Accountable Care, Affordable Care Act, Triple Aim

Hey, Remember IPAs, PPOs and TPAs?

by Gregg A. Masters, MPHAAPAN 2016 Forum

In a last man standing of sorts in what some may call the legacy and aging infrastructure of the ‘vote with your feet‘ PPO industry including it’s allies in the TPA (Third Party Administrator) space, the American Association of Payors, Administrators and Networks (AAPAN) is holding its 2016 Annual Forum in my former hometown of Dana Point, California at the Ritz Carlton, Laguna Nigel.

The mission of American Association of Payors, Administrators and Networks (AAPAN) notes it provides:

….the platform for the unification of payers, administrators and networks and the ability for a stronger collective public policy voice to enhance the position of each stakeholder as essential to the future of affordable healthcare delivery options centered on patient choice.

According to its subsidiary the American Association of Preferred Provider Organizations (AAPPO) the ‘PPO chassis’ accounts for:

An estimated 200 million Americans, or about 81 percent of all Americans with health care coverage (excluding those receiving military health care), receive their health care services through a PPO delivery system.

A history of managed care As a ‘collaborative association’ on behalf of the PPO industry initially positioned as a complementary (if not an HMO-lite) alternative to the more aggressive gatekeeper HMO option (see history of managed care era in graphic), AAPAN has a track record of success from advocacy, to thought leadership and operating best practices and solutions.

The Association aligns two potentially silo-ed (though synergistic) interests: the American Association of PPOs (AAPPO), the Third Party Administrators Association of America (TPAAA). For an issue brief on valued based healthcare and the need for network standards, see: The Need to Standardize Network Value-Based Purchasing Requirements.

So one might say, though a larger share of the employer based insurance market remains in a PPO type (vs. HMO) benefit plan design their role and industry leadership visibility may have been somewhat muted (if not, absent from the health reform narrative) since the rollout of the Affordable Care Act (ACA) and it’s emphasis on Accountable Care Organizations (ACOs) dominated the reform narrative.

AAPAN intends to raise this profile and remind many in the space that PPOs, TPAs and even IPAs (Independent Practice Associations) have a material and meaningful role to play in enabling the triple aim even if their initiatives aren’t tagged ACOs per se.

The 2016 Forum hashtag is #AAPAN16, and the digital dashboard is here. Do follow the tweetstream for thought leadership insights from key industry executives, entrepreneurs and change agents. See keynotes and sessions here, including Health Innovation Media co-host, Douglas Goldstein aka @eFuturist.

The program schedule is here.



Summer Doldrums in ‘Taming The Beast’? Hardly!

We’ve been on somewhat of a ‘hiatus’ from the health reform, accountable care and health care enterprise organizational and market positioning conversation, yet the industry is not standing still.

A few notable announcements will highlight some of the quiet if not ‘semi-stealth’ movement underway while the CMS/provider community regulatory fermentation process plays out. Congrats to Dr. Wayne Pan, et al!

Anthem Blue Cross and Individual Practice Association Medical Group of Santa Clara County to Form First ACO for PPO Members in Northern California

Agreement includes direct contract with an IPA for Anthem Prudent Buyer Population 

WOODLAND HILLS, Calif. and FOSTER CITY, Calif., Aug. 10, 2011 /PRNewswire/ — Anthem Blue Cross and Individual Practice Association Medical Group of Santa Clara County (SCCIPA) today announced they are launching an Accountable Care Organization (ACO) program to provide coordinated, seamless medical care to Anthem PPO members in the Silicon Valley. The ACO is the first of its kind in Northern California, and includes a direct contract agreement between Anthem and the IPA.

Anthem Blue Cross expects that initially tens of thousands of PPO members whose physicians participate in the SCCIPA network will benefit from the care coordination, chronic disease management, increased provider accountability, and improved availability of medical information for patient decision-making that are hallmarks of the ACO model. SCCIPA’s network includes 284 primary care physicians, 550 specialists and ten acute care facilities throughout Santa Clara County.  Members will be included in the program if they have received the majority of their medical care from these same treating physicians in the past and where there is already a strong physician/patient relationship.

“We are pleased to expand our relationship with SCCIPA to include both a direct provider group contract and the launch of an ACO model,” said Pam Kehaly, president of Anthem Blue Cross. “Individuals who receive coordinated, patient-centered care through a collaborative partnership with their physicians can better navigate their options and more effectively manage their health care needs. SCCIPA’s investment in its innovative coordinated care IT platform and demonstrated quality clinical and administrative management performance across its electronically integrated network, make them an ideal partner to offer our first ACO model in northern California.”

J. Kersten Kraft, MD, a practicing urologist and president of SCCIPA notes, “We continue to… (read complete article here).

[Editors Note: This is a rather signifiant announcement as it pertains to the commercial market via a ‘PPO’ book of business, or alternatively known as ‘HMO lite’. To make ‘accountable care’ inroads into this population will clearly create value for the payor, participation providers, as well as covered health plan members. One to watch!]

The American Medical Association chimed in with:

Implementing Accountable Care Organizations: Ten Potential Mistakes and How to Learn From Them

By Sara Singer, PhD, MBA; Stephen M. Shortell, PhD, MPH, MBA

Achieving the triple aims—higher-quality patient-centered care, improving population health, and moderating per capita costs—will require fundamental change in the US health care system.1 Accountable care organizations (ACOs) as outlined in the Affordable Care Act represent an early initiative in restructuring health care.2 Accountable care organizations accept responsibility for the cost and quality of care for defined patient populations. Under the Medicare shared savings program, ACOs will face expenditure targets based on their previous 3 years of Medicare Part A and Part B experience.3 Qualifying organizations can choose between 2 risk arrangements. The first involves upside potential from shared savings in the first 2 years, adding downside risk only in the third year of operation. In the second arrangement, organizations share a greater percentage of the savings but are responsible for downside risk from the beginning. The shared savings program will require organizations to conduct quality improvement initiatives, care coordination, performance measurement, and public reporting.

To succeed, organizations contemplating participation in ACOs will need to develop and improve organizational capabilities necessary to meet program requirements. Hospitals and physician organizations will need to forge new relationships and take on new responsibilities. Success will require adaptation and change, learning quickly from mistakes, and developing an ability to transfer knowledge among participating entities. This will require ACOs to become learning organizations that can comprehend and expand what works and move to correct things that do not.4

In this commentary, we discuss 10 potential mistakes that organizations may experience in becoming ACOs whether with Centers for Medicare & Medicaid Services (CMS) payment or working with private payers. To read the complete article, click here.

There is more, but for now these two items at the top of my list!

Also, on ACO Watch: A Mid-Week Review, Wednesday August 17th, 2011 at 11AM Pacific and 2PM Eastern, my special guest commentator is Justin T. Barnes, Vice President of Greenway Medical Technologies. We’ll discuss accountable care and enabling health information technology,  key trends and updates.

Please consider joining us.