February 2014

Physician Brief

Building and Strengthening the Private Practice of Medicine through Patient Partnerships

ACO Approved by CMS

Kick-Off Meeting Held

Primary PartnerCare Associates IPA, Inc. has been selected as one of 123 new Accountable Care Organizations (ACOs) in Medicare, providing approximately 1.5 million more Medicare beneficiaries with access to high-quality, coordinated care across the United States, Health and Human Services (HHS) Secretary Kathleen Sebelius announced today.Doctors, hospitals and health care providers establish ACOs in order to work together to provide higher-quality coordinated care to their patients, while helping to slow health care cost growth. Since passage of the Affordable Care Act, more than 360 (ACOs) have been established, serving over 5.3 million Americans with Medicare.  Dec. 23, 2013

Primary Care Physician members gathered in late October to learn more about CMS MSSP budgeting, patient alignment and the critical role of accurate coding and capture in a MSSP ACO. This data not only is used by CMS to establish the preliminary budget through Hierarchial Condition Categories (HCCs), but accurate coding is an intricate component of capturing quality metrics. Moreover, the ACO will be utilizing diagnoses and procedure codes, along with other clinical data, to identify high risk patients for additional services to assist and coordinate care. The ACO will initially be targeting common chronic diseases to the Medicare population, and will soon be launching a specialized frail elderly program. 

Expensive Hospitals: Strong Reputations But Little Evidence Of Better Care, Study Finds

Editorial Response to “Expensive Hospitals: Strong Reputations But Little Evidence of Better Care, Study Finds”, KHN Blog, Jordan Rau, 01/29/2014 by Harry S. Jacob, MD, Chief Executive Medical Officer This article reviews a study of autoworker claims which found that hospitals with the highest prices tended to have the strongest reputations and "tightest holds" on their local markets yet little evidence of providing better quality care.  The piece in the Kaiser Health Blog goes on to explain that the actual prices that insurers pay hospitals are "closely guarded secrets" in health care which has made it hard for researchers to study whether patients get better treatment from more expensive hospitals. For the most part, no one can quantify "more expensive hospitals". That is until  a study in Health Affairs gave researchers a peek into hospitals "real" prices by analyzing nearly 25,000 insurance claims for current and retired auto workers. The workers sought care at 110 hospitals which the researchers divided into three categories: low, medium and high priced hospitals. Conclusion.... High priced hospitals were twice as large as low priced hospitals and their market share was three times as large as low priced hospitals - often through affiliations with large health systems. 

For most working physicians this is not such enlightening news. We know that big is not always better - sometimes big is just powerful. All we have to do is to look around us. Why would anyone assume that price is related to quality? Up until ACA, there rarely if ever was the mention of quality as it related to price negotiations. Hospital DRGs used to reward hospitals for patients that became infected during their inpatient stay by paying more for the DRG with UTI. The ACA changed this and introduced quality metrics through Value Based Purchasing. Commercial health plans I can only assume are adopting some of these same measures. However, based on my experience and in discussions with other healthcare executives, the bigger the hospital system... the bigger the rate. So, what is a physician to do? Be conscious of your referral patterns when it affects your patients out-of-pocket expenses.  Its unfair that this data is not available to us as doctors or to our patients when they are directly impacted, but I try to educate my patients and provide them a choice when I am aware. Having the knowledge is quite a battle. Should it be? 


AMA Protests Costs of ICD-10

Retail Pharmacies Embrace Blue Button

The AMA hasn’t yet given up on  being vocal about the burden of the ICD-10 transition slated for October 1, 2014, and has released a new report warning providers that the implementation process will drain significantly more money than most organizations have planned for.  From the impact assessment to vendor upgrades to productivity loss remediation, the financial hit to a typical small practice may range from $56,639 to $226,105 over the next two years.  Compared to an initial report released in 2008, the 2014 projected costs are significantly higher. “The markedly higher implementation costs for ICD-10 place a crushing burden on physicians, straining vital resources needed to invest in new health care delivery models and well-developed technology that promotes care coordination with real value to patients,” said AMA President Ardis Dee Hoven, MD in a press release. “Continuing to compel physicians to adopt this new coding structure threatens to disrupt innovations by diverting resources away from areas that are expected to help lower costs and improve the quality of care. EHR Intelligence, Feb 12, 2014

A user-friendly interface redesign in 2013 has encouraged adoption of the technology, which lets patients download a summary of their PHI to share or keep for their own records.  Adding retail pharmacy data will help complete the record and give providers and patients a more detailed look at medication adherence. The pharmacy companies joining the initiative in this announcement are Walgreens, Safeway, CVS Caremark, Rite Aid, and Kroger, most of which already provide their customers with the ability to access pharmacy records and medication histories online.  The National Association of Chain Drug Stores, the Pharmacy Health IT Collaborative, and the National Alliance of State Pharmacy Associations have also signed on to promote the adoption and use of Blue Button within their member populations. The en masse commitment from some of the most recognizable names in the pharmacy business will help patients access their data at the corner store in addition to the doctor’s office, and extends the network of online engagement and health information exchange to thousands of new locations already integrated into the local community. EHR Intelligence, Feb 11, 2014


Patients New Access to Lab Results

CIGNA Launches PCP ACO in AZ

ASC vs. Hospital Outpatient

The new rule revises the CLIA and HIPAA privacy rules to require laboratories to give a patient, or a person designated by the patient or his or her “personal representative” access to the patient’s completed test reports upon the patient’s or patient’s personal representative’s request. In general, the rule requires laboratories provide individuals with access to their laboratory test reports within 30 days of the request. For the most part, the rule provides clinical laboratories with the flexibility to determine the processes that allow them to fulfill the patient’s request, including the process of verifying the identity of the patient. ASPC, Feb 6, 2014

Cigna has sealed a collaborative accountable care arrangement, Cigna’s version of an ACO, with Commonwealth Primary Care ACO. It is Cigna’s sixth collaborative care arrangement in Arizona.  “They are highly motivated to deliver value-based care,” said John Keats, senior medical officer of Cigna Arizona. “They wanted to be rewarded for delivering the high quality, lower cost care they are committed to practicing.” The arrangement started on January 1, 2014 and will cover more than 7,000 lives as patients of the 120 primary care physicians affiliated with Commonwealth Primary Care ACO.  Commonwealth Primary Care ACO is not affiliated with a hospital. ACO News, Feb 7, 2014

Nationally, patients, physicians, health plans, IPAs and ACOs are questioning the cost of Medicare surgical procedures offered in the hospital outpatient setting as compared to those same services in an ASC setting. A quick Google search will produce articles, blogs and white papers as to the differing Medicare payments for seemingly the same service. This difference in payment is not only important to entities such as health plans and ACOs looking to find the most cost-effective setting for surgical procedures, but more important  for patients since they pay approximately 20%  in both settings. This 20% could be significantly different based on the site of care. CMS publishes the Top 25 procedures for ASC by state.  

AMA Throws Support Behind Bipartisan Bill To Repeal, Replace SGR

The American Medical Association on Tuesday announced its support for the newbipartisan, bicameral proposal to repeal and replace Medicare's sustainable growth rate formula, Modern Healthcare reports.  However, the physician group did not offer any suggestions on how to cover its estimated $126 billion price tag (Robeznieks, Modern Healthcare, 2/11).

The SGR Repeal and Medicare Provider Payment Modernization Act- which was crafted by the Senate Finance Committee and the House Ways and Means and Energy and Commerce committees - would repeal the SGR formula, which sets physician payment rates, and institute a 0.5% annual payment increase between 2014 and 2018. The increase would be maintained until 2018 to ensure payment stability and help doctors transition to new care models.

Since 2003, Congress has spent nearly $150 billion on short-term patches to stave off Medicare payment cuts scheduled under the SGR formula. The most recent short-term "doc fix" is set to expire March 31 (California Healthline 2/7).

During a conference call with media, AMA President Ardis Dee Hoven said that "Congress can manage this" and that she "trust[s]" the members of Congress to get this right." Hoven also said that the new proposal's annual payment increases and use of doctor-developed quality standards were suggested by AMA. The association does not support alternative legislation, which would enact a none-month suspension of SGR-driven pay cuts, she noted.  California Healthline, Feb 12, 2014



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