After the Accountable Care Act, physicians face a new world.
By William L. Rich III, MD
The passage of the Patient Protection and
Accountable Care Act (ACA) in 2010 marked
the culmination of the US government's
attempts to broaden citizens' access to care
that were first proposed by President Theodore Roosevelt
in 1911. First, let's examine the state of the nation's health
care in 2010 before the passage of the ACA:
- Medicare Part A was projected to be bankrupt by 2019, and Part B costs were exploding.
- Patients' premiums had doubled since 2001.
- Forty-three million people were uninsured.
- Health care costs reached $2.2 trillion in 2006. They constituted 16% of the gross domestic product, a figure projected to reach 20% by 2017.
- Employer-sponsored premiums increased 85% from 1996 to 2002. In 2008, the average premium was $12,846 (1/3 out of pocket).
- Out-of-pocket costs for a family of four were $16,900 in 2009 and $18,000 in 2010. They were projected to rise to $36,000 in 2019.
- Only 50% of patients received recommended care 10 years after a randomized clinical trial.1
The bipartisan consensus was that payment reform was required in order to extend coverage to the uninsured. There was also agreement on the attributes of payment reform: it should be based on evidence and centered on patients, reimbursement should be based on the value rather than the volume of services, and reform should stimulate the use of health information technology (HIT) and integrated care.
This article reviews some of the ACA programs of interest to the specialty.
CENTER FOR MEDICARE AND MEDICAID INNOVATION
Headed by Richard Gilfillan, MD, the Innovation Center is charged with designing innovative approaches to the delivery and payment of medical services. The goal is to stimulate quality, cut costs, and increase the US population's health. These new models include gain sharing, medical homes, bundled payments, and accountable care organizations (ACOs).
Of most interest to those of us who see glaucoma patients is the bundling initiative. Initially, the Centers for Medicare & Medicaid Services (CMS) will bundle the payments for high-cost hospital services. For example, major joint replacement surgery entails imaging, surgical fees, devices, hospital costs, and short-stay nursing and rehabilitation. A single payment will be made to the facility, and any savings will be shared between the CMS and those who provided the service. This will be extended to yearly payments for chronic conditions like glaucoma. We will be paid a lump sum to provide all services related to that disease. In effect, physicians who provide care economically will profit. There will be outcome and quality metrics that will have to be met to protect the patient.
ACCOUNTABLE CARE ORGANIZATIONS
ACOs will be organized around hospitals or large physician groups, and they must assume total care of a pool of Medicare beneficiaries. There must be at least 5,000 primary care patients. The care must be integrated, use HIT, and meet quality goals. The entity will be paid through a shared savings or risk program.
Hospitals are rapidly hiring physicians in anticipation of this influx of patients and dollars. Forty percent of cardiologists have sold their practices to hospitals, and a similar percentage of all residency graduates have signed employment contracts with hospitals. Fortunately, ophthalmologists are not financially attractive to hospitals, so we will remain independent and develop contracts with our local ACOs. We should never sign an exclusive agreement with a single ACO that will preclude our participation in new entities that enter the market.
VALUE-BASED MODIFIERS
In 2015, the CMS must differentially pay physicians who provide the 20 services with the highest total costs and variation. Physicians will be judged on their ability to achieve quality goals in a cost-efficient manner. There will be software to measure the use of resources for an episode of care. Each doctor will be evaluated on three or four conditions. Those who reach quality and efficiency goals in a risk-adjusted population will be paid a premium on their entire Medicare services the following year.
Let us assume that two physicians achieve quality goals but have large differences in their use of resources. The one who is efficient will receive a bonus in the range of 5% to 10%, whereas the one outside two standard deviations will incur a penalty in the same range.
Glaucoma is one of the top 20 Medicare conditions in terms of cost and variation. All physicians will be paid with this value modifier by 2017.
HEALTH INFORMATION TECHNOLOGY AND QUALITY PROGRAMS: VALUE-BASED PURCHASING
Health-policy mavens believe that the adoption of HIT will increase the coordination of care, decrease medical errors, improve quality, and decrease the duplication of services. Congress adopted a carrot-and-stick approach to stimulate physicians to report their performance on quality measures and to encourage their adoption of HIT. Bonuses are followed by penalties far into the future. Table 1 summarizes the impact of these programs in percent change. Cuts continue beyond 2018.
The impact of value-based purchasing is dramatic. Ophthalmology has had the highest percentage of participation in the Physician Quality Reporting System and electronic prescribing. The criteria to achieve the bonus for adopting electronic health records are difficult for ophthalmologists, but changes in the meaningful-use criteria were strongly advocated by the American Academy of Ophthalmology and adopted in final rule making. This should make attaining the bonus for adopting electronic health records a more realistic goal for practitioners. Table 2 illustrates the impact of value-based purchasing on our profession calculated from our 2009 Medicare revenues.
CONCLUSION
By the year 2015, the payment for glaucoma services will have changed dramatically. We will be paid based on our ability to attain publicly reported quality goals in a cost-effective manner. Efficient physicians will be paid a premium, and those who are less efficient will be penalized. Payers will collect patient-reported outcomes and patient-satisfaction surveys. Despite its unproven benefits, we will use more HIT or pay the price. Coverage and treatment modalities will be subject to comparative effectiveness research. Things will be very different, but we have seen huge changes in our health care system in the past and have always adapted and flourished.
William L. Rich III, MD, is a senior partner at Northern Virginia Ophthalmology Associates. Dr. Rich may be reached at hyasxa@aol.com.
Business planning and flexibility will allow your glaucoma practice to continue to care for patients successfully.
By David G. Godfrey, MD
Early in 2011, health care costs are rising, reimbursement
is decreasing, and the Patient
Protection and Accountable Care Act is coming
to fruition (or not). A qualified practice administrator
may be in charge of preparing for any changes in
financial status that may occur in your practice, but you
still need to have a good understanding of how the flow of
your business operations should work. I encourage you to
be ready for change, to participate in it, and to prepare for
the wild ride to continue for the next couple of years.
The first key to managing your business is being flexible about change, not sticking to “the way we have always done things.” The second requirement is to have a staff and manager ready to adapt to a fast-changing world and quickly evolving technology. Most important, do not fret over making money; it will come if you do a good job and plan appropriately.
Mine is a five-physician glaucoma tertiary referral practice in Dallas-Fort Worth, Texas. It has endured many significant changes during the past few years, some of which could have wreaked havoc on our financial situation. With careful and deliberate planning, however, the practice has remained successful financially, and my colleagues and I feel that we are taking even better care of our patients. The advice in this article reflects important measures adopted by our practice that have contributed to its success.
MAKE YOUR CLINIC AS EFFICIENT AS POSSIBLE
Here are several tips:
- Set standards for what you expect and lead by example. There is no way your staff will be efficient if you, the physician, are not efficient.
- Reduce patients' waiting time. Perform a patient-flow study and analyze where the backups occur in your clinic. Adjust templates and schedules as necessary.
- Try to solidify the general manner in which the clinic flows and the timeline for testing, despite different habits in the practice. This information helps the staff get into a daily routine and reduce mistakes.
- Do not be afraid to ask for help. Hire a consultant, if necessary.
- Pay for extra staffing if it makes financial sense. If having a scribe permits you to see five more patients a day, consider expanding your staff.
- Do the research and purchase an electronic medical/ health record system that is workable. Be ready to make changes as you go. Flexibility is the key.
- Use electronic prescribing as much as you can. Not only does it improve efficiency, but it also impresses patients, reduces errors, and saves you time on the telephone.
PLAN FOR THE YEAR APPROPRIATELY
Construct and adhere to a budget that is prepared before the year starts. Keep track of and manage overtime and incentivize your managers to control overhead. Examine reductions in reimbursement (for example, optic nerve imaging) and evaluate how they will affect your revenue. In our practice, the imaging situation is likely a wash because of the increased reimbursement on the eye codes.
DO NOT LEAVE MONEY ON THE TABLE
Make the switch now to electronic health records so as to enjoy the “meaningful use” bonus. Take advantage of the Physician Quality Reporting Initiative bonus. Start electronic prescribing. Otherwise, you are throwing away money.
Order tests that are needed in an organized fashion. (By no means am I suggesting ordering extra tests.) For example, if you feel most of your glaucoma patients need annual visual fields and nerve imaging, develop a system by which to keep track of when these tests should be ordered. Electronic medical records can do this for you.
COMMUNICATE YOUR PLANS AND PUT THEM INTO ACTION
Compliment all members of your staff and remind them of the good things they do to help you achieve your goals; motivated employees are more productive. Meet monthly with your doctors and weekly with your administrators. Be in constant communication with your clinical staff. Hold everyone accountable for his or her position.
CONCLUSION
With careful planning and execution, you can keep costs under control and increase the bottom line revenue. Unfortunately, doing so requires you to spend extra time away from the practice of medicine. It can be gratifying, however, to know that you can keep your medical standards high while continuing to “squeeze the turnip” (ie, providing revenue sufficient to keep a good standard of living).
Most important, let us always remember that we are in this profession to make life better for our patients. That is our top priority. The money will come if we worry about the right things first and are smart about taking care of our financial resources second.
David G. Godfrey, MD, is in private practice with Glaucoma Associates of Texas and is an associate clinical professor at UT Southwestern Medical School, both in Dallas. Dr. Godfrey may be reached at (214) 360-0000; dgodfrey@glaucomaassociates.com.
Quality of care.
By Paul Lee, MD, JD
As Jaccob Bronowski said, “Knowledge is an
unending adventure at the edge of uncertainty.”
The future becomes less sure the longer
our time horizon. How the quality of care will
be incorporated into the US health care system 20 years
from now is unknowable, but enduring principles can
provide guidance. A lasting tenet is that any successful
economic system delivers more value over time, defined
as the benefit per unit cost. One of the most prominent
notions today is value-based purchasing for health care
and health care insurance.1 Value can be augmented by
increasing benefit (quality), decreasing cost, or both.
Regardless of reforms in health care financing, we
should be able to anticipate greater value in our health
care system. As clinicians, we thus need to understand
what quality is and how we can characterize and measure
it as a benefit.
UNDERSTANDING AND MEASURING QUALITY
In the Donabedian framework that underlies all current systems related to the quality of care, quality can be conceptualized as having three specific domains. The first, structure, is to set up the system to maximize desirable features. The second, process, is doing the right thing at the right time. The third, outcomes, is the result of care and generally what most people mean when they talk about quality.2-4 A less-appreciated element of quality is the patient's experience, traditionally defined as satisfaction but today encompassing the whole physician-patient interaction from the patient's perspective (sometimes referred to as part of a larger framework of patient-centered care).
In the context of glaucoma, structural quality can be assessed by the availability of essential technology such as automated field perimeters, four-mirror gonioscopes, and corneal pachymeters to measure corneal thickness. At another level, it can be described by the availability of trained subspecialists in glaucoma or the range of available surgical options to provide the appropriate care for patients with different severities of disease. In terms of process, quality can easily be measured by adherence to practice patterns such as the AAO's Preferred Practice Patterns.5 The outcomes of care include traditional measures such as visual field loss or IOP control, an intermediate outcome relative to the ultimate result of visual loss. Outcomes, however, can also include parameters such as costs, cost-effectiveness, patient-reported functioning, and nerve fiber layer anatomy.4
That said, measuring outcomes is fraught with important considerations that any fair system needs to address explicitly.2 The relative severity of disease in a given doctor's patients compared with another's, the impact of socioeconomic disparities in patient populations, ethnic differences in disease prognoses, the ability of patients to adhere to treatment, and many other factors make it necessary to “risk adjust” outcomes. Even the best risk-adjustment systems, however, do not explain all of the variance in results; in many models, less than half the variance is explained by the variables included in the analyses. Ideally, systems that directly affect the livelihood of physicians and the availability of care should explicitly state the risk-adjustment systems used and how they perform, and their use should be guided by the performance characteristics of those systems. Even more fundamentally, there should be some assessment of the accuracy of the diagnoses used for analytical purposes, since it is possible that a worse doctor may have better performance scores, particularly if he or she misdiagnoses normal patients as having disease.6
RELEVANCE
The considerations described in this article are particularly important today, because entities such as the National Quality Forum and the Centers for Medicare & Medicaid Services (CMS) have stated that only outcomes measures are likely to be welcome in the future. For that reason, continued engagement by specialty and subspecialty organizations is critical to maximizing the fairness and accountability of measures of quality. Further, there is a growing push to include more robust measures of quality in virtually every aspect of professional eye care, from medical licensure to hospital and surgical credentialing to board certification. In addition, payors have started to make data on individual providers' quality and costs publicly available; such disclosure of performance will only grow as the movement to increase accountability and reduce the trajectory of rising costs gains momentum from both political parties.
CONCLUSION
As we move forward, as practitioners, we should include all externally mandated measures (especially those of CMS) in regular assessments of our practices' performance, such as those required by meaningful use,7 the Patient Quality Reporting System, and new announcements from the CMS and other payors. Moreover, indicators related to activities for board-certification maintenance as well as to credentialing and institutional needs (department, hospital, practice, or ambulatory surgery center) must be included in practice planning. The need for these measures will, in turn, affect our ability as well as our practices' to maintain certain practice models. As more centralized reporting becomes necessary, pressures will mount to form larger groups in many areas in order to economize with efficiencies of scale. In the future, it is likely that efforts underway to increase accountability for quality performance will lead to additional changes in practice structures and patterns.
Paul Lee, MD, JD, is the James Pitzer Gills III MD and Joy Gills professor of ophthalmology and vice-chairman of the Department of Ophthalmology at Duke University in Durham, North Carolina. Dr. Lee may be reached at (919) 681-2793; paul.lee@duke.edu.
