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.

 

 

 

 

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About Janr Ssor

Author, doctors, inventor of holistic eye care, programmer, community activist, network organizer, public speaker, salesman, Marketing specialist, Musician, ...lives outside the box.

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