Monthly Archives: March 2014

Shopping For Your Future

Vendor Rebates y y n n n
Ownership y n n n n
co-op y n n n n
Reduced Reimbursement n y y y y
Inreased Reimbursement Y n n n n
National Support y y y y y
Grassroots Leadership y n n n n
Reduces material profits n y y y y
Increases material profits Y some n n n
Aprox fee $50.00/mo 2.5% gross 60% of your fees 60% + of your fees 60% ++ of your fees
Dictates Policy n y y y y
You set policy y n n n n
Local Integration with ACOs y n n n n
Rapidly Growing! y n n n n
naional Aco Evaluation y possibly n n n

Other Health Care Professionals

This morning I had the pleasure of speaking with Matt  Minela,  Insurance director of the Association of New Jersey Chiropractors (ANJC).  Why?  Well they like us provide a medical alternative that can be a huge cost savings for hospitals, insurance plans and patients.  I was wondering how they are doing with ACOs?  Like us they can keep people out of emergency rooms saving thousands of dollars per visit.  Like us they can provide very cost effective treatment that allows for prevention and diagnosis of serious systemic illness before it costs lives and huge expense to health care organizations.  It is a dialog that I think should continue and so did he. chropractic

Matt told me that they had been approached by an ACO for a medicaid based program.  He was finding that most ACOs are forming around hospitals.  This ACO had not planned on considering chiropractic.  A second party involved in the ACO suggested that chiropractors be included as they had a proven record of bringing down costs of care for musculo-skeletal pain issues. Nevertheless, the hospital was not interested in allowing access to chiropractors as primary care agents, they were looking at keeping MDs as the gatekeepers.  This is what happened with HMOs in the 1990s.

He then mentioned that he had an opportunity to contact an old established California ACO.  Their program was based on a “fee for service” with the caveat of capitated risk. pyramid After the ACO received its funding for the year and paid its top brass their guaranteed salaries, money went down to the doctors to pay  “competitive” fees.  If there was a profit at the end of the year,  it was shared by a complex formula.  If there was a loss the same applied.  They would not share how this was done.  Again as he viewed it,  the structure was again the pyramid with an insurance company having no risk just profit and the doctors taking all the risks.  Sound familiar?  He posed the same question I do.  He said we are fighting for inclusion in these ACOs but do we really want to be part of this kind of risk?

I still have not resolved this issues in my mind but believe we have one choice!  Get big, powerful and untied so that we can at least have an influence if ACOs become the game your must be part of.

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What Optometrists Need To Know About ACOs

An Informative Article Republished from AOA....

By Norma Bowyer, O.D., Greg Caldwell, O.D., Clarke Newman, O.D., Jason Ortman, O.D., David Redman, O.D., Harvey Richman, O.D., and Richard Soden, O.D.Greedy-ACO-stakeholderstable1

(EDITORS NOTE:  Euphemisms are a key to marketing many concepts  to uninformed Americans. Name it scrumptious and even horse shit can look like chocolate till you bite into it.  In this well written well researched article from the AOA,  a look at the coming ACOs and Medical Homes are given some fairly balanced thoughtful evaluation worth reading. Don't miss the stated point however, that none of these 1990's reborn capitated creations are REQUIRED to include Optometry.  Note too that from their founding it appears that the real profits are given from congressional legislators to the organizations that are at the top and the risk is totally placed at the bottom, at the doctors feet. In the past the insurance companies took the risk and like a casino earned profits.  Under ACOs doctors will now take the risk and you are not guaranteed inclusion. So who sat at the stakeholders table in designing this concept? I included a cartoon for your contemplation. Ed.)

By now, you have probably heard something about accountable care organizations (ACOs).  Some policymakers think ACOs are the most promising provision of the entire Affordable Care Act and an exciting opportunity to improve health care efficiency by improving quality and lowering costs.  Some critics and skeptics think ACOs are gatekeepers that threaten patient choice and access to optometrists.  Both views could be correct, to some extent.

In this article, the AOA dispels myths, point outs legitimate concerns, and helps you better understand the role of this new delivery model.

The managed care concept in the 1990s slowed the growth of health care spending temporarily, but the concept collapsed when patients and physicians pushed back.  Rather than control utilization to improve care, insurance companies used restrictions on utilization to enhance corporate profits.  Instead of putting profits back into the health systems to improve patient outcomes, managed care organizations didn’t reinvest.  Administrative staff, including accountants, seemed to have the last word on coverage.  But in the ACO model, savings from improved care management and coordination will be shared between practitioners and facilities, not just payers.  Medicare will determine which patients can be attributed to the ACO based on the primary care services that the patients receive, and compare their actual cost of care to the cost that would have been expected for those patients based on their health status and recent history under the traditional Medicare model.

The idea of an ACO grew out of influential research purporting to show that the cost of health care varies across the country inversely proportional to quality of care.  In other words, researchers thought that health care in some areas of the country was both high quality and low cost, while care in other areas was low quality and high cost.  Leading health policy experts believe that higher spending in parts of the country does not lead to better health care outcomes, and that overall spending on health care can be reduced while maintaining or improving quality.  By putting geographic areas in competition with each other, and rewarding top regions and improvement, all areas would be incentivized to find ways to lower costs and increase quality.  There was serious discussion of grouping all Medicare providers and suppliers into regional collaborations centered around large hospitals to compete against other regions on costs and quality.  There is also a belief that physicians – a high-achieving group – will embrace such competition and innovate.

In the Affordable Care Act, Congress declined to take a radical approach of ACOs for all.  Instead, the law opened the door for voluntary ACOs to be part of the Medicare program.  Instead of competing with other geographic regions for cost efficiency, the ACOs in the Medicare Shared Savings Program are measured against the recent history of health care costs for their own patients.  With participation voluntary instead of mandatory, the federal government implemented complicated and demanding requirements to prevent patient shopping and adverse selection.  Rather than accountants making coverage decisions in the old managed care world, lawyers became essential for the complex arrangements of previously competing, independent entities.

Read more here…….  this is a very well written article, with well respected contributors it is worth your time!

Be In The Local NYIPA Network Or Be Out!

A colleague sent me a very interesting article from Vision Monday <–read more here.   It is a must read if you want to do more then refractions for the rest of your professional career!

aco cover where do I fit in clear image Screenshot from 2014-03-16 16:18:20Here below are some of the excerpts from this lengthy but informative article.  Note that the important statement is that in every state every ACO or PCHM is different and to be IN you must be part of a Network.  Private practices that are not part of networks will be very unlikely to be included!

Big National networks will be of little benefit as they cannot coordinate or work with local ACOs and they will not have the connections or the ability to deal with each to its needs as each will be unique, as you will see from the excerpts from the article below…………

The ability to meaningfully use electronic health records sets the foundation upon which the basic tenets of health care reform are built, reduced costs and improved patient care, achieved, in the case of EHRs, through electronically storing and sharing information. Once providers have achieved the goals of meaningful use stage 1 (data capture and sharing), stage 2 (advance clinical processes), and stage 3 (improved outcomes), then they are ready to participate in the loftier goals of health care reform, among them the ability to share information via health information exchanges.
The Nationwide Health Information Network Exchange, Direct Project, and Connect software solution are three initiatives launched to help expand secure health information exchange efforts.

“One of key things a provider has to do to be on ACOs is to be able to share information,” confirmed Jim Grue, OD, director of health policy integration with OD Excellence. “This is accomplished through approved communications—Direct and Connect. To achieve meaningful use stage 2, electronic health records software has to support Direct messaging. This enables any EHR to share consolidated continuity of care documents with any other EHR via secure communications and then be able to take apart that document to retrieve the information it contains. With one click of the mouse I know exactly what’s wrong with the patient without having to ask the patient.” It is through health information exchanges being established on the state level through which medical professionals will securely share information.

For example, the Pennsylvania eHealth Partnership Authority, in conjunction with optometrists and ophthalmologists who currently use or are willing to install Direct messaging, is conducting a statewide study in conjunction with primary eyecare providers on the effectiveness of electronically sharing medical records on compliance reporting for diabetic eye exams and glaucoma tests.
Another new health information exchange is OcuHub, powered by AT&T and Covisint and designed specifically for optometrists by the AOA. Recently sold to TearLab Corp., OcuHub was created to enable ECPs to connect electronically to physicians, hospitals and their ancillaries, pharmacies, payers, benefit managers, optical labs, medical labs, imaging and radiology services, employer human resource departments, home care providers, and with patients themselves. “The OcuHub platform will be a competitive advantage for EHR incentive payments, access to insured patients, participation in ACOs and other new payment systems,” said Barry Barresi, OcuHub CEO and former executive director of the AOA.
You Can’t Go It Alone With ACOs
When health care is driving toward team-based delivery, what happens when you’re not on that team?” asked EyeCare Advice’s Jackson, implying that optometrists need to join in or be leftout. By definition, ACOs are groups, organizations of specialists led by a primary care physician or hospital system. You can no longer stay alone on “eyecare island,” as Jackson puts it in his book, The Value-Driven Eye Care Game.

This also means that although it is possible but challenging to do so as a sole practitioner, joining an ACO will most likely be as a networked group of optometrists, according to most of those involved who spoke with Vision Monday.

“Individual optometrists will not be of interest to ACOs,” said 4PatientCare’s Guterman. “ACOs will contract with organizations that bring a network of optometrists into the ACO.”
Optometrists Must Be Proactive to Be Included in ACOs
The market for ECPs will change,” Edward Barnwell, president/founder, KDD Health Solutions, told Vision Monday. (Essilor hired KDD to write The Eye Care Professional and Emerging Models in the Reform of Healthcare.) “Those willing to embrace change and initiate organizational competencies will be successful. There are very few independent community pharmacists,” he said as an analogy. “If the independent ECP does not adopt some of these strategies, they will be subject to risk.”

“Someone is not going to do this for you; you have to do this for yourself,” added EyeCare Advice’s Jackson. Unlike legislation favoring optometrists, often promulgated by national and regional optometric associations, joining an ACO will be leftup to each and every optometrist. “Looking back at Medicare parity legislation, everything changed at the stroke of a pen, but health reform is not like that,” continued Jackson. “If you are not learning where you fit in the rubric of ACOs, you are going to be left out.”

Optometrists Must Prove Their Value to ACOs
With reducing costs while improving care among ACO’s tenets, optometrists who contribute to these goals are better positioned to join them. One way to achieve this is by showing that they can raise patient quality measurement scores.

For example, the Physician Quality Reporting System (PQRS) combines incentive payments and payment adjustments for reporting information such as e-prescribing, exchanging health information, implementing electronic health records, and tracking results through clinical data registries. Beginning in 2015, the program penalizes those who do not satisfactorily report data on quality measures.

“The performance of an ACO-like system indicates the importance of the ECP in helping achieve improved quality of care and the awarding of millions of dollars in shared savings and PQRS incentives,” stated the KDD white paper on Emerging Models in the Reform of Healthcare commissioned by Essilor. “ECPs participating within a network of over 600 physicians in a 2005 Physician Group Practice Demonstration Project involving Medicare fee-for-service beneficiaries at St. John’s Health System (now Mercy Clinic) in Springfield, Mo., identified early symptoms of diabetic retinopathy and other disease in otherwise asymptomatic patients. The organization did not achieve its threshold for savings in the first two years of service but did record 100 percent of its quality measures in the same period. Since then it has achieved millions in CMS shared savings each year while significantly improving patient satisfaction scores.”

Another quality measurement system, Star ratings determine patient outcomes and are tied to Medicare reimbursement. The Star rating program reimburses some Medicare plans at a higher rate, depending on how many stars they reach on a scale of five stars. In 2014, those with three to five stars will receive bonuses up to 5 percent, but only those with four or five stars in 2015 will receive bonuses.  One component of the Stars rating system is the Healthcare Effectiveness Data and Information Set (HEDIS), which includes 76 quality measures across five realms of care—effectiveness, access, utilization, descriptive information, and experience.

Because of optometrists’ ability to influence the diagnosis and continuing care of certain chronic diseases, such as glaucoma, diabetes, hypertension, and others, optometrists can contribute to the elevation of these important Star, HEDIS, and other measures. “There are several quality metrics that ECPs are in a unique position to help with ACOs,” said 4Patient- Care’s Guterman, citing diabetes, glaucoma and hypertension among them.

The AOA’s Third Party Center has also determined a way optometrists can show value by reducing health care costs. After analyzing four years of paid claims data encompassing over 161 million member months from 2006 to 2009, an AOA study determined the role of optometry in diverting emergency services from hospital settings. The study revealed that diverting eyecare services from the emergency room or primary care physicians to ECPs in an outpatient setting, benefits realized included improved clinical outcomes and a potential cost savings of $0.18 per member per month.

Optometrists must understand these systems are being formed around big ticket items such as hospital stays,” said the AOA’s Third Party Center’s Montaquila, “but at about 1 to 2 percent of the total health care spend, eyecare is way down the list. It’s important to show this cost savings that results from emergency room diversion.”

Not HMOs or MCOs, ACOs Are a New Entity (and Acronym) Altogether
One of the reasons the jury is still out on whether ACOs will be effective and successful is because some detractors view them simply as a rehashing of the decades-old HMO models or just another form of managed care organization.  “When I first started practicing in the early ‘90s, talk of capitation was the best way for practices to establish themselves and make money, assuming you kept costs under control and visits normal,” said Dan Dietrichs, OD, formerly of the National EyePA Coalition. “It was supposed to be a huge profit margin, but it was a pyramid scheme. Somebody gets all the money and somebody does all the work, but not necessarily the same guy. I’m not sure people want to do more work for the same amount of money.”
Stephen Montaquila of the AOA’s Third Party Center concluded, “The most thing important thing to do right now is to make the relationships with the local leadership of ACOs. If an optometrist has a relationship with a primary care doctor, and if that primary care doctor is part of an ACO, that could be a key to get in. Get involved now! 

ACOs: What You Must Know
• The goals are to improve care for people and communities while reducing costs.
• ACO growth is projected to accelerate.
• Payments will become outcomes based, not fee-for-service.
• Financial incentives encourage providers to work together and reduce costs.
• Evolved from HMOs, ACOs are a different model of coordinated care.
• Both CMS-based and commercial, ACOs come in many forms.
• You need electronic health records to participate in ACOs.
• Networks of ODs will be more attractive to ACOs than sole practitioners.
• ODs must be proactive to be included, or risk being left behind.
• ODs must prove their value to ACOs by improving quality and reducing costs.
• A major role for ODs will be identifying and managing chronic diseases.
• ACOs are local and regional, not national, different in every state and every community.





Your Bus Is Ready Sir, And You Own It!

resultGetting a bus ride to where you want to go is always a challenge in NY, unless you happen to own the bus.   We do and you do, so climb on board for the ride of you life as the NYIPA is coming to NY City!   Currently with practices in The Bronx,  Manhattan,  Scarsdale, etc,  It is time for you to add your name to the listings and to learn about your future and the Power Of Optometric Unity.

Just two months ago, under the direction of Dr Joseph Ross,   the NYIPA built it first launch pad up in Putnam County and then rapidly expanded to Dutchess County and Orange County.  Where a team of experienced leaders build the foundation for our future success. In just two months we have developed tools for virtually uniting ODs and OMDs  by technology and communications that make us all one team.   In just two months we have gained national attention from powerful people involved in the evolution of health care and vision care.  In just two months we have become participants in the National effort to build a vertically integrated system of services that is already bringing  down the cost of goods and service to keep you profitable in the coming world of  Obama-care’s lower medical fees.  In just two months we have sent representatives to the Arizona ECPA result (1)meeting where leaders from all over the nation gathered to share ideas about the future of medical eye care and over 20 other states, like us, joined in the growing unity!

Our Director of Urban Expansion and President of the NYIPA Urban Advisory Board,  Dr Vincent Calderon,  has helped communicate the visions he saw of our future, while in Arizona.  Dr Calderon has helped create the communications that are reaching the hearts and minds of ODs in NYC who want and now know they can control their destiny.  Your bus is ready Sir and you own it. Would you like to come along for the ride?  Let you colleagues know,  it takes a big team to fuel this ship, but what great ride for those with vision!

Contact Dr Joseph Ross,  or Doctor Calderon to arrange a presentation and discussion so your society, and county’s doctors do not miss out!

Dr Joe Ross,  President  NYIPA

United We Stand (against EMR?)

Medical Economics reported physician dissatisfaction with EMR,  in a very thorough EMR-Issuesarticle published 2/10/14.  This is another reason why you want to be part of the NYIPA.  As you read this article you will see that EMRs have cost physicians far more than they brought in value.   In addition they have  reduced the patient volume doctors can handle, seriously affecting profitability. The NYIPA will help you be more profitable despite the EMR issues!  Emr may pose an opportunity for future expanded integration of holistic patient care; but, for now it is far from this goal!   Here is a summary taken from that article and a link to the entire publication:

Here are other key findings from the national survey:

  • 73% of the largest practices would not purchase their current EHR system. The data show that 66% of internal medicine specialists would not purchase their current system. About 60% of respondents in family medicine would also make another EHR choice.
  • 67% of physicians dislike the functionality of their EHR systems.
  • Nearly half of physicians believe the cost of these systems is too high.
  • 45% of respondents say patient care is worse since implementing an EHR. Nearly 23% of internists say patient care is significantly worse.
  • 65% of respondents say their EHR systems result in financial losses for the practice. About 43% of internists and other specialists/subspecialists outside of primary care characterized the losses as significant.
  • About 69% of respondents said that coordination of care with hospitals has not improved.
  • Nearly 38% of respondents doubt their system will be viable in five years.
  • 74% of respondents believe their vendors will be in business over the next 5 years.

Read more of the Medical Economics article  here…..

Don’t anticipate stuffing the genie back into the bottle.  Despite doctor dissatisfaction EMR is here to stay.  The goals of using EMR to communicate better between physicians is not unreasonable or something to avoid.  If we are ever to contain the cost of healthcare and wholistic Caredeliver better services it will come from a holistic approach to health care.  This means doctors of all types sharing information to better asses the patients needs.

Right now EMR is a challenge but it is a start up of a powerful future potential, hopefully to come.  In all start ups we have and expect challenges.   But looking down the road through the effort of many hands we can site blue skies and a better future.   Working with doctors in my community and other health care practitioners I feel I have seen the true potential of such a system as it may come to fruition.   In my office we have encourage patients to do retinal photographic screening for nearly 10 years now.  The outcome is the discovery of an incredible epidemic of arteriosclerosis.  Even young slender patients in their 20’s can have serious vascular issues. Communicating with physicians and other health care practitioners  in our community to enlist  a cooperative effort has lead to a reversal in an increasing number of patients.

Preventing a stroke or heart attack or helping the patient avoid becoming diabetic should be the responsibility of every primary care eye doctor. Think of the vast savings for our health are system if we do this!   Some authorities have estimated that over 70% of our medical expenses come from “heroic efforts” to save patients lives in their later years, when good outcomes are few to be found.  Preventing these events should be a priority for all of us and that may be possible in the evolving prevention-is-better-than-curesystem.   Look at EMR,   ACO’s  and PCMHs as the tools for  beginning this journey.   It will likely be much bigger than any of us can imagine.   It is not only doctors who have to be “accountable”  but patients who also make an effort.  It is not only patients who have to be accountable but a media and food producing industry that has to be accountable.  This will be evolving process the potential rewards are breathtaking.