MIA? Not Really…

There is much happening in the whirlwind of health reform, and the granular transformation enabled by the passage of the Patient Protection and Affordable Care Act (PPACA). The theater in Washington notwithstanding and well as the growing storm of legal challenges to the insurance mandate leave much of the implementation path somewhat clouded.

Yet the ‘roll up your sleeves and make a difference’ crowd rather than whine and obstruct, are rather busy and focused on the granular transformational opportunites written into PPACA.

You will find some of the more interesting posts and updates from the proactive players at ACO Watch, and well as it’s sister podcast via ACO Watch: A Mid-Week Revew.

Three recent posts are well worth singling out, they include:

Jaan Didorov, MD, and publisher of the Disease Management Blog, on ‘No Faux ACO’s Here!’ A play witty on CMS Administrator Don Berwick’s earlier industry admonition, as well as ‘How To Get Independent Physicians Into an Accountable Care Organization‘, offers select insights and commentary of a mature IDN, absent the staff (or employed group)  model DNA typically associated with Mayo, and Kaiser Permanente ACO strains, but more of a private/voluntary medical staff model culture, over at Advocate Health Partners.

Also, check out ACOs and the Shared Savings Program; Some Common Misconceptions, by Reed Tinsley, CPA.

We welcome your comments and engagement!

ACOs and Direct Medical Practice: What’s one got to do with the other?

On the fourth segment of ‘ACO Watch: A Mid-Week Review’ this Wednesday, December 15th at 11AM Pacific and 2PM Eastern my guest commentator is “Exemplary Primary Care’ thought leader L. Gordon Moore, MD, aka @lgordonmooreMD on Twitter, and President of Ideal Medical Practices, Inc.

Come join us for an informational session on how these dots can and will connect under the ‘innovation’ initiatives in the Patient Protection and Affordable Care Act (PPACA).

For updates, and all developments in the Accountable Care Organization (ACO) industry check out ACO Watch. The most recent post features several of the letters supplied to CMS Administrator, Don Berwick per the request for comment published in the Federal Register on November 17th, 2010.

Workshop Examines Effects of Waiver Authority on Development of ACOs

J. Peter Rich

J. Peter Rich is a partner in the law firm of McDermott Will & Emery LLP and is based in the Firm’s Los Angeles office.   He co-chairs the Firm’s Insurance / Payors Affinity Group.

The FTC, CMS and OIG hosted a public workshop on October 5, 2010, featuring panel and listening discussions on regulatory issues surrounding how the development and operation of accountable care organizations would be affected by the use of waivers, safe harbors and other exceptions to various fraud and abuse laws.

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The U.S. Federal Trade Commission, the Centers for Medicare & Medicaid Services (CMS) and the Office of the Inspector General (OIG) hosted a public workshop October 5, 2010.  A previous newsletter summarized the morning sessions of the workshop, which concerned antitrust issues. This newsletter focuses on the afternoon sessions of the workshop, which featured a panel discussion and listening session regarding how the secretary of the U.S. Department of Health and Human Services (HHS) may encourage the creation and development of accountable care organizations (ACOs) by using the position’s waiver authority or creating new exceptions and safe harbors related to the Anti-Kickback Law, the Stark Law and the Civil Monetary Penalty Law.

Summary

Workshop participants shared a range of viewpoints concerning how the formation and operation of ACOs would be affected by the use of waivers, safe harbors and other exceptions to various fraud and abuse laws.   The OIG and HHS did not provide any details as to precisely what forms such waivers, safe harbors and exceptions might take, instead, they merely received input from participant-stakeholders regarding the range of views and possible approaches that should be considered when structuring the ACO model.

For complete blog post, click here.

 

Launch of ‘ACO Watch’

Welcome to ‘ACO Watch‘. With the first official ACO to be so anointed shortly by the regulatory apparatus in Washington, DC and/or Baltimore, we thought there might be a place to monitor, track, educate, inform and perhaps even entertain as we witness the ramp-up for the ACO indusry – staggered as it may be.

Opening post is pasted below:

Welcome to ‘ACO Watch’ – keeping a pulse on the race!

October 5th, 2010 § 1 Comment

With the March passage of the ‘Patient Protection and Affordable Care Act (PPACA), the ‘follow the money’ floodgates are once again opening for hospitals, physicians, integrated delivery systems, health plans, and consultants. This time, instead of migrating ‘HMO lite’ (neither staff nor group model) platforms into mainstream medicine via IPAs, we’re now talking about their ‘new and improved’ successors broadly cast as ‘Accountable Care Organizations aka ‘ACOs’.

Some call it ‘managed care 2.0′, while the more cynical among us envision it as the full employment act for consultants, and health care lawyers, shopping a not ready for prime time, if not fundamentally flawed ‘business model’.

Given the high level of interest in these ostensible quality promoting, while cost restraining entities, the staggered implementation timeline in general, the ACO January 1, 2012 fuse in particular, and the broad brush framework intentionally reflected in PPACA, we thought it a good idea to keep a pulse on the ramp up to the highly anticipated ‘go live’ date.

We welcome your interest and contributions to this conversation.

Please check out ACO Watch or updates, guest posts, news, conferences and webinars that may be useful to you!

A Strategic Medical Group Algorithm To Assess ‘Social Media Readiness’

So what is social media really all about in terms of its relevance and application to medical groups, whether single or multi-specialty? Is it really about a better way to push an often boring, ‘look what I/we can do’ PR messaging? Or is it a genuine offer of a transformational opportunity to re-engineer health care operations and practices in service of quality, access, cost transparency and patient engagement? I say one way to get closer to an answer is to walk through this initial set of questioning recently developed for a client.

ACO Medical Group (ACOMG) Strategic Questions

Is there a perceived need among the partners for a formal planned marketing and communications function at the Group level? Yes/No?

If no, end of conversation and on to the ‘next prospect’.

If yes,

Is the web viewed as a material source (actual or potential) for patient acquisition, business development, and connectivity with key ACOMG constituents? Yes/no?

If no, end.

If yes, should ACOMG invest in a coordinated and comprehensive ‘web presence’ that builds, positions and maintains real-time, interactive capabilities via a coordinated yet distributed set of both ‘push’ and digital interactive properties.

If no, end.

If yes, is ACOMG presently enabled to perform as a content development, publishing and management company that feeds and curates these content, keyword, market and niche rich community management properties?

If yes, end.

If no, are these core skill sets presently domiciled at ACOMG staff (whether via professional or administrative staff, consultants, etc.)?

If yes, end.

If no, how will ACOMG acquire, develop or otherwise embed the needed skill sets and core competencies?

Build, buy or do nothing?

If build, or buy is there a budget benchmarked to a formal marketing and communications program consistent with published management company guidelines as a percent of revenue or expenses? If yes, game on. If no, end of conversation or need for additional education (good luck!).

And while you consider this ‘social media readiness assessment’ do bear in mind that the world continues to spin and has minimally surfaced the following things to consider:

Additional strategic considerations to throw into the mix as market conditions and environmental context:

On the future of community medicine in general, or your version of community medicine via your specific specialty:

1. What alliances and/or networking arrangements should your group be considering?

2. What vehicles (legal entities or other forms of organizations) should your group be considering, e.g., single specialty IPA, or ‘super IPA’ (re-purposed specialty GPO), MSO, super MSO, associating with a 3rd party PPMC (i.e., US Oncology), linking with an hospital system (which one, might there be more, or even a multi-hospital vehicle to be created?)

3. What formal strategic positioning thought is underway given the relatively short horizon for ACO participation? Have you evaluated the range and wisdom of various participation options, i.e., as single sites; as an integrated group; with hospital participation or not ( a very key question)?

Basically [medical group leadership], do you have previous experience in dealing with these strategic issues (many of which seem to be re-cycling prior themes albeit with ‘new and improved’ acronyms)? Is there ‘institutional memory’ from the HMO, IPA, MSO, or PHO days? Is the ‘wisdom’ of the senior members of the group being shared with the younger generation, who carry the longitudinal stake in the practice’s sustainability? Or is the default position just to do nothing and see what happens?

Bottom line is it’s all about choice… and there is no ‘good’ or ‘bad’ here, only informed/uninformed choices and consequences; and inaction, denial or minimization is a firm choice, no doubt with inevitable consequences! Cheers!

Direct Provider Access Networks: DIY Healthcare Reform Now! – A SxSW Panel Picker Entry

Thanks to the initiative of Alex B. Fair, founder, CEO and chief evangelista of FairCareMD, the priceline for matching doctors to patients ‘one deal at a time’; an impressive roster of healthcare innovators have teamed up to carry the message on alternative forms of healthcare delivery and finance at SxSW 2011.

The program description reads:

Doctors, Employers, and most Americans are unclear on how the Patient Protection and Affordable Care Act (PPACA) will work for them but a few million of us are not waiting to find out. With over 100 million Americans paying directly for a large portion of their care themselves, the need for a better way to Go Direct for care has never been greater.

In the past year over 2 million Americans and thousands of doctors have started using “Direct Provider Access” networks (DPAs) rather than traditional insurance-based medicine alone. This is because these new websites and physician practice models allow for DIY Healthcare Reform NOW and provide better care at reduced costs compared to insurance-based medicine.

Patients are taking charge of their own healthcare, paying directly, and using insurance for emergencies only. Doctors love DPAs too because being paid directly lets them put the Care back into Healthcare. Direct Pay medicine reduces overhead costs by up to 40% allowing them to spend more time on giving great care. This significant mindshift is changing the healthcare landscape.

In 2010 DPAs have been the fastest growing networks in America and they have even been written into the Healthcare Reform legislation. In a short, interactive play starring some of the leaders of the DIY Healthcare Reform/ Patient Empowerment movement we will show how DPAs are changing the ‘patient experience’ and improving care.

1. What are Direct Provider Access networks and what can they do for me?

2. How do/ will DPAs interact with the healthcare reform act of 2010?

3. Why did these not exist before? Isn’t this the same as old fashioned doctors? How does this tie in with Social Media?

4. Why can’t we have true pricing transparency in healthcare and what needs to change in order to get there?

5. What is the future of DPAs – will they just be swallowed up again by Insurance companies?

Confirmed panelists include:

• ePatientDave
• Garrison Bliss, MD, Qliance
• Jefferey Rice, MD, Healthcare Blue Book
• Howard J. Luks, MD, iMedExchange
• Alex B. Fair, FairCareMD

Please consider voting us into the first ever healthcare track at SxSW, here!

The ‘Medical Aggregators’: Are We Entering Round Deux?

First a little historical context:

For those with a healthcare ‘event horizon’ slightly more seasoned than the current health reform and related social media data frames, you might remember the initial round of aggregation in medicine lead by disruptive nameplates such as MedPartners (now operating the PBM CareMark), PhyCor, FPA Medical Management, and their second or third tier physician practice management ‘me too’ copycats.

They all emerged from a robust round of venture capital backed industry determination tagged as ‘PPMC’s’, i.e., physician practice management companies. These ‘aggregators’ were the darlings of Wall Street for a while, though with some exceptions, i.e., US Oncology (formerly Physician Reliance Network), most witnessed relatively short life spans, from IPO to unwinding in perhaps a 10 year run (see: MedPartners collapse and Aftermath).

Yet, despite the promise outlined in the offering prospectus’, why did these entities fail so miserably as the ‘white knight’ consolidators or aggregators of a multi-trillion dollar ‘cottage medical industry’? Their business model proferred essentially three core benefits:

1. Centralized, standardized and more efficient back office medical administrative management
2. Scale of market asset concentration and therefore increased sophistication and leverage (improved pricing) with third party payor negotiation, and downstream contract management; and
3. Serve as an ‘anchor play’ with respect to the broader design and implementation of rational though market based local delivery organization and financing, i.e., PPMC’s would harness and more effectively articulate a business culture among physicians that valued clinical integration, medical risk management, and ultimately the allocation of limited health care resources

At least this was the longer term expectation from a ‘win/win’, i.e., payor and provider perspective, of the more established players. Most however, in an effort to demonstrate value (i.e., earn their management fee) to their physician boards, focused on short term margin improvement (better rates, focus on more profitable services via improved payor mix, maximizing the contract revenue/recovery cycle, and reduced overhead, etc.), vs. the strategic focus of managing the risk (both quality and cost) of their local population (i.e., enrolled members).

So rather quickly the strategic basis of the PPMC appeal was subordinated to a short term focus (i.e., increasing net revenues) due to a rising chorus of claims that at its core the business model was merely a third party ponzi scheme which introduced another mouth to feed from an increasingly constrained health care supply chain.

Net/net, the PPMC industry flamed out big time and did not fulfill its ‘roll-up’ promise of the practice of medicine. Now many years later, we are at another tipping point. Witness the current round of promising vehicles with a similar vision of organizing physicians. These candidates include: hospital systems, health plans, integrated delivery systems, emerging ACOs, medical homes,  and even niche play organizers in the concierge, or direct practice space including SignatureMD, MDVIP, HealthAccess Rhode Island, CarePractice, Qliance, and HelloHealth, as well as the rapidly emerging series of retail pharmacy sponsored primary care clinics, e.g., CVS/CareMark Minute Clinic, etc.

Too many docs are unwilling to risk the capital of private practice, and instead are looking to hook-up with one or more of these institutional or VC backed entrepreneurial sponsors. Will they succeed where their predecessors failed? If so, why?

From my perspective, it will clearly depend on the business model chosen to enable competition of the right variety, and the degree to which the venture embraces, nurtures and expresses physician culture that values collaborative group practice. Top down, corporate strategies dependent upon an over worked and out gunned medical director or VP of medical affairs will miss the mark. The more likely way for these ventures to succeed is by ‘baking’ the culture from the ground up. In other words, ‘seed it and they will come’. One of my mentors (Ernest Holmes) once wrote long ago: ‘the soil can’t argue with the seed’. Lets nourish the soil first, then make sure we plant the seeds with the right constitution and vision.

From ‘Health Reform’ to ‘Delivery System Transformation’

Well we made it! It’s over for now. Obama thrashed through the red zone and against all odds drove the football of health reform across the plane of the goal line. But no rest for the weary, since that drive was the ‘easy’ part. Congrats Mr. President, the ‘Patient Protection and Affordable Care Act‘ as amended by the ‘Health Care and Education Reconciliation Act of 2010‘ is now U.S. law. Yet, phase two, aka the ‘devil is in the details’ implementation challenge is now before an industry that has historically opted the path of least resistance, rather than risk true game changing innovation.

For an excellent recap and summary of the combined bills, see: Kaiser Family Foundation’s ‘Summary of Coverage Provisions‘. Yet, I am most interested in the quality, and payment provisions that will drive the innovators’ in the mix. Most of the applicable language can be found in ‘The Timeline for Accountable Care: The Rollout of the Payment and Delivery Reform Provisions in the Patient Protection and Affordable Care Act and the Implications for Accountable Care Organizations’.

While the law falls short of what I hoped for (I stood for a robust public option to ‘discipline’ the health plan community, and most certainly favored a ‘Medicare E’ option for the 55-64 demographic), it offers many needed incremental improvements to the U.S. health insurance industry practices, as well as the granular ‘patient’s first’ innovation imperative if the reform effort is to honor it’s coverage goals, and not bankrupt the country.

Bottom line, is we’re  entering the era of ‘Managed Care 2.0‘, a do-over or ‘Mulligan’ – if you will. Since the failure of the grand HMO experiment, and subsequent risk ‘push back’ in the mid 90’s when the typical hospital sponsored integrated delivery system (a poorly equipped and improperly motivated first generation risk management vehicle) constituted mainstream efforts to manage care, we’re now hoping this time will be different. But will it? What’s changed to suggest we’ll have a different experience this go round, or are we just doing the same thing over (and over) again expecting different results?

To monitor and re-tweet these discussions, I’ve started a Twitter notebook and associated ‘managed care 2.0’ (#mc20) hashtag to pool tweets. I anticipate a robust discussion in both the blogosphere as well as on twitter, so get ready for a flood of activities on Patient Centered Medical Homes (PCMH), Accountable Care Organizations (ACOs), PHOs versions 2.0, and a re-invigorated IPA community including their Management Services Organizations’ (MSOs) as ‘infrastructure and strategy’ hosts.

Also add to this mix the growing membership (and buzz) into direct practice (boutique, concierge, retainer, etc.) medical models that offer access to basic medical care outside of an insurance or health plan context. This is a space that is likely to witness a clash of definitional interest as to what constitutes a ‘patient centered medical home’ and for what purpose, whether it be as defined by law as an ACO or PCMH vs. a primary care practice that opts out of Medicare or participating with health plans, to service their members as de facto equivalents of medical homes albeit of the ‘unregulated variety’.

May you live in ‘interesting times’ or so goes an ancient Chinese proverb or perhaps curse; and yes we do!