Friday, December 24, 2010

Winthrop EMR Subsidy for Beacon Members

There is a sizable subsidy available through Winthrop University Hospital for physicians who have not yet signed with an EMR vendor. This subsidy is open to all physicians on staff at Winthrop, or BIPA physicians who may wish to get privileges at Winthrop.

If you are interested, please let me know.

Thursday, December 9, 2010

CMS Expects to Issue ACO Rules by Mid-January 2011

The Centers for Medicare & Medicaid Services could release the proposed regulations for accountable care organizations (ACOs) by mid-January 2011, according to a posting from the law firm McDermott Will & Emery.

The law firm reported that on Dec. 3, Head of CMS, Donald Berwick, and Jonathon Blum, deputy administrator of CMS and director of Medicare, made the announcement while speaking at during the annual policy conference of the National Committee for Quality Assurance.  They also announced that Medicare beneficiaries will be notified when they are assigned to an ACO.

One-Year Medicare Doc Fix Clears Senate and House


Following the Senate's lead yesterday, the House approved a one-year "doc fix" Thursday afternoon that will prevent a dramatic cut in Medicare physician payments.

The measure was approved in a 409-2 vote today by the House, one day after the Senate approved the $19.2 billion fix by unanimous consent. 

Without the action, Medicare payments to doctors would have been cut 25 percent on January 1st. 

Thursday, December 2, 2010

AMA makes recommendations to CMS for physician-led ACOs

The AMA submitted its most detailed comments (PDF) to date to the Centers for Medicare & Medicaid Services (CMS) on how Medicare should structure physician-led and patient-centered accountable care organizations (ACOs). The recommendations were submitted today, Dec. 2, in response to a specific request from CMS for comments on how to ensure that solo and small group practices have the opportunity to actively participate in Medicare's ACO program. 


Top recommendations 

The AMA's recommendations to CMS on structuring physician-led ACOs include:
  • Developing new payment models for physicians that move Medicare away from today's dysfunctional physician payment system—the threat of Medicare physician payment cuts will impede physicians' efforts to improve care coordination, such as employing case managers and investing in infrastructure to monitor and improve quality
  • A range of specific new payment methods that CMS should consider in addition to shared savings, including an accountable medical home payment system and bundled payments for specific medical conditions, such as congestive heart failure
  • Increased access to loans and grants for small physician practices
  • Easing of antitrust restrictions that prevent physicians from collaborating
  • Timely access to quality data
The AMA also urges CMS to allow patients to voluntarily select a Medicare ACO and to undertake a proactive effort to educate and encourage beneficiaries to take steps that will help make ACOs successful. For example, patients should be able to:
  • Choose and consistently use a primary care physician as a medical home
  • Select specialty physicians, hospitals and other providers that coordinate effectively with their primary care medical home and each other
  • Engage in shared decision-making processes with their physicians about appropriate treatments for their conditions
  • Participate in other types of programs developed by their physicians to maintain and improve their health at an affordable cost
This education effort should be developed in cooperation with physicians and launched well in advance of the ACO program's initiation. 

The AMA also makes recommendations on the types of quality measures ACOs should use. At least in the initial years of the program, CMS should avoid making ACOs collect and report quality measures beyond those already required under other CMS programs, such as the Physician Quality Reporting System (PQRS), formerly known as the Physician Quality Reporting Initiative. 

Although additional quality measures may ultimately be warranted, it is impractical to develop a single national set of such measures prior to implementation of the Medicare Shared Savings Program, because the areas where ACOs will focus their cost reductions will likely vary significantly from region to region. Furthermore, measures that may be appropriate for one ACO model may not be appropriate for another. ACOs should be allowed to report on a hybrid of nationally and locally focused quality measures related to their particular patient population. 

Physician-led ACOs will encourage innovation, competition 

When the AMA submitted its comments, AMA President Cecil B. Wilson, MD, said, "The physician-led ACO model injects competition into the market by eliminating the need for consolidation under a hospital system. Competition fosters innovation, which ultimately helps patients receive efficient, high-quality care. Care coordination is vital, and physicians can work together with a health care team to keep patients healthy and out of the hospital while maintaining independent medical practices. CMS should adopt policies that facilitate physician-led ACOs and do not inadvertently bias participation in favor of large health systems and hospitals. Our goal is to ensure that new models of care benefit patients, and for this to happen physicians must be able to successfully participate in and lead ACOs." 

Learn more about the AMA's advocacy efforts on ACOs.

Thursday, November 25, 2010

PhysiciansPractice.com- Trendspotter: Featuring Beacon IPA

Trendspotter: Fledgling IPA Charts Its Own Course

By Ken Terry | November 24, 2010



Accountable care organizations (ACOs) are supposed to improve quality and cut costs by getting hospitals, doctors, and other providers to work together. But increasingly, observers are raising the possibility that ACOs might raise costs faster by consolidating providers and forcing payers to accept big payment increases.


The main reason for this concern is that hospitals are expected to be the driving force behind the ACO trend. As they grow by acquiring other hospitals and employing more physicians, healthcare systems are becoming ever more influential in many markets. The advent of ACOs promises to increase that dominance — assuming the government lowers the antitrust and other regulatory barriers to forming these organizations.


But hospitals need not control ACOs. In fact, under the health reform law, they don’t even have to be ACO members, although their cooperation will be needed. The American Medical Group Association (AMGA) has started an ACO collaborative to help large group practices form ACOs. There are also clinically integrated IPAs and PHOs that could easily become ACOs, and 50 to 75 other physician-led organizations are on the same path, according to one estimate.


Among these entities is the Beacon IPA of Manhasset, NY, on the north shore of Long Island. Formed last summer, the IPA already has about 200 physician members, according to nephrologist Simon Prince, the IPA’s leader. The IPA’s long-term goal, Prince says, is to become clinically integrated and ready for whatever healthcare reform brings, including ACOs.


The IPA is not affiliated with any hospital “by design,” says Simon, the immediate past president of the medical staff at North Shore University Hospital in Manhasset. “We are trying to remain free agents.” Instead of being part of a hospital strategy, he says, the IPA wants to create its own strategy.


The main impetus for formation of the IPA, he explains, is the growing power of the North Shore-LIJ Health System, which is the dominant healthcare player on Long Island. North Shore-LIJ has hired a lot of physicians, creating fears among some private-practice doctors they might not be able to survive on their own.


“A lot of doctors didn’t go into medicine to become employed physicians, but the environment is such that it’s very difficult to maintain your independence,” Prince says. “So I felt an IPA was the best alternative that would allow the individual practices to maintain as much autonomy as they can.”


To become clinically integrated — which would allow the IPA to negotiate with payers, as North Shore-LIJ does — the doctors must have EHRs. So its members have agreed that, within six months, they will either have EHRs or have plans to get them, Prince says. At that point, the IPA will start to build the infrastructure for clinical integration, following the Federal Trade Commission’s guidelines that have allowed other IPAs and PHOs to bargain with payers.


The government incentives for meaningful use of EHRs will be a significant help to the practices in the IPA, Prince says. In addition, the IPA will provide some technical support to help physicians implement their EHRs and show meaningful use.


Where will the money for these activities come from if the IPA isn’t affiliated with a hospital? Prince says the IPA is in discussions with Empire Blue Cross Blue Shield and other payers. He suggests that the plans might be willing to kick in some extra funds to help the IPA become clinically integrated with the prospect of lowering overall costs down the line. Later on, if the IPA’s added value brings in enhanced payments, he says, part of that extra money could finance the IPA’s operations.


So far, Prince has been pleasantly surprised by the local payers’ interest in working with the IPA. He speculates that their interest might be prompted by their inability to limit cost increases from North Shore-LIJ, which has negotiated “very big rates… If they give us something extra and help to avoid that, I think that’s attractive to them.”


Meanwhile, Prince doesn’t rule out a future agreement with a hospital to form an ACO. “Remaining a free agent and seeing what the best fit is for us could be our advantage. If we grow and become a little more attractive, it might put us in a better position to negotiate a deal with a hospital or health system down the road.”

Thursday, November 18, 2010

The Physician's Place in the ACO

This is a nice, thoughtful piece by Philip Betbeze today in HealthLeaders Media... "The Physician's Place in the ACO"

_____


"ACOs will include confederations of doctors, specialists, and hospitals working together to administer payments, determine quality and safety benchmarks, measure performance, and distribute shared savings, according to a June 2010 report from the American Hospital Association. Still, as we enter a four-year transition into new payment methodologies on which long-term strategic decisions must be made, organizations are left with making little more than educated guesses about how they might become an ACO.

Amid all this uncertainty, one thing does seem certain: The physician will play a key part—perhaps the key part—in whether such organizations are ultimately successful at removing waste from the healthcare payment system."
______


I encourage everyone to read this article and stay up to date with this important topic. It remains to be seen how the ACO movement will unfold and what role Beacon IPA will play. But although there is a great bit of uncertainty, there is also the potential for a great opportunity. 

Tuesday, November 16, 2010

Sequel Systems’ EMR receives Important Meaningful Use Certification

Melville, NY – November 15, 2010 – Sequel Systems, Inc, a dynamic, service-oriented healthcare technology company, announced today that its Electronic Medical Record (EMR), SequelMed Meaningful Use EMR version 8.0, has been tested and certified under the Drummond Group's Electronic Health Records ONC-ATCB program. The EMR software is 2011/2012 compliant in accordance with the criteria adopted by the Secretary of Health and Human Services. The certification deems the electronic medical record (EMR) software capable of enabling providers to meet the Stage 1 meaningful use measures required to qualify for incentive payments under the American Recovery and Reinvestment Act (ARRA).

In addition to the monetary incentives, the adoption of EMRs can improve quality of care, advance patient safety, increase customer satisfaction and enhance office efficiency for physician practices. Facilities and practices using a certified EMR may also experience increased profitability through reduced costs and increased revenue.

“Choosing to test with The Drummond Group made sense for Sequel Systems because the organization is an independent leader in testing methodologies and test process management.” said Khurshid Mughal, CEO and President of Sequel Systems. “Given the level of experience The Drummond Group has, it offers a greater level of confidence to our customers and partners that the SequelMed software meets the requirements as set forth by The Office of National Coordinator.”

“Drummond Group has more than 10 years of software testing experience in several industries and we are pleased to bring that experience to the HIT marketplace. It is a privilege to carry out testing and certification in Electronic Health Records for HHS,” said Rik Drummond, CEO Drummond Group Inc.

Sequel Systems, Inc. is a leading provider of EMR and practice management software and solutions, serving approximately 12,000 physicians in North America. Meaningful Use Certification of SequelMed’s EMR means clients seeking federal incentives will be technologically prepared to do so.

SequelMed Meaningful Use EMR version 8.0 is a comprehensive clinical, financial and administrative solution that empowers physicians to advance the quality and efficiency of care they deliver. The SequelMed family of products includes integrated electronic health records, practice management, clinical and business intelligence, and Patient Portal - a Web-based tool for online patient engagement. Providers can access SequelMed EMR from multiple practice locations, from home, or other remote locations either through a central patient database server, or as a Sequel-hosted solution on a monthly subscription basis. The software allows for users to easily track the details of a patient’s clinical history, share and manage clinical information and combine complex medical practice functions into easy-to-navigate menus. SequelMed v8.0 features centralized financial operations including billing, reporting, task management, and EDI services.

BIPA Names New IT Committee Chairman: Dr Inderpal Chhabra

I would like to announce the new Chairman of our IT Committee, Inderpal Chhabra MD an Internist practicing in Glen Oaks, NY on staff at Long Island Jewish Hospital and North Shore University Hospital in Manhasset.

Dr Chhabra will help to coordinate and lead this vital  BIPA committee.

Last night, we had our first IT Committee meeting. It was well attended and productive. In brief we are moving ahead with our deal with Sequel Systems EMR. Some important language in the agreement was reviewed by the committee with legal counsel. Additionally we spoke about our plan for Clinical Integration and putting some regulations into place in regards to our expectations of the adoption of EMR and CI for Beacon IPA providers.

Furthermore, there was the exciting news of a potentially large subsidy to BIPA members who will be getting on EMR now.

All this will be discussed in more detail by Dr Chhabra at our next Steering Committee Meeting on Tuesday November 30th.

Thursday, November 11, 2010

NEJM: Physicians versus Hospitals as Leaders of Accountable Care Organizations



Another interesting perspective was published online yesterday in NEJM's 'Health Policy and Reform' section. Here they tackle the burning question... who will control the ACOs? Will it be primarily physician or hospital controlled?


"We can envision two possible futures: one of physician-controlled ACOs, with physicians affiliating and contracting with hospitals, controlling the flow of funds through the marketplace; and one of hospital-controlled ACOs that will employ physicians. Whoever controls the ACOs will capture the largest share of any savings."


Click here to read the complete perspective.


There is no doubt it will be difficult to accomplish a successful physician controlled ACO. The resources and infrastructure required should not in any way be minimized.  But, just because it is difficult, doesnt mean it cannot, or should not be done. There is a great opportunity for the private practitioners to collaborate without a hospital or health system. The first step is to organize ourselves. A clinically integrated IPA like Beacon IPA was put together as a potential vehicle to become an accountable care organization. We need your help and support.


Together we can do this.... please join Beacon IPA today!

Kaiser Family Foundation: Health Reform Hits Main Street

Tuesday, November 9, 2010

WSJ: Employed Physicians on the Rise --- The Beacon Alternative

The article in Wall Street Journal yesterday, "When the Doctor Has a Boss: More Physicians Are Going to Work for Hospitals Rather Than Hanging Up a Shingle" should not come as a surprise to anyone. The accompanying graph also clearly shows this disturbingly strong trend.

A study quoted in the article revealed that the share of practices that were hospital-owned last year hit 55%, up from 50% in 2008 and around 30% five years earlier. Projections show that this trend is likely to continue for a variety of valid reasons that include, but are not limited to:

·        Decreasing reimbursement
·        Fear of the unknown in regards to Health Care reform
·        Rising administrative burden
·        Increasing oversight
·        Expanding technology requirements
·        Shrinking referral base
·        Malpractice and health insurance concerns
·        Possessing a shrinking voice being increasingly marginalized due to lack of size

and more...

If it sounds like I am making the argument for consolidation… you are right, I am.

But you can still come together without becoming an 'employed physician' and maintain your independence and autonomy.

There is an alternative way in which you can keep your private practice and enjoy the benefits of consolidation without joining a hospital or health system. It can also be done effectively without having to rip down the corporation you have built to form one big multispecialty group. 

We believe our model is the most attractive for the independent physician in private practice. It is a clinically integrated independent practice association.

We value private practitioners, because we are private practitioners.

Together we can stop this disturbing trend highlighted by the WSJ and well know to every physician practicing medicine today. Be part of our movement, we need each other. Join Beacon IPA.

For more information, please contact us.

Thursday, November 4, 2010

Beacon IPA Featured in Long Island Business News

Independent docs pool resources

by Claude Solnik
Published: November 4, 2010


In some instances, small is not beautiful.


Doctors working solo or in small groups are at a disadvantage in negotiating reimbursement rates with insurers. These same practices have seen flat reimbursement rates while costs have risen due to new expenses such as electronic medical records.


Rather than merge a small practice with other doctors or a health care system, as some already have done, a different business model is catching on.


With an independent practice association, a group of doctors pool resources and collectively bargain with insurers and vendors while remaining independent.


The Manhasset-based Beacon IPA has grown to nearly 200 doctors since it was founded this summer, expanding more quickly than its organizers expected.


“This is a very good alternative where we can come together, provide value and clinical benefit and work to become a strong organization,” said Beacon President Dr. Simon E. Prince, who is also president of North Shore Nephrology in Manhasset and immediate past president of the Medical Staff Society at North Shore University Hospital in Manhasset. “Our model allows everybody to keep their independent practice and do what they want to do to their highest ability. Yet it still allows us a framework to come together in numbers, affect change and have higher-level discussions with payers.”


Jill Hummel, vice president of provider engagement and contracting for Empire BlueCross BlueShield, said although her company doesn’t only look at a practice’s size, larger practices often obtain “enhanced reimbursement” for certain measures.


“I think in some ways we are rewarding the larger groups, not just because they’re large,” she said. “It’s the value they bring to the table.”


That is so because large practices often are able to provide better care through electronic medical records, 24/7 access, prescribing generic prescriptions and other services, Hummel said.


Beacon is one of a still small number of Long Island IPAs, including Valley Stream’s South Shore Health System and Garden City-based Healthcare Partners.


Prince said the process of starting these groups is complex. Although they face state regulations, additional pressures make them more attractive.


“It’s very difficult for a small practice to survive. That’s why there’s so much consolidation,” he said. “That’s the economic reason. There’s utility in other things. We have autonomy, self-governance.”


Esther Horowitz, vice president of provider relations for 600-physician South Shore Health System, said her group obtained several reimbursement rate increases over the past few years while many doctors’ rates fell or were flat.


“We are an advocate for the physicians. We look at not only better reimbursement, but how to maintain their independence,” she said. “We have the clout to negotiate for our doctors for better treatment, rates and opportunities.”


Beacon, which hopes to be funded by receiving a portion of rate hikes it negotiates as well as dues, already is putting together best practices and negotiating on behalf of physicians.


“If I go as an individual practitioner and call an electronic medical record company, the price is prohibitive,” said Dr. Michael Ditkoff, an ear, nose and throat surgeon in Manhasset and Beacon member. “Now with this group, we’re negotiating to get a better rate. They’re getting a higher volume of physicians.”


Ditkoff said the group hopes to negotiate better deals with billing companies and provide better care by analyzing data from various practices.


Prince said even if physicians choose different electronic medical records, the group expects to analyze their information to help them qualify for up to $44,000 in federal money for providers who prove they’re using data to improve medical care.


“There’s a pressure, real or perceived, that if you’re not part of a group, you’re going to be left behind. You’re not going to be able to survive,” Ditkoff said. “I could’ve kept going the way I’m going. But the way things are going, every year it gets harder and harder. Everyone’s joining someone.”


Ditkoff said some physicians are merging their practice into bigger entities. Large multipractice groups such as ProHealth in Lake Success also provide strength in numbers. But he believes an IPA provides freedom and financial benefits.


Prince said Beacon will set basic medical standards for members, while leaving a great deal of latitude to doctors in terms of their practice.


“If you’re not providing quality care and doing what we expect through our guidelines, you’ll be asked to leave,” he said.


While Ditkoff believes small practices play an important role in providing care, he said without strengthening their position, they will remain at a disadvantage in negotiating rates.


“They’re not going to sit down with each practitioner,” Ditkoff said of insurers. “I can barely get them on the phone to talk about a patient let alone my rates.”

Tuesday, November 2, 2010

LIBN: Empire creates physician panel

Empire creates physician panel

by Claude Solnik
Published: November 2, 2010
In a move designed to open a better dialogue between the state’s largest insurer and healthcare providers, Empire BlueCross BlueShield has created a physician advisory council.
Although other insurers have long used physician panels to help develop policies, Empire earlier this month held the first meeting of a panel designed to advise it on an ongoing basis.
The insurer, which covers more than 6 million members in New York State, in the past relied on panels set up around specific initiatives and administrative policy changes.
“What we found is we didn’t have this forum that met on a regular basis to get input from a consistent pool of physicians,” Jill Hummel, Empire’s vice president of provider engagement and contracting for Empire, told LIBN.
She said the group will meet at least quarterly and as needed to deal with particular issues, proposals or changes.
Hummel said the panel is comprised of physicians from across the state, including two Long Island doctors, an obstetrician/gynecologist and a nephrologist.
“It’s a wonderful opportunity to represent my fellow physician colleagues, advocate for the patients we serve and partner more meaningfully with Empire,” said Dr. Simon E. Prince, a member of the panel, president of North Shore Nephrology in Manhasset and past president of the medical staff society at North Shore University Hospital in Manhasset.
Prince, who said doctors volunteered to serve on the panel, said he thinks it should be good for “physicians, Empire and most importantly the patients we serve.”
Empire at the first meeting discussed how it does business, including setting reimbursement and administrative policies and creating quality initiatives.

Monday, November 1, 2010

New BIPA logo

After a great deal of hard work and back and forth with Rohit Barman of DPS America - 'Digital Promotions Strategy for NY Brands' we narrowed our new logo down to a handful of choices. They were distributed to the group last week for review. The steering committee voted and our new logo has been finalized.


Thursday, October 28, 2010

Local Physicians are Joining Efforts to Improve the Value and Quality of Healthcare Services

Beacon IPA - Long Island FREE Press at LongIsland.com, 10-25-2010


Manhasset, NY -- As the healthcare landscape in America continues to evolve, many physicians are struggling to maintain their autonomy, improve patient care, and adjust to rising challenges in today’s environment. To address some of the major issues facing private practice medical practitioners, a new entity has recently been formed.

Beacon IPA, founded in the summer of 2010, is a fast-growing Independent Practice Association (IPA) consisting of more than 100 local physicians. Through Beacon IPA, an expanding network of physicians can share costs, risks and accountability for quality of clinical care, and as a result, deliver better value to patients and providers. While many doctors consolidate by joining hospital health systems or other large groups, Beacon IPA has emerged as a viable alternative.

“The sky isn’t falling, private practice is not dead, and physicians can still maintain their independence,” says Dr. Simon E. Prince, Beacon’s president and manager, who is also the immediate past president of the medical staff society at North Shore University Hospital in Manhasset, NY. “One of the most significant functions of Beacon IPA is to exert influence on behalf of our members, negotiate contracts and partner more meaningfully with the healthcare insurers in order to meet both sides’ needs”.

Beacon has opted for a clinically integrated model of IPA, requiring its member physicians to share patient records and work together as a team to deliver high-quality care at less cost. Furthermore, electronic medical records (EMR) adopted by Beacon IPA will facilitate communication between doctors, eliminate unnecessary testing procedures, and reduce medical errors.

“We are striving to evolve into an accountable care organization (ACO) and make a difference in healthcare,” adds Dr. Prince. “ACOs have rapidly gained importance under the healthcare reform legislation introduced by President Obama. Although many questions remain about the viability of ACOs, we at Beacon embrace its philosophy. Beacon IPA is owned and operated by physicians, and we will make every doctor in our network accountable for their performance. The success of our venture will be of great benefit to all parties involved, including our patients, physicians and insurers.”

Dr. Prince hopes that the new initiative will not only empower physicians and help them maintain independent medical practice, but also enable them to increase administrative efficiency, embrace the latest technology, and deliver more value to patients.

About BIPA
Beacon IPA is a Clinically Integrated Independent Physician Association headquartered in Manhasset NY. Organized and directed by nephrologist Dr. Simon Prince, Beacon IPA provides a platform for doctors to negotiate with insurance companies in return for quality care. It was formed in an effort to help local independent private physicians to maintain their autonomy, tackle the challenges of healthcare reform, combat rising administrative costs, and deal with increased regulation. Counsel for Beacon IPA is being provided by David Manko, Esq., Chair of the Health Services Practice Group at Rivkin Radler, LLP and consulting services provided by Jonathan Goldstein, Director of Profitability Consulting at Lion & Company CPAs, LLP. For more information, please visit www.beaconipa.blogspot.com or call (516) 365-5570

About Dr. Simon E. Prince
Dr. Prince is the founder and president of North Shore Nephrology in Manhasset NY. He is the immediate past President of the Medical Staff Society at North Shore University Hospital in Manhasset and the recently-appointed Medical Director of the new Queens Long Island Renal Institute at Parker Jewish Geriatric Institute. Dr. Prince is an Assistant Professor of Medicine at NYU School of Medicine and a board-certified nephrologist specializing in chronic kidney disease and hypertension. For more information, please visit www.nsneph.com or call (516) 365-5570.

Thursday, October 7, 2010

NEJM: Becoming Accountable — Opportunities and Obstacles for ACOs



This just came out in the New England Journal of Medicine today. It is a perspective on Accountable Care Organizations. There is also an interesting video roundtable discussion of ACOs if you have a subscription to NEJM.  

It is our goal that Beacon IPA, as a Clinically Integrated IPA will be a vehicle to become an ACO. 

Prince Named to BCBS Physician Advisory Committee

I am honored to have been named to BCBS's Physician Advisory Committee (PAC). It is a two year commitment with meetings quarterly.

"The mission of the Empire PAC is to enhance the relationships between physicians, their patients, and Empire, by discussing regional or national health care, quality and administrative matters between Empire and physicians" 


I am looking forward to engaging with BCBS in this manner and representing the interests of my physician colleagues as well as Beacon IPA.

Monday, September 27, 2010

RSA Animate - Drive: The surprising truth about what motivates us

I really enjoyed this book. It is Daniel Pink's Drive: The Surprising Truth About What Motivates Us.

What motivates you? Here Pink speaks of what he believes to be the 3 tenents of motivation: AUTONOMY, MASTERY and PURPOSE. I believe this speaks for what motivates me, including the motivation for BIPA. What about you? Please enjoy the video:

Monday, August 23, 2010

What is Beacon IPA?

WhatisBeaconIPA_20101118

BIPA Has Been Formed!

It is finally official!

The Beacon IPA, LLC has gone through regulatory approval and is a recognized entity of the State of New York. BIPA has been approved by the State of New York's: Department of HealthState Education Department and Insurance Department.

The State of New York's Department of State signed off with the official stamp declaring Beacon IPA, LLC a reality as of August 20, 2010.

We are all excited and look forward now to officially signing up BIPA members and taking our next steps together.

Wednesday, July 14, 2010

"Meaningful Use" Finally Defined

It is widely recognized that the widespread use of the electronic health record is inevitable. We believe it will improve the quality of care if used appropriately... and that it is necessary to accomplish our goal of clinical integration.

In order to incentivize the use of an electronic health record (EHR) / electronic medical record (EMR), the government, through the Health Information Technology for Economic Clinical Health Act (HITECH) has offered a subsidy as part of the stimulus package. This subsidy will provide payment of up to $44,000 per physician.

However, the mere adoption of the EHR is not enough to qualify for this payment. The particular EHR chosen must qualify for meaningful use. The concept is simple enough, but the details were not put forth. What exactly is "meaningful use"? Without a firm understanding, the possibility of spending an inordinate or time, energy and resources (read- money) on an EMR and not qualifying for the subsidy continued... until now.

Finally, there is something concrete to sink our teeth into.... No matter how big your appetite is... The 864 page definition is available for your perusal. But, if you are like me and just may not have the time to digest War and Peace this document, you may want to check out the condensed version by Dr David Blumenthal and published online by the New England Journal of Medicine.

While our EMR offering is forthcoming, the plan to ensure that all Beacon IPA members will be positioned to qualify for meaningful use and the associated government subsidy is on underway!

Tuesday, June 29, 2010

What is Clinical Integration?



The Federal Trade Commission and Department of Justice define Clinical Integration as:

“…the network implementing an active and ongoing program to evaluate and modify practice patterns by the network’s physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality.” 

Source: DOJ and FTC, Statements of Antitrust Enforcement policy in Health Care, Statement 8

Friday, June 25, 2010

ACOs Key to Health Care Reform Law

Accountable Care Organizations Are Key to Health Reform Law

06-25-2010

Now that the federal health reform legislation (the Health Reform Act)1 has been enacted, efforts have turned to its implementation. Although so far the attention has been focused on the provisions relating to health insurance coverage, the most revolutionary portion of the act may turn out to be those provisions that aim to improve the quality and efficiency of health care services, particularly through payment and delivery system reform. Such reform is designed to set in motion a process that will lead to the restructuring of the organization of the health care delivery system with the aim of improving its "value," i.e., its quality and efficiency. It entails reforming the way providers are paid to incentivize them to change the way they deliver care in a manner that improves the value of such care.


Among the most significant of the payment and delivery reforms in the Health Reform Act are those that would encourage providers to organize into new entities known as "accountable care organizations" (ACOs). ACOs are intended to serve as a vehicle through which physicians can become integrated with each other and other health care providers to improve the coordination of their care and be rewarded for improving the quality and efficiency of their care.


Specifically, the Health Reform Act requires the federal Centers for Medicare and Medicaid Services (CMS) to establish an ACO program under Medicare, which is known as the "Medicare Shared Savings Program." With Medicare being the largest third party payer in the United States, the establishment of the Medicare Shared Savings Program has the potential to drive payment and delivery system reform throughout other public and private health care programs.


Why ACOs?

Health spending has reached unsustainable levels. It accounts for almost $1 of every $5 spent in the United States and is growing faster than the economy. Studies have shattered the myths that have justified such rising spending in the past, including that it is the price our society has to pay for achieving higher quality,2 or that it is due to the aging of the U.S. population.3


Cost containment efforts are being pursued through a new approach, which is commonly referred to as "payment and delivery system reform." As mentioned earlier, this entails changing the way providers are paid to promote changes and greater efficiency in the delivery of care. The central target of payment reform is the fee-for-service (FFS) payment methodologies, which pay providers a fee for each separate medical procedure they perform. FFS reimbursement is viewed as the primary culprit of rising health care spending because it rewards providers for performing more procedures, regardless of the health outcomes achieved. Payment reform aims to gradually phase out FFS methodologies and replace them with value-based payment (VBP) methodologies, which reward or penalize providers based on their successes in improving "value," i.e., in achieving better health outcomes at reduced costs.


What Is an ACO?

An ACO is a health care organization in which providers are accountable for the quality and total costs of care for a specific subpopulation of patients whom they jointly serve by accepting value-based payment with respect to such patient population. The ACO becomes "accountable" for the care it provides to its patients by contracting with the third party payer for VBPs with respect to the patients. Importantly, certain VBPs have been designed specifically for ACOs, including shared savings bonuses, in which the ACO receives a portion of the savings it achieves for the third party payer by improving the value of the care it delivers to the third party payer's beneficiaries.


The ACO concept gained traction when it was taken up in 2008 by MedPAC, an independent agency that advises Congress on issues relating to Medicare, which recommended it to Congress as a way to reduce the growth of health spending. The ACO program that was ultimately included in the Health Reform Act, the Medicare Shared Savings Program, is modeled after the Medicare Physician Group Practice Demonstration Project (PGPD). The PGPD was a five-year demonstration project that ran from April 1, 2005 to March 31, 2010. It involved 10 large multi-specialty group practices, which represented approximately 5,000 physicians (ranging from 292 to 1,291 affiliated physicians) and over 220,000 Medicare fee for service patients. In the third year, five of the 10 practices achieved savings of $32 million in the aggregate, of which $26 million was shared with the practices.


The Health Reform Act

The Health Reform Act requires CMS to establish ACO programs under Medicare and Medicaid. With respect to Medicare, it requires CMS to establish a "Shared Savings Program," which must begin no later than Jan. 1, 2012. With respect to Medicaid, it requires CMS to establish a Medicaid Pediatric ACO Demonstration Project, which would give states the opportunity to establish a pediatric ACO demonstration project under their state Medicaid programs. The Health Reform Act also requires CMS to create a new Center for Medicare and Medicaid Innovation (the Innovation Center) to develop, test, and expand new VBPs in Medicare and Medicaid, and it is possible that the Innovation Center may establish other types of ACO pilot programs under Medicare and Medicaid.


Although the principal features of the program are set forth in the Health Reform Act, many of the specifics were left by Congress to be developed by CMS through administrative rulemaking. Because CMS has not yet issued the implementing regulations regarding the Shared Savings Program, there are still a number of issues that remain open at this point, as noted below.


Eligibility

The Health Reform Act provides that five types of organizations are eligible to serve as an ACO:


(a) Physician group practices (i.e., multispecialty group practices);
(b) Networks of individual physician practices (i.e., independent practice associations);
(c) Partnerships or joint ventures between hospitals and physicians (i.e., a physician hospital organization);
(d) Hospitals employing physicians (i.e., an integrated delivery system); and
(e) Other groups authorized by CMS.


In assessing the precise configuration of an ACO, the key practical issue is identifying the combinations of providers among which there are opportunities to coordinate care in order to improve value. For example, in an ACO consisting of physicians only, which may consist of a group practice or an independent practice association (IPA), primary care physicians and specialists work together through the multi-specialty group practice or IPA to improve care for medical conditions for which hospital inpatient admissions are potentially preventable through better outpatient care.


Savings on hospital expenses are achieved by keeping patients healthy and out of the hospital. In an ACO consisting of physicians and at least one hospital, primary care physicians, specialists, and the hospital or hospitals work together through an integrated delivery system or other organizational structure to improve quality and efficiency throughout the continuum of care, such as by reducing lengths of stay, readmissions, and so on.


Requirements

The Health Reform Act sets forth 11 minimum requirements that must be satisfied by an eligible organization for it to quality as an ACO. Although the legislation does not do so, these requirements may be organized into five categories, as follows:


Capabilities to Serve a Specific Subpopulation of Patients. The Health Reform Act sets forth three requirements relating to the ACO's capabilities to serve a specific subpopulation of patients:


(i) The ACO must be willing to become accountable for the quality, cost, and overall care of the Medicare FFS beneficiaries assigned to it. Accordingly, an ACO must be able to provide or manage the continuum of care for a specific subpopulation of patients as a real or virtually integrated delivery system. Moreover, the ACO must be able to place a strong emphasis on the promotion of health and prevention of disease, and, in connection with the foregoing, ensure that each patient has access to and obtains appropriate primary care and coordinated specialist care.
(ii) The ACO must have at least 5,000 Medicare beneficiaries assigned to it.
(iii) The ACO must include primary care physicians who are sufficient for the number of Medicare beneficiaries assigned to it.


Capabilities to Improve the Value of Care. The Health Reform Act sets forth three requirements relating to the value of the care the ACO delivers to its assigned patients:


(i) It must define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care. To be successful, an ACO must continuously make improvements to the value of the care it delivers. It also must possess health information technology that improves patient care by enabling clinicians to share the clinical information of a patient across all clinicians involved in that patient's care, regardless of where such care is delivered.
(ii) The ACO must demonstrate that it meets "patient centeredness" criteria established by CMS. These criteria will be developed by CMS through administrative rulemaking.
(iii) It must meet certain quality performance standards. These quality standards will be developed by CMS through administrative rulemaking.


Capabilities to Contract for Shared Savings. Pursuant to the Health Reform Act, the ACO must enter into an agreement with CMS to participate in the program for at least three years. Accordingly, an ACO must be capable of contracting with Medicare (or another payor), distribute shared savings, and administer and manage its ACO-related activities.


Capabilities to Govern its Internal Operations. The Health Reform Act sets forth three requirements relating to the ACO's abilities to govern its internal operations:
(i) The ACO must have a formal legal structure that would allow it to receive and distribute shared savings bonuses.
(ii) It must have a leadership and management structure that includes clinical and administrative systems.
(iii) It must have a mechanism for shared governance.


Capabilities to Report on Value. Finally, the Health Reform Act requires that an ACO be capable of reporting to CMS data regarding the quality of the care it delivers.

How Does an ACO Get Paid?

The Medicare Shared Savings Program establishes a shared savings payment arrangement for ACOs, which works as follows:


• At the beginning of each applicable annual period, Medicare and the ACO would establish budget targets for the Medicare spending incurred during that year by the Medicare beneficiaries assigned to the ACO. Medicare beneficiaries will be assigned to the ACO based on their utilization of primary care services, with the specific methodology to be established by CMS through administrative rulemaking. Such assignment will take place between CMS and the ACO; the beneficiaries will not be required to enroll. The spending benchmark will be determined by CMS using the most recent available three years of per-beneficiary expenditures for physician and hospital services for the beneficiaries assigned to the ACO.
• During that year, the ACO would render medical services to such Medicare beneficiaries and would be paid in the same manner as it would otherwise be paid (i.e., FFS payments for physicians and "diagnosis-related group" payments for hospitals).
• At the end of the year, the actual spending and the target spending would be reconciled. If there are sufficient savings and certain quality criteria are met, then Medicare would pay to the ACO a bonus equal to a percentage of the savings.


Under the above shared savings payment methodology, there is no penalty. If the ACO fails to achieve savings or meet the quality standards, the only consequence is that it does not receive the shared savings bonus. The primary financial risk is that the ACO may not recover its up-front investment to become an ACO (such as by investing in health information technology to develop the ability to collect and report data or investing in redesigning its care processes to achieve efficiencies).

What's Next?


Now that the Health Reform Act has been enacted, the most important next step with respect to the Medicare Shared Savings Program is for CMS to issue regulations implementing the program. It also can be anticipated that there will be complementary developments on the state level and in the private sector. As is often said, "all health care is local," so the success of ACOs ultimately depends on local action.

David A. Manko is a partner in the Health Services Group of Rivkin Radler, where he concentrates on healthcare regulatory and transactional matters. George Choriatis is an associate in the firm's Health Services and Corporate & Commercial Practice Groups. The authors can be reached at David.Manko@rivkin.com and George.Choriatis@rivkin.com, respectively.

Endnotes:

2. See e.g., Fisher, E. S., et al. 2009. Slowing the Growth of Health Care Costs—Lessons from Regional Variation. NEJM 360(9):849-52 (examined the difference in quality and costs across providers and regions and concluded that higher costs had no relation to higher quality); Skinner, J., F. Elliott, and J. E. Wennberg. 2005. The efficiency of Medicare. In Analyses in the Economics of Aging, edited by D. Wise. Chicago, IL: University of Chicago Press and National Bureau of Economic Research. Pp. 129-157 (estimating that 20 percent to 30 percent of health care spending is for either too much, too little, or the wrong type of medical treatments and technologies, relative to the evidence of their effectiveness).
3. Congressional Budget Office. 2007. The Long Term Outlook in Health Care Spending.