Physician Brief

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. 

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? 

 

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

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