ACO Update: The Rise of Physician-Led ACOs

In the June issue of Health Affairs a study was published discussing ACO’s and the rise in physician leadership within the organizations.  One of the goals of the Affordable Care Act was to hold physicians more responsible for the care of their patients, by rewarding healthcare providers for improving the quality of care and lowering healthcare costs, the ACO model was born. Slow to start, ACOs have no risen in popularity, with more than 600 Accountable Care Organizations operating throughout the U.S.

“What is an ACO? — An ACO is an accountable care organization made up of doctors, medical groups, hospitals, and other healthcare professionals who work together to deliver high-quality, coordinated care to the patients they serve.”

— Healthcare Partners

There are many various types of ACOs, some are made up of solely primary care providers, others include a variety of specialists and others encompass hospitals and post-acute care providers. However, the study showed that physician-led structures seem to be operating best, meaning they are more likely to have complete care management programs, advanced IT programs and the most satisfied patients.

Former CMS Administrator, Dr. Mark McClellan attributes this to physicians’ personal experience and ability to identify areas for improvement firsthand and measure the impact of their efforts. The Director of the Dartmouth Institute and co-author of this study, Elliott Fisher, MD, MPH stated, “Physicians’ buy-in the payment reform is likely to be critical to the success of the health care reform.” He continued to say; “The findings suggest that physicians are taking seriously their responsibility to lead change in the health care system on behalf of their patients.”

It is certainly pleasing to know that physicians are in support of these changes and are taking on the responsibility of helping to ensure the betterment of care for their patients. As more ACOs are brought together, this report will help providers determine if the path is right for them and consider which structure is best.

To read more about how ACOs originated and to view statistics on the success some organizations have found, check out the Health Affairs blog here: http://healthaffairs.org/blog/2014/05/30/aco-results-what-we-know-so-far/

Catch 22: The Impact of Obamacare on Patients

Meeting with some of the healthcare industry’s best marketers earlier today, we discussed the Affordable Care Act and how it has affected our business.  Obamacare aimed to lower healthcare costs and get more Americans covered with health insurance, but that concept has proven almost too good to be true.  It’s become quite the Catch 22 for some patients.

We have seen a number of patients whose policies were cancelled as of December 31st, leaving them uninsured for months until their new coverage kicks in, which could be as late as March.  So, why are these people getting dropped from their coverage?  It is because their previous coverage, considered catastrophic plans, are no longer recognized by the federal government as suitable insurance. A number of these individuals are simply waiting to enroll in a new plan, or are waiting for government coverage to begin; but a significant amount are opting out of coverage entirely. 

Hence, the Catch 22. While the ACA made it possible for patients with preexisting conditions to get the coverage they need, it has also lead those who had coverage previously, to now go without.

Oh, I know what you’re going to say now. “What about that stinkin’ penalty fee for those rebels who choose to remain uninsured?”  It’s been rumored that Americans might get charged up to $1200 for refusing to pay for coverage, but in reality it is much less.  The penalty is supposed to be $95 or 1% of your annual salary and no one is really sure when the fees will be implemented.  This has led many Americans to think to themselves, “Well, I could pay $3400* for this coverage I don’t need, or I could just pay $95. Yeah, I’ll go with the cheaper option.”

This means the types of patients that practices will see will be a mixed bag of sorts as far as coverage goes.  Some will continue to be self-pay, some will have high-deductible plans and many will opt into government coverage. If your practice hasn’t yet, be sure to reach out to your state, to find out how you can get set up with a network for the Affordable Care Act. That contact information should be listed on your states’ government website.

*This is an estimate based on data found on ObamacareFacts.com

Impact of Supreme Court Decision on Obamacare With Jeff Greenberg, Lead Health Care Counsel for Atlantic Health Solutions

After hearing about the Supreme Court’s decision to uphold President Obama’s Affordable Care Act, we were interested to learn what the historical decision means for healthcare professionals from a legal sense. We spoke with Atlantic Health Solutions’ in-house legal counsel Jeff Greenberg, to hear his predictions for what’s to come.

What does the Supreme Court’s decision to uphold the ACA mean for patients and their quality of care?

There will be a lot more patients in the health care system, as more will be covered with some type of health insurance. Some people have said that the quality of health care provided will suffer, because there will be so many more people with access to care and no increase in providers. Patients will likely see longer wait times and a difference in how quickly they can get appointments. It has been predicted that with more patients gaining access to care, patients could see the same scheduling issues typical of Canadian health care. Also, as lower reimbursement is expected, physicians might be led to be less motivated due to lack of revenue, leading to lower quality care. Fortunately, others say that providers have planned for this influx of volume, so the quality should remain the same.

What does the decision mean for Physicians from a stability and care standpoint?

For physicians, this decision is a double-edged sword. While they will see greater patient volume, at the end of the day, physicians’ reimbursement is going to be lowered even more. Because someone is going to end up paying for these patients’ care, they will be forced to examine other options such as being pushed into the ACO model and bundled payments. Unfortunately, these options do not benefit specialists as much as primary care health care providers.  Many hope that while they will be getting paid less, they might make up for it with volume; the question will be if they can truly make a profit off of patients with government supplied insurance. Physician’s main priority is to provide care to those in need, so many will accept lower paying insurance work, especially if their schedule needs to be filled, but many high quality providers will not be required to accept these patients, and if their schedule is full with high-revenue patients, there might not be room for others.

What can we expect to see happen in regards to hospitals purchasing IDTFs?

A lot more physicians may go work for hospitals as surviving as an outpatient facility is not necessarily easy or secure. Hospitals are also required to take all patients and they always have, so until now they have missed collecting from patients without means. Now they will collect from the government entities and be able to feed revenue to their hospital-owned providers.  This is good for those physicians comfortable with being an extension of the hospital, and fewer will see the benefits of being an IDTF (independent diagnostic testing facility) as oppose to being purchased to some.

What are the implications for patients who opt not to purchase insurance and continue to be uninsured?

If patients don’t purchase insurance, they can continue to be uninsured. Patients that cannot afford care and prefer to remain uninsured will not be penalized, however if you can afford insurance and decide to remain uninsured, you will pay a penalty each year. As for employers who are now required to provide insurance plans to their employees, many are determining whether purchasing the insurance or simply accepting the penalty is more affordable. Many believe that the penalty will be less expensive.  Businesses with less than 50 employees are not required to provide insurance and are presently unaffected by the Affordable Care Act.

So, is this the end of cash-pay?

This is absolutely not the end of self-pay and cash-pay patients will still be demand concierge services and other cash-pay procedures. It is predicted that even after the decision to uphold the ACA, 20 million Americans will remain uninsured and will continue to utilize cash pay options.  It is also important to remember that the mandate is still subject to being repealed.

How do you think this will affect our nation’s healthcare system long term?

Long term, it is too early to tell. If Romney gets elected, he will likely try to overturn the decision immediately and some states will still opt out of Medicaid Expansion, which could cause huge issues.  The conversation about Medicaid Expansion for states is still going on and the end result is still not clear. However, if everything remains as it is I would speculate cost and payment challenges, physicians being forced to work for hospitals/ACO’s, a larger patient population and some limited access to providers, with quality care and price transparency attempted to be driven.

A look at what’s important to each side in politics… Yet there’s nothing about Health Care and the Affordable Care Act Mandate, learn what all the fuss is about in this blog post.