Signal to Noise Challenges in ACO Actuarial Data: Who’s ‘At Greater Risk?’

This post originally appeared at HealthHombre.

HealthHombre.com | BlogThe national health expenditure data released last week showed relatively modest 2011 growth, which promptly provoked a back-and-forth about what the figures truly say and what they portend for holding spending in check going forward.  Amid considerable mental gear gnashing, the data have been assessed in light of such potential cost influencers as lingering recessionary effects, clinical v. administrative drivers, and imminent arrival of the full-bore ACA.  Occupying several nodes along the public-opinion continuum, headlines ranged from “Spending Growth at 52-Year Low” to “Americans Boost Spending” to (out on the far edge of the limb) “Future is Not Clear.”

More clear is the sharp relief into which the expenditure data cast other data, detailed in a new analysis that suggests a greater risk of Medicare Shared Savings Program underpayment of ACOs in precisely this type of environment — i.e., when no one’s altogether sure about the ups and downs of health care spending.  As a CMS summary put it:

[T]he role of random fluctuations in year-to-year healthcare spending may play a larger role in savings measurement than previously anticipated. Although CMS is fairly well protected from the chance that an Accountable Care Organization (ACO) would be rewarded inappropriately for savings that did not truly occur, ACOs are much less protected from the analogous chance that they are inappropriately denied rewards for savings that do occur.  (emphasis supplied)

And so as CMS moves forward with the latest wave of ACOs, the agency seems to have its own bets pretty well covered.  ACOs themselves, however, could face “denied rewards,” with the risk that genuine savings will go unshared particularly acute for smaller ACOs.  The analysis mused that the new data may mean ACO participation will be skewed toward groups of larger providers better able to buffer themselves against the vicissitudes of future health spending patterns.

In a risky world, ACOs, perceived by some as potentially “fragile” to begin with, seem little strengthened by this latest confluence of data.

ACOs, Oncology and the Future of Better Cancer Care

By Gregg A. Masters, MPH

As originally posted at JustOncology.

The best business model for oncology care is not yet obvious to me. But it is crystal clear that innovative new models are being hatched before our eyes.. via Oncology Times

Since CMS (via HHS) issued the final rule addressing ACO provisions and specifically ‘excluded’ oncologists from participating as ACO organizers, instead relegating their involvement in at least via the Medicare Shared Savings Program to ‘participants’, there has been rumbling underneath the surface of ‘ACO-dom’.

Perhaps as best evidenced by the April announcement of a tripartite venture between FlordiaBlue, Advanced Medical Specialties (a former US Oncology Affiliate now part of the McKesson fold), and Baptist Health System, the competitive positioning in the oncology market is not sitting idly by as other medical specialties, including primary care, carve out their niche and actively experiment with their version and local vision for accountable care aka ‘the triple aim.’

In the broader conversation on ACOs or their derivatives including medical homes or accountable care collaborations, etc, there has been much discussion from very smart and accomplished wonks including periodic banter, i.e., Goldsmith v. De Marco] as to the significance and forward [reasonably expected] benefits from duly organized [or in the latter case - arranged] ACOs. Bottom-line,  there is a fair amount of credible disagreement over whether these entities as variably configured actually make a difference?

Meanwhile, in the oncology domain, much of the action seems relegated to a few forward thinking players who have taken the initiative regardless of CMS’ decision to limit their participation (at least to this point in time) to contracted participant suppliers of specialty services.

For a deeper dive into the question: ‘Who Is Taking the Lead in Incorporating Oncology into ACO Thinking?’ see: The Rapidly Evolving ACO World, we have the following observation and summary data:

There are several examples of organizations that have stepped up and have taken the lead in exploring payment re-design in oncology, some within an ACO shared savings context and some outside the ACO context.

The vanguard includes:

  • Consultants in Medical Oncology & Hematology. Oncology Patient Centered Medical Home®, Drexel Hill, PA
  • United Healthcare (5 episode payment pilot sites)
  • Texas Oncology/Innovent Oncology and Aetna
  • Oncology Physician Resource (OPR) and Michigan Blue Cross
  • Wilshire Oncology and Wellpoint, Southern California
  • CareFirst Blue Cross pathways and medical home initiative, Maryland
  • Priority Health oncology medical home initiative, Michigan
  • Florida Blue, Baptist Health South Florida and Advanced Medical Specialties Oncology ACO, Miami
  • Harvard Pilgrim Health Plan with oncology medical home demonstration pilot, Massachusetts;
  • Innovative Oncology Business Solutions with CMMI Innovation Challenge grant to demonstrate value proposition of community oncology medical home (COME HOME) at 7 community oncology practices nationwide.

And certainly there will be more organizations joining the vanguard in the near future.

We are working on getting Ronald Barkley, CCBD Group, and Linda Bosserman, MD, President and CEO of Wilshire Oncology and Hematology Associates to share their thoughts on ‘This Week in Oncology’. We’ll keep you posted when we’re able to lock them down.

Meanwhile, with the elections now behind us, the future is rather clear at least for those who want to manifest the spirit and intent of the Affordable Care Act, so ‘warp drive Mr. Zulu’ as the ACO movement shifts into overdrive.

The Anatomy of a Patient Centered Medical Home: the Physiology of an ACO?

By Margalit Gur-Arie

Obamacare is here to stay, and with it a host of initiatives small and large, some intended and some not so much so, targeting massive transformation of the health care delivery system. One of those initiatives involves the adoption of the principles of a Patient Centered Medical Home (PCMH) for primary care as formulated by the primary care medical associations, and to a large extent, as translated into operational processes by the National Committee for Quality Assurance (NCQA). There are other implementations of the PCMH put forward by public and private organizations, but NCQA’s Medical Home recognition program is considered the gold standard for PCMH. The PCMH concept is also here to stay, and as is the case with Obamacare, the Medical Home model has its supporters, its detractors and all sorts of misconceptions and implementation missteps.
If you randomly ask a primary care physician about his/her opinion on the Patient Centered Medical Home model of primary care, you will most likely get one of the answers listed below in order of increasing prevalence:

  1. Absolutely fantastic way to practice medicine. We’ve been doing this for a while and are a Level III recognized Medical Home.
  2. The idea is good and we are currently making the transition and working on obtaining NCQA recognition. It’s not easy, but we are hopeful.
  3. We are part of a PCMH pilot in our state. It’s a lot of work and I am not convinced that it will have any benefits for my practice.
  4. I read about it, but I can’t afford to hire dieticians and social workers and spend time on all the paper work.
  5. I don’t have time for this.  Just a bunch of government regulations that do nothing for patient care.
  6. This is the final nail in the coffin of primary care. It’s going to drive all remaining independent physicians out of practice, which is what the government wants anyway.
  7. My mother-in-law is in an assisted living facility, but other than that I don’t have any patients in nursing homes….. I don’t take Medicaid.
  8. Say that again…?

Just like Obamacare is not something invented by overzealous socialists, but the brainchild of extremely conservative thinking, the PCMH is not a government invention, but instead it is based on a statement made by physician associations attempting to define good primary care and the need for insurers to pay more for such excellence. The devil of course is in the details. It’s been said that the “official” NCQA PCMH requirements consist of too many details, and that some of those details are bureaucratic in nature, burdensome, expensive and contribute little to patient care. It’s been said that true quality of care and practice transformation, whatever that may be, is largely independent of counting points, formal testing, certifications and recognition’s   Granted, all these contentions seem reasonable, but before deciding to walk away, how about a quick bird’s eye tour of what NCQA PCMH recognition really is?

The six parts of formal NCQA 2011 PCMH recognition are called Standards. Let’s take a critical look at each one and note the order in which they are arranged.

Standard #1 – Enhance Access and Continuity – Continuity here refers to people having a personal physician instead of seeing whoever happens to have time that day. I don’t know many practices where this is not the case anyway, but it’s hard to argue against the need to build a long term relationship between patients and their doctors, and it’s even harder to argue against this being the #1 foundational requirement of delivering high quality longitudinal patient care. Note that by definition solo practices are automatically set up to care for patients this way (just saying…). The second part of this Standard is a bit more problematic from a physician’s point of view, because it does require availability after hours and seeing patients the same day as much as possible. It is not an easy task to start tinkering with your schedule, if you are not currently offering same-day appointments, and done haphazardly, it may have serious financial implications to your practice. How about being available after hours, particularly for a solo or very small practice? How about your family and personal life? If you are one of the new concierge docs with a tiny panel of well-behaved patients, this is obviously not an issue. If you have 2500 patients, or so, on your panel, some creative thinking may be required. How would your patients react if, say, every Tuesday you’d start seeing patients from 12 pm to 8 pm? Or if you closed early on Wednesdays and twice a month you saw patients on Saturday mornings? Or if you had an arrangement with a couple of other practices to provide urgent care at odd hours on a rotating basis?

A recent study in the Annals of Family Medicine found that total health care expenditures were 10.4% lower for patients who had access to extended hours of care. This is great news for the “system”, but how about benefits to you and your practice? Whether you like it or not, you are now competing against business models with extremely low overhead, such as grocery store clinics and virtual tele-medicine clinics, offering pseudo-primary-care to your rushed and hurried patients for simple needs, leaving you to deal with complex visits that cost you a lot to deliver, but pay as much (or as little) as the simple ones. Unless you start thinking outside the box, your model of business is destined to become obsolete. Offering some electronic visits, providing hours for urgent care needs and collaborating with others on extended coverage may very well be a matter of survival. Interestingly enough, another recent JAMA study, although limited to community health centers, finds measurable correlation between access and continuity and lower operational costs per unit of service. There should be very little doubt at this point that Standard #1 is the place to start work on the viability of any practice, or ignored at significant peril.

Standard #2 – Identify and Manage Patient Populations – This one sounds onerous and a departure from individualized patient care, but is it really so? The “populations” term notwithstanding, all this Standard requires is that you document patient demographics and clinical information in the chart (seriously?), that you take good histories and that you send reminders to your patients to mind their chronic and/or preventive care needs. There is really nothing here that a good primary care physician doesn’t already do, and probably to a much greater extent than the NCQA standards specify. The one thing that may be different is that this Standard talks about proactive reminders to patients that don’t come in to see you on their own. Good for business and definitely good for patient care on an individual level.

Standard #3 – Plan and Manage Care – Another statement of the obvious, but this standard uses terminology that may raise some eyebrows. For example, it asks that your care is evidence-based. Is your care not evidence-based? Surely you decide how to treat patients based on your education, what you learned along the years, books, articles and latest research, instead of throwing darts at a random treatments list hanging in your office. And this is really all there is to this Standard, other than practicing medicine, i.e. seeing patients, evaluating conditions, planning care, talking to patients, and generally speaking, being their doctor.

Standard #4 – Provide Self-Care Support and Community Resources – This may sound like the new age fluff of patients taking care of themselves, and granted, there is some of that here, but the details are again pretty straightforward in their intent to have patients understand their conditions and do something about it. Primary care docs don’t usually fit the much publicized portrait of aloof and paternalistic doctors who won’t give you the time of day. It is the time constraints in fully loaded practices that may prevent some from fully engaging with their patients, and no certification process will change that without proper shift in reimbursement, or a change to a more direct practice model with smaller patient panels. This Standard’s feasibility is also highly dependent on patients themselves, but there are simple things you and your staff can do to better enable patients to take some responsibility for their own health (most of which you are probably doing already), and this is all this Standard is about.

Standard #5 – Track and Coordinate Care – Do you send patients to specialists and then forget all about them? Do you order lab tests and don’t care if the results come in or not or if they are normal or not? Do you get calls from the hospital notifying you that one of your patients was admitted, and you hang up thinking that this is not your problem? No? Then you are tracking and coordinating care. Can you do more? Probably, but here you are largely at the mercy of specialists and hospitals in particular. You most likely already have tickler lists to help remind your staff about getting specialists notes and test results, but it is extremely difficult to have the hospital contact you if you are not admitting your own patients (and sometimes even if you do). There is effort (and costs) involved in better tracking and better coordination and payers are starting to take notice as evidenced by the latest care coordination CPTs added to the Medicare physician fee schedule.

Standard #6 – Measure and Improve Performance – Here it is. This is the measuring, reporting and all administrating bag of requirements, complete with patient satisfaction surveys, sending data to payers and using electronic medical records. While most items here are optional, a medical home is required to set some improvement goals for clinical measures (just goal setting, not necessarily outcomes). So after doing everything outlined in previous Standards, this is where the assumption is implicitly made that a medical home should be able to continuously improve the care it provides. Perhaps you believe that you are already providing excellent care, and no doubt most of you do, but is there anything more you can do? This Standard is asking you to consider this question, and if you have an answer, begin acting on it. And yes, this too may take more time and more effort on your part, and thus be dependent on payments to support these efforts.

Did I leave anything out? If your opinion of the PCMH was something along the lines of #6 above, you are probably wondering about some “strategic” omissions. How about all that “team care” and nurse practitioners? How about those case managers and dieticians? What of the need to buy, implement and use an expensive EMR? Well, for starters these things are optional in nature. Unless you are a team of one, you already have people helping you out with patient care and administration, and you are not required to use or augment your staff more than you are comfortable with. A good EMR should help, but it is not mandatory either. And yes, NCQA will recognize nurse practitioner led practices as medical homes, but this is reflective of legislation at State levels, and it should be appropriately addressed at a policy and legislative level as well. As to the infamous amounts of paperwork involved, yes, there is plenty of that, but there is also plenty of help out there and you just need to find it.

On the surface the NCQA PCMH recognition process is an administrative test for primary care, but if you look at it carefully, you can see that it is also a logically ordered roadmap for quality primary care and a tool for you to take a fresh look at your practice and position it to change with the times without having to sacrifice your ethics and your principles. Some things in this roadmap are at the heart of what you do every day, others are things that you may want to do if time and finances allowed, and few are in the realm of “forget it”. Unlike Meaningful Use, the NCQA PCMH “test” is not an all-or-nothing proposition and there is reasonable freedom for you to discard those “forget it” items, or postpone the wishful thinking for a better day. There should be financial benefits accruing from just doing some of the things on this roadmap (such as Standard #1), and there are financial incentives from payers for doing other things or from just “passing the test”.

The medical home is a timeless model of care, repackaged for these troubled and technology driven times, and as such, it is also a business model for the future of primary care. You could approach the entire exercise as yet another payer and government mandated intrusion, or you could make this roadmap your own, and look at it as a means by which to refine and sustain an already excellent practice. It is ultimately all up to you.

Margalit Gur-Arie is a partner at BizMed, and formerly Sr. Vice President Operations at Physician Advantage (GenesysMD). She publishes ‘On Healthcare Technology‘ and tweets via @margalitgurarie.

Yes We Can? No, He [POTUS] Didn’t. Not Tonight.

Note: An Opinion Piece By Gregg A. Masters, MPH

If you were not dialed into the first presidential debate tonight, you missed a rather tortured, poorly moderated, POTUS failed series of opportunities to credibly discredit his health reform ‘etch-a-sketch’ opponent. In the post debate punditry, and fact checking, this one is likely to ascend to the Romney ‘distortion zone’ hall of fame collection.

Going into the debate, odds makers favored POTUS to win the match, while most assumed his challenger would benefit though not land anything remotely resembling exchange parity if not the ‘out of the money’ and long shot knock out punch. In fact many saw this debate as an opportunity for POTUS to land just such a fatal blow to this master of health policy obfuscation.

Yet the results are in, and the sentiment is perhaps best be summarized by a series of tweets proffered by Atul Gawande, MD, aka @atul_gawande:

@Atul_Gawande 1. Obama was meandering and confusing.

@Atul_Gawande 2. Romney made a shockingly better case for government being a protector of the weak and vulnerable than Obama.

@Atul_Gawande 3. Romney’s stated policies—cutting coverage for the uninsured, Wall St regulations, and top tax bracket—weaken those protections.

@Atul_Gawande 4. That Obama could not convincingly explain this is utterly depressing.

@Atul_Gawande 5. The key policy Q: did Romney’s promise to leave the tax share of the rich the same walk back his promise to cut top tax bracket?

No doubt a wake-up call to the Obama camp.

In the attribution department, the title for this post ‘ Yes we can? No, he didn’t. Not tonight.‘ was sourced from: Warren Kinsella, aka @kinsellawarren, who described himself as ‘…a raconteur, bon vivant, and – occasionally – a Toronto-based lawyer, author and consultant. He is not profound, but he enjoys a good scrap.’

J.D. Kleinke Makes It Perfectly Clear!

By Gregg A. Masters, MPH

Amidst the relentless noise, fear mongering, hand wringing and incessant misrepresentation of both the legislative history as well as decades of development of sensible health policy context for competing models of managed competition or healthcare market reform, J.D. Kleinke in a recent New York Times Opinion piece titled ‘The Conservative Case for Obamacare‘ essentially clears the air once and for all.

If you have not read his piece, I strongly encourage you to do so!

For those of you without the time to scan right now, let me cite two key observations. But first, please be mindful that J.D. Kleinke is a resident fellow at the American Enterprise Institute, a former health care executive and the author of the novel “Catching Babies”, and not some fringe liberal dwelling in a pseudo think tank pumping ideological fuel into the health reform disinformation rant. J.D. notes:

The core drivers of the health care act are market principles formulated by conservative economists, designed to correct structural flaws in our health insurance system — principles originally embraced by Republicans as a market alternative to the Clinton plan in the early 1990s. The president’s program extends the current health care system — mostly employer-based coverage, administered by commercial health insurers, with care delivered by fee-for-service doctors and hospitals — by removing the biggest obstacles to that system’s functioning like a competitive marketplace.

So much for the ‘Government takeover’ enshrined in Republican town hall talking points designed to to stir the pot and focus grandma’s attention on the inevitable death panels in her future.

J.D. further observes the likely source of the vigorous opposition to the Heritage Foundation inspired ‘individual mandate’ included in the Patient Protection and Affordable Care Act aka ‘Obamacare’, as a market driven alternative to the Clinton administration’s ‘American Health Security Act of 1993, aka ‘HillaryCare':

In the partisan war sparked by the 2008 election, Republicans conveniently forgot that this was something many of them had supported for years. The only thing wrong with the mandate? Mr. Obama also thought it was a good idea.

All I can say is ‘thanks J.D.’. I now wonder whether Matt Holt was projecting on your future when he tweeted:

Matthew Holt ‏@boltyboy
JD Kleinke’s resignation letter from AEI

SCOTUS Consideration A ‘Pyrrhic Victory’ Regardless of Ruling

By Gregg A. Masters, MPH

Ladies and Gentlemen, start your engines!

A P/Y/R/R/H/I/C victory is defined by Wikipedia as:

(/ˈpɪrɪk/) is a victory with such a devastating cost to the victor that it carries the implication that another such victory will ultimately cause defeat.

An army of professional, neo-professional and outright ‘amateur’, including skin in the game patients and consumers, healthcare insiders, ‘pigs at the trough’ (of $2.8 trillion ‘healthcare market’) channel partners, and a vast stakeholder constituency with ‘interests’ in the outcome of the SCOTUS decision, are minimally scrambling to position themselves for what’s to come, if not attempt to influence the Court’s ultimate ruling.

As noted in a previous post, 75% of Americans believe the SCOTUS process will be influenced by ‘politics’ vs. the ‘legal merits’ of the arguments submitted to the Court. Ergo, the battle has now entered a new phase to shape the national narrative and ultimately position the consumer friendly public perception of ‘the Act’, or as pejoratively tagged, ‘ObamaCare’ by those less inclined to read vs. deploy cute sound bytes for public consumption.

In an updated post, I will supply some credible contextual pieces to support the following claim:

The President has already won the narrative regardless of the Court’s ruling. We are where we are perceptually for political not legal reasons. Yet, the nature of the malady is apolitical, it is fundamental and structural.

Any attempt to rule in whole or in part the Act as ‘unconstitutional’ will face severe narrative “head winds” and political fallout as very popular line item provisions of ACA are repealed or otherwise diluted.

Meanwhile, a tasty morsel of consumption is offered here c/o Chas Roades, Chief Research Officer of The Advisory Board, titled: ‘Five Quick Reactions to the Supreme Court Hearings.’

SCOTUS and the ACA: Day 1

By Gregg A. Masters, MPH

Perhaps the hearing of the new century thus far? The Supreme Court of the United States takes up the challenges submitted with respect to the Patient Protection and Affordable Care Act.

From the social media ‘journalism domain’, two hashtags received the predominant volume of tweets tagged to the event; they include: #SCOTUS, and #ACAhearings (both are partial digital footprints representing the last 50 tweets only, including the accounts reached and impressions generated).

For complete realtime coverage collapsing both #ACAhearings and #SCOTUS hashtags, click here.

Several blogs were tweeting contemporaneous commentary on the proceeding, two notable sources include:

The Wall Street Journal and the SCOTUSblog.

With some color and tea leaves interpretation, check out Dr. Jaan Sidorov’s blog for the bi-partisan common theme extraction on The Disease Management Blog via ‘Showdown at the SCOTUS Corral‘.

Useful context pieces include:

For those of you healthwonk junkies, C-Span is airing the replay of the event here (check for schedule).

Finally, the complete transcript from Day 1 is available here.