Dissecting An Article Published by – United Hospital Fund
Following the passage of the Affordable Care Act, Medicare is sponsoring two accountable care initiatives. To date, 4/2013, there are 17 Medicare accountable care organizations (ACOs) in New York, and a growing number of accountable care arrangements between provider groups and commercial payers. If you are not part of a group which is making these contracts for you, then even if you are in Aetna, UHC, or B CBS, it appears you are out! Could you continue to run your practice if all you have is vision plans?
A new Fund report provides a clear explanation of accountable care, this new approach to health care delivery and payment. Moving Toward Accountable Care explains how ACOs work, the kinds of groups that can enter into accountable care contracts, the challenges they face, and the ways in which they will be able to succeed. It also includes detailed profiles of 12 different Medicare ACOs in New York, showing the wide range of approaches around the state. Notice that this has been achieved by 4/2013. That is 8 months ago. Who is offering you a chance to be part of a group working with the ACOs that have control of the lives? If you are not part of an IPA, as an optometrist, the answer is no one! This is why the NYIPA is here.
Simply put, an ACO is a group of health care providers that agrees to be held accountable for providing health care services to a defined population. In return, the payer agrees to allow providers to share in any savings that come from providing more efficient, high-quality care to that population. This builds on two trends in health care: the aggregation of providers into larger and more capable networks, and the movement of payers away from fee-for-service payment systems toward arrangements rewarding providers for performance. Lets clarify this statement, The system creates entities in control of lives, which push providers into IPAs (large provider organizations) that can negotiate as ACOs. The ACOs arrange what is like the old HMO’s of Bill and Hillary’s era, a capitated system that pays a fixed yearly sum to large provider groups. The goal is to encourage them to minimize usage, so that at the end of the year there is profit to share vs loss to absorb! There is a new twist, you are monitored by EMR and a system that tracks your patients care and referrals. Entry into this system is potentially done by Gatekeeper physicians who may refer patients to their “buddies,” who send them patients, and also keep you out of the loop unless you are in a powerful group! This happened over and over during 1993 when Bill and Hillary ruled the world.
If you are not in a powerful IPA (group) then MDs who are organized by hospital affiliations, or huge powerful groups like The MKMG that “owns” almost all the docs in Westchester, Rockland and Putnam counties will get the contracts and you will not. MDs have these organizations everywhere! This is why we need an IPA.
From the attached PDF, file, which I encourage you to download and read, comes these statements one of MANY important statements:
Ultimately, the Medicare ACO program is designed to shift some or all of the financial risk (the difference between the actual costs of care and premiums paid) from the Centers for Medicare & Medicaid Services (CMS) to the participating provider groups. This means that the “insurance” companies will run around with potentially guaranteed profits and you as a provider take all the financial risk!
Accountable care also depends on information systems to support the delivery of care, including EMR systems and regional clinical data exchanges that can enable effective communication among providers, and help coordinate patients’ care during referrals and care transitions. Updated information systems claims systems to identify and track discrete populations; to measure, analyze, and report on provider performance relative to the population covered by the accountable care contract; and to identify variances from quality, utilization, and cost benchmarks at the provider level and at the system level, in order to focus and support utilization management and quality improvement processes. Insurance companies have controlled what drugs doctors can use for each patient’s care, based on their “formulary.” Now we will be advised as to how to meet the goals of the ACO by what we do professionally. Though I am not yet sure of this, it looks like the basic concept is to provide the palliative drug to create a record of a “good outcomes.” This insures that there is profit for the IPA you belong to. However what if you want to not drug the patient but instead work on preventive care through diet, lifestyle modification, education, counselling? Will this be rewarded? Is this the kind of care we all want? Can we do better and is there an opportunity for creative solutions that really helps the patient? Only time will tell and groups with sufficient creativity and diversity may make “good outcomes” really become good care.
For now we have no choice. For now if we are not organized we have no really bright future. For now you and I need and IPA, the NYIPA…. Join now, if you qualify! Help us become stronger to support your future!
Download the full PDF here From the United Hospital Fund Website.
Dr Joe Ross, President NY IPA 12/2014