish Health System also operates an IPA.

"Beacon IPA physicians are working together to produce regular performance reports, determine specific quality and safety benchmarks, and identify potential issues in patient care," Beacon CEO Dr. Simon Prince said.

Beacon last week reached a landmark, signing its first contract with an insurer, Empire BlueCross BlueShield, enhancing reimbursements in return for accepting standards.

"It's more of a partnership with Beacon in a different approach to managing care," John Caby, Empire's vice president of provider engagement and contracting, told LIBN. "They'll agree on certain parameters to justify reimbursement on an ongoing basis."

Beacon will pool data and take measures, including extending office hours, which Empire believes will save money and improve care.

"You should see a reduction in ER visits," Caby said. "I don't need to go in the ER in that scenario. It impacts total cost of care."

Despite their promise, IPAs face potential problems, including the fact that earlier efforts to band together in the 1990s largely failed and there's no guarantee cooperation will improve care and cut costs.

"We learned people took on risk and weren't capable of managing the risk," Caby said of those earlier, failed efforts. "That created a financial problem."

IPAs under managed care typically were paid per patient, which Caby said resulted in rates so low some couldn't survive. He said the new generation of IPAs, at least so far, isn't paid per patient.

"It's a big difference, except there is an expected outcome," Caby said. "Although there may not be a budget established for Beacon, at the end of the day, you expect to see lower costs of care with higher-quality outcomes."

Others said electronic data makes it easier for doctors to share and track information.

Some doctors worry the new generation of IPAs may also fail.

"They never worked before. Are they going to work?" asked Dr. Dort Ben-Moha, a physician in Plainview who belongs to the North Shore-LIJ IPA. "What's going to happen to the little person like me not employed by the hospital, not in a large practice?"

She doesn't believe she's obtained big benefits by belonging to the North Shore-LIJ IPA.

"Our rates only keep going down," she said. "Has it got better? No. Our malpractice (insurance) is still sky high."

Although some IPAs like Beacon and Nassau/Suffolk County were created exclusively by doctors, hospitals are helping set up their own physician groups.

"There are benefits and disadvantages," Guarino said of organizations involving hospitals. "You can't have two masters. Am I worried about the physicians or the hospital system?"

Rules are still forming regarding these groups and reimbursement, leaving a big question mark.

"There are a lot of challenges these organizations face," Manko said. "As government tries to incentivize providers to create networks, the government has to come out with new regulations."

Caby said groups need to use data to benefit patients, eliminating duplicate tests and providing follow up and more prevention.

"They need to be clinically integrated and have the physician leadership to make it work," Caby said. "Clinical integration is a very big obstacle. If physicians don't work together, you can be pulled in different ways. The resources expended don't always result in better outcomes."

Manko also said it's easier to form these groups than to make them work, noting "they're not complicated to do from a legal standpoint, but achieving clinical integration is difficult."

Guarino believes they also can provide economic benefits, by pooling physicians for group purchasing.

"They're all small businesses," Guarino said. "They buy 10 vaccines. I could buy 10,000."

David Manko, a partner specializing in health care law at Uniondale-based Rivkin Radlersaid physicians are "going to have to do something, because staying by themselves isn't really an alternative anymore" as health care reform requires greater cooperation.

"The main goal is how to aggregate the data so we can change the way healthcare is delivered," Guarino said. "For independent physicians, this is what we have to do. We have to get this started."

Wednesday, May 25, 2011

Long Island-Based Beacon IPA Inks Deal with Empire BlueCross BlueShield


                                                    Press Release

Long Island-Based Beacon IPA
Inks Deal with Empire BlueCross BlueShield

Media Contacts:
Sally Kweskin, (720) 373-4836,
Dr. Simon Prince, (516) 570-3580,

May 26, 2011 – Manhasset, NY – Beacon IPA, a young and rapidly-growing physician network consisting of almost 200 healthcare practitioners, has proudly announced a three-year agreement with Empire BlueCross BlueShield. The new contract brings together two premiere organizations, committed to finding new ways to enhance the overall quality, efficiency and safety of clinical care at reduced costs.

“We anticipate major changes driven by new healthcare reform at both the State and Federal levels,” said John Caby, VP, Provider Engagement & Contracting, Empire BlueCross BlueShield. “We believe there are great opportunities for collaboration between payors and physicians in the interest of better aligning payment with value, reducing fragmentation and placing greater emphasis on wellness and prevention.”

As Empire continues to amp up its focus on quality-based reimbursement, this collaboration will serve as a long-term strategy to curb rising healthcare costs and improve the patient experience. Beacon’s sound leadership, clearly-defined performance standards, and management strategies, were some of the factors that encouraged Empire to join efforts with the young network.

“In today’s environment, accountability is absolutely critical for success,” said Nephrologist Dr. Simon Prince, President and CEO of Beacon IPA. “Beacon IPA physicians are working together to produce regular performance reports, determine specific quality and safety benchmarks, and identify potential issues in patient care.  We are convinced that our relationship with New York’s leading insurance company will not only benefit the payor and all our member physicians, but will also pave the way for better, safer and more affordable care. Therefore, I look forward to working with Empire BlueCross BlueShield in support of this goal.”

At a time when millions of people are struggling to make sense of the intricate healthcare system, Beacon IPA has created a solid infrastructure for improved clinical care and doctor/patient communications. Patients stand to benefit significantly from instant medical attention, streamlined communications with their providers, and improved follow up system, while avoiding unnecessary testing procedures or frequent visits to the emergency room. For people suffering from chronic conditions, Beacon IPA physicians will focus on helping their patients make more informed decisions and more effectively manage their illness.

“As we move towards becoming a clinically-integrated IPA, we are intent on leveraging the latest technology and helping all our physician members implement electronic medical records in their offices,” added Dr. Prince. “It will invariably facilitate the communication process between our doctors and reduce medical errors that are prevalent in the medical field.”

Since its inception in July of 2010, Beacon IPA has established itself as a cohesive and patient-centered independent practice association, comprised of primary care practitioners and specialists. As economic pressures continue to rise, Beacon IPA is countering a growing trend towards consolidation in the healthcare market.

“We’ve been closely watching other states, such as Massachusetts and Rhode Island, that have been deeply affected by the changing landscape of healthcare reform,” said Mr. Caby. “We are anticipating what may be coming down the pike in the near future. Our agreement with Beacon IPA is a way to improve the health status of our communities and help reduce the avoidable expenses that continue to increase the cost of health care.”

About BIPA
Beacon IPA is a grass roots physician-owned and -governed organization founded in 2010 which looks to become a recognized leader in implementing comprehensive care management programs, pay-for-performance and provider reimbursement models tied to quality measures and patient outcomes. Beacon IPA is committed to becoming a clinically integrated physician network that enhances the viability and sustainability of independent private practice physicians in the New York metropolitan area. For more information about Beacon IPA, visit

About Empire BlueCross BlueShield
Serving New Yorkers for over 75 years, Empire BlueCross BlueShield is the largest health insurer in New York supporting nearly six million members and more than 38,000 business, union and small employers in New York. Empire BlueCross BlueShield (Empire) is the trade name of Empire HealthChoice Assurance, Inc., and Empire Blue Cross Blue Shield HMO is the trade name of Empire HealthChoice HMO, Inc., independent licensees of the Blue Cross Blue Shield Association, serving residents and businesses in the 28 eastern and southeastern counties of New York State. Additional information about Empire is available at Also, follow us on Twitter at, on Facebook at, or visit our YouTube channel at

Tuesday, May 24, 2011

Meaningful User: Anyone Can Do It


Juan Salazar, M.D., a solo internal medicine practitioner in McAllen, Texas, recently received one of the first Medicare electronic health records meaningful incentive checks (for $18,000). He's been practicing for three decades and only adopted an EHR about 18 months ago. Salazar understands the fears of peers to switch to electronic records, believing them to be cumbersome and adding little value to their practice. "When I started with EHRs I had the same fears," he notes. "I was changing cultures."

But he'll never return to paper because the ambulatory EHR from Cerner Corp. has made him and the office far more efficient while improving care. Patients, for instance, can see their health status trends on the laptop "and it gives a sense of wellbeing that they're getting better."
Salazar sees the same number of patients and goes home at the same time that he did in a paper environment, but now his charts are done before he leaves.  The time he spends on entering data is more than offset by the time saved as he isn't asking patients the same basic health history and status questions each visit because that information already is on his screen. His message to peers: "I'd never worked on an EHR in my life and if I can do it, anyone can."
As Salazar and the staff learned how to use the EHR, they found out how inefficient they were without it, says Janie Davila, office manager.
Achieving meaningful use actually was quite easy, she adds. The toughest part was learning how to access all the data in the system, which includes scanned historical information as patients are seen for the first time since the EHR went in. But all the information they needed to attest to meaningful use was in the system and accessible, Davila notes. "The end-of-month reports are right there and I can graph anything I want."
She cautions other providers, however, to be prepared for some push-back from patients who may feel offended when asked for certain demographic information, particularly race and ethnicity. But they accept an explanation that information is a new requirement.
Salazar will use some of the first-year meaningful use incentive check to pay bonuses to staff, and save the rest.
--Joseph Goedert

Wednesday, May 18, 2011

CMS Today Announces Three New Initiatives Intended to Enable Prospective Accountable Care Organizations to Hit the Ground Running

Legal Bulletin

By David A. Manko, Esq. and George Choriatis, Esq.

The Centers for Medicare and Medicaid Services (CMS) today announced three new initiatives in connection with its efforts to advance accountable care organizations (ACOs) – a new type of healthcare organization being promoted under the Patient Protection and Affordable Care Act (“Affordable Care Act”) enacted last year.  As discussed in our prior alerts, the Affordable Care Act requires CMS to establish a new Shared Savings Program under Medicare, which is intended to encourage physicians, hospitals, and other healthcare providers to form ACOs to assume accountability and coordinate their services for a defined patient population and to be rewarded for improving the effectiveness and efficiency of their care with respect to that patient population.  Today’s announcement follows several important developments regarding ACOs that have taken place over the past two months.  On March 31, 2011, CMS had issued proposed regulations implementing the Shared Savings Program.  On that same day, the HHS Office of Inspector General, the Federal Trade Commission, and the Internal Revenue Services had made various proposals to provide protection to ACOs under the federal healthcare fraud and abuse laws, the anti-trust laws, and the tax laws.  During that same week, the New York State legislature had enacted a law establishing an ACO demonstration project in New York State.  

The new initiatives announced by CMS today are intended to help ACOs hit the ground running when the Shared Savings Program commences, which is planned to commence in 2012.  These new initiatives are as follows:

(1)        The Center for Medicare and Medicaid Innovation (Innovation Center) is establishing a new “Pioneer ACO Model” program, which is intended to support “vanguard” organizations that already have extensive experience in coordinating care for patients and are well-poised to serve as ACOs to test innovative payment models and other innovations that differ from those established in the Shared Savings Program.  Up to 30 organizations will be accepted into the program.   Organizations interested in participating in the Pioneer ACO Model must submit to CMS a letter of intent by June 10, 2011 and a complete application by July 18, 2011. 

            (2)        The Innovation Center also issued a request for comments on a new initiative it is considering, the Advance Payment Initiative.  The Advance Payment Initiative, if implemented, would provide that certain ACOs participating in the Medicare Shared Savings Program would be entitled to receive pre-payments of a portion of their future shared savings for use in investing in the infrastructure necessary to coordinate care and improve value for patients.  Parties interested in submitting comments must do so by June 17, 2011.

(3)        CMS is establishing a new series of free training sessions, the Accelerated Development Learning Sessions.   The sessions will be made available to providers interested in participating in CMS’s ACO initiatives.  They will teach providers interested in becoming ACOs how to develop an action plan for moving toward providing better coordinated care.

Huffington Post: Healthcare Costs Double In Less Than A Decade

U.S. healthcare is so expensive that records are broken even when cost increases slow.
According to a new report by Milliman, a global consulting and actuarial firm, the total cost of healthcare for the average family of four, if covered by a preferred provider organization, is now a record $19,393.
That might be only 7.3 percent higher than last year's average cost of $18.074, which is the smallest year-over-year increase in almost a decade. But it's also the highest year-over-year increase in total dollars spent per family at $1,319.
Trends over the last decade more completely illustrate the toll taken on the average American by rising healthcare costs.
"In 2002, American families had healthcare costs of $9,235, and those costs have now doubled in fewer than nine years," said Lorraine Mayne, Milliman principal and consulting actuary, in a press release. "As costs continue to grow -- and even as the cost trend decelerates -- the total cost of care for American families constitutes a larger and larger portion of the household budget."
Of that $1,319 increase, employers were paid for 48.6 percent of the increase, while the additional 51.6 percent was the responsibility of employees.
That's only slightly different from trends of the last five years. Over that period, employers have absorbed $3,023 in additional healthcare costs, employees themselves absorbing only slightly less, at $2,988.

Tuesday, May 17, 2011

Berwick touts ACOs in an exclusive online commentary

We can have it all

By CMS Administrator Dr. Donald Berwick
Posted: May 17, 2011 - 1:00 pm ET

American healthcare is at a crossroads. Thanks to the Affordable Care Act, we are now well on route to assuring that all Americans have the peace of mind that comes with access to healthcare insurance. Thanks to the new law, insurance companies won't be able to deny coverage based on pre-existing conditions, seniors will have access to important preventive care, and health insurance will become affordable through “exchanges” to people who otherwise couldn't afford it.

But better coverage isn't enough. We also need better care. The reason is simple: In its current form, American healthcare is not sustainable, either for many of the people who already have insurance or for the tens of millions who now will be newly covered. It is too often fragmented, uneven in its quality and unsafe for patients, all of which raises costs and degrades care at the same time.

I am absolutely certain that we can have what we want and need—better care, better health and lower costs—all at the same time. But we can have that only if we are willing to improve the healthcare system, itself—only if we are willing to change the way we deliver care. If we are willing, then the Affordable Care Act can help. Because it doesn't just extend coverage and provide new routes to health insurance; it also gives our nation new tools for improving the care system.

One of those important new tools is the so-called accountable care organization. The idea of the ACO is to encourage and support physicians, hospitals and other providers to lower costs by providing better quality care, and to reward them for success by allowing them to share in the resulting savings. ACOs are part of an important agenda of change: to shift American healthcare from a system based on the volume of care (the more you do, the more you get paid) to one based on the results of care (the better you do for patients, the more you get paid).

ACOs won't just be a new way to pay for care; they will be a new and better way to deliver care.

In late March, the CMS published its initial, proposed rule on how to implement ACOs, and we are now in the midst of a public comment period. We've heard from hospitals and physician groups about their concerns related to the need for capital, shared savings and reduced complexity. We also know consumers want choice and quality. We are listening to these comments, taking them seriously and working to improve the proposal into an even better final rule.

That's a challenging job, because the ground rules for ACOs have to strike several careful balances. We want to give providers incentives to achieve savings and tools to help coordinate and improve care, but we also want to make sure that they don't stint on care or withhold care when it's needed. We want to make sure that patients get far better coordinated care, but we don't want to burden ACOs with rafts of cumbersome regulations. We want ACOs to form close relationships between primary-care providers and specialists, but the Affordable Care Act requires that patients in ACOs retain the right to see any Medicare provider they want. ACOs need data, but patients need their privacy protected. The CMS and our partner agencies have been holding feedback sessions and soliciting input from all stakeholders—physicians, hospitals, patient advocates and many more—on the proposed rule, so that we can get these balances right.

Meanwhile, we're moving ahead quickly. Even as we continue to seek input on the ACO proposal, we are launching several initiatives to allow us to hit the ground running. Providers who are already ahead of the pack in coordinated care will have an accelerated pathway to becoming ACOs even before the new regulations go into effect, thanks to a Pioneer ACO program just announced by the CMS's new Innovation Center. We are seeking comments on a proposal to provide some up-front payments to providers who want to form ACOs but lack access to capital to invest in new infrastructures and staff to coordinate care. And the Innovation Center will soon launch a program of instruction and technical support to help newcomers who want to form ACOs learn how to do so.

As we navigate toward a final version of the ACO design, we are impressed by the level of engagement on this topic; people sense that we are at the threshold of an important and productive change. And, as difficult as it is, coming up with a workable, promising framework for ACOs based on stakeholder feedback will be well worth the effort, because, if implemented correctly, ACOs will be a driving force in improving health and lowering costs. They will be one key to sustainable, high-quality care for all of us.

Dr. Donald Berwick is the administrator of the CMS.