If your not in a group — you’re out!

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! fixing healthcareCould 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

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About janrssor

Author whose Nome De Plum and main character share the same name. I am a programmer, eye doctor, holistic practitioner, student of religion, student of mysticism, student of science, business net-worker and I strongly believe that life without a challenge and daily growth is not worth living. My motto is Live Outside The Box.

3 thoughts on “If your not in a group — you’re out!

  1. What is the MKMG ? Can you please identify this acronym ?
    Also, please forgive this detail-oriented English student for noting that the title of this article should be :
    If you’re not in a group – you’re out !

    1. The Mount Kisco Medical Group (MKMG) is a multi-specialty medical group that provides medical care in twenty-eight different locations throughout Westchester, Putnam and Dutchess counties; with major campuses in Mount Kisco, Carmel, Katonah, Fishkill and Poughkeepsie. They OWN nearly every major practice that used to exist by virtue of their ability to put you out of business and then take over your practice since without referrals, which they keep in group, your established patient data base shrinks dies. Are they evil or are they good? Hard to say but they are a “response” of the medical community to the challenges that Optometrists have way too long ignored!

      What happened to pharmacists years ago, has pretty much been repeated in what they have done to private MD practices of all specialties. Optometrist are guaranteed the same destructive forces under ObamaCare via ACOs. If you are not in, you are out. It is the Goal Of The NYIPA, to empower private practice ODs to not have to be destroyed and absorbed by the outside forces that ‘Affordable Health Care has unleashed.” Not that we will not have to change to survive and prosper but that we can maintain our own practices and own our own IPA rather than become employees of some big corporate entity. If it can happen to MDs be very sure it can and will happen to ODs. MKMG did it before ObamaCare unleashed the forces in play. ObamaCare, makes their hurricane look like a summers breeze.

      As for the “You’re”, we use self correcting internet ink, as you can see 🙂

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