physician leader perspective of aco transition scott d. hayworth, md, facog president and ceo mount...
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Physician Leader Perspective of ACO Transition
Scott D. Hayworth, MD, FACOGPresident and CEO
Mount Kisco Medical Group, PC
• Multi-specialty group practice founded in 1946 and servicing Westchester, Dutchess and Putnam Counties in NYS
• 300 primary care and specialty physicians, 25 office locations servicing 300,000 patients
Mount Kisco Medical Group, PC
Mount Kisco Medical Group, PC
• Affiliated with 4 local community hospitals and academic affiliation with Massachusetts General Hospital
• Practice Data:o 760,000 patient visitso 2 million lab tests, 125K imaging testso $425 million in gross revenue• Recently implemented NextGen EMR; 3rd EMR in
over 15 years
Current Trends in Physician Practices• Consolidation of small
groups into larger group practices
• Acquisition of medical groups by hospitals & integrated delivery systems
• Imperative to capture market share
Current Trends in Physician Practices
• Risk-based contracting with payers• Pay for performance growing as adjunct to
usual payment • Blurring of roles between payers and
providers, i.e. groups become insurance plans and insurance companies are buying groups
Accountable Care Organizations(ACO)
• Established by federal government under Medical Shared Savings Program created by Section 3022 of Health Care Reform Law
• Initial guidelines published March 31, 2011
• Final guidelines published October 20,2011
Accountable Care Organizations• Definition: voluntary groups of physicians,
hospitals, and other health care providers willing to assume responsibility for care of a clearly defined population of eligible beneficiaries attributed to them on the basis of patient’s use of primary care services
Accountable Care Organizations
3 Types• Medicare • Commercial• Medicaid
Accountable Care Coalition of Mount Kisco (ACCMK)
• Signed “upside only” shared-risk contract with CMS in April, 2012
• Established partnership with Universal American to provide consulting services through Collaborative Health Systems, a wholly owned subsidiary
• Currently 14,000 lives in the ACO
Collaborative Health Systems (CHC)
• Facilitated key management committees• Provided requisite provider training• Established compliance program• Identified patient cohort and sent out “opt
out” letters to patients• Will provide necessary analytics to assist with
managing population
Care Management Services
• Staffing: PT Medical Director and six FTE care coordination staff
• Activities: - Identify high risk patients through CHC
analytics, hospital discharge/ER reports, PCP referrals, personal health assessments
- Link with affiliated hospital discharge planning departments
Care Management Services
• Work with PCP offices to provide services to high risk patients and insure appropriate follow up visits
• Telephonic follow up with patients• Facilitate appropriate point of service care:
home care, transitional care, etc.• Communicate with hospitalists re: discharge
planning
Challenges to Group Adoption of ACO Model
• Understanding the definition of an “ACO patient”
• Explaining “opt out” process to patients• Integrating ACO care management staff with
existing physician nursing staff• Involving physician staff in “transition of care”
process post-hospital discharge
Challenges to Group Adoption of ACO Model (cont’d)
• Achieving “buy-in” to maximizing quality metrics, i.e. “standardization of care”
• Encouraging referrals from physicians to case management staff
• Integrating case management notes into EMR• Distribution of savings to group participants• Making move from “volume” to “value”
“Brave New World” of Value
Volume Based• Payment: Fee For Service• Incentives: Volume• Focus: Acute episodes• Role of provider: single
episodes• Information: retrospective
Value Based• Outcomes• Value• Populations• Care Continuum
• Real-time & predictible
How Should Groups React to “Value Proposition”?
• Develop integrated care models using care managers partnering with providers
• Develop or contract with continuum of care providers: home health, SNF’s, etc.
• Optimize radiology and lab test ordering• Create patient-centered medical homes at
primary care office sites
How Should Groups React to “Value” Proposition
• Standardize care: evidence-based guidelines• Rationalize/consolidate clinical assets• Build Care Management Department with
imbedded case managers, transitions of care coordinators and telephonic outreach
What Do I Do If I Am In a Small Group?
Ethical Issues Associated with ACO
• Patient autonomy v. referral patterns within the ACO, i.e., leakage
• Unintended financial effects re: market share growth of ACO
• Distribution of savings fairly• Where to focus quality improvement efforts,
i.e. those closest or furthest from targets?• Potential loss of physician autonomy
Ethical Issues Associated with ACO
• Impact on risk management of reduced resource utilization
• Role of beneficiary on the ACO Governance Board: independence and strength of the role
• Comfort level with ACO referral patterns
Summary Points
• ACO’s with shared risk will be a significant venue for reimbursement in the future
• Medical groups must prepare for the transition from “pay for volume” to “pay for value” in the near future
• Group practices will need to standardize care, incorporate care coordination and respond to pay for performance metrics
• Medical groups must be prepared to address the ethical issues associated with ACO adoption
Thank you…questions?