Accounting for Independent Physicians
Philip Betbeze, for HealthLeaders Media , June 13, 2011
Innovative and forward-thinking organizations haven’t been waiting around for the government to act before transforming the way they deliver care. Yet even with proposed regulations out for accountable care organizations, many organizations are still taking a wait-and-see approach. But Summa Health System’s top executives and a cadre of independent physicians don’t see the value in waiting, and have been working diligently to create the structures and systems required to deliver care that is better and cheaper—in short, an ACO.In many ways, Summa possesses the ideal infrastructure for an ACO. It has a health plan with 155,000 lives, 25,000 of whom are enrolled in the Medicare Advantage plan. Although it has contracts with other insurers, ownership of the health plan allows for a true closed loop between the payer and the provider. Summa has most of the pieces of the continuum of care, from urgent care clinics to a Level I trauma unit in a full-service acute care hospital. It also has much of what’s in between, including long-term care. Finally, Summa has a CEO who sees ACO creation as a strategic imperative. But despite all those advantages, the health system still has a formidable challenge in integrating physicians in the community who are not employed. Its staff numbers more than 1,000 physicians, only 255 of whom are direct employees.
“Summa has the health system that fits this model,” says Tom Strauss, the president and CEO of the seven-hospital, Akron, OH-based system. “The health system physicians, both employed and affiliated, and SummaCare [health plan], allows us to move toward ACOs. It’s a sweet spot for us because not many in our state have this ability.”
More than 700 of Summa’s physician staff are independents, and their participation is essential to its ACO project. That’s where many hospitals and health systems see substantial hurdles to attaining the continuity of care and shared responsibility for patient outcomes that is central to the ACO concept.
Strauss sees significant hurdles there as well, but his leadership team is actively taking on the challenge.
“Creating this ACO is my No. 1 objective for this year and next,” he says. “We want as many physicians as possible to join our model. If you stay with the old system, your payment is just going to be ratcheted down.”
The ACO, at this point, focuses only on Medicare Advantage patients in order to test and figure out what tactics work best to improve a population’s overall health. Strauss explains that the ACO’s 11,000 patients have an existing relationship with both Summa and the physician practices in the ACO. The ACO essentially is paid under a capitated model that brings in about $80 million in revenue per year, regardless of the interventions the population may need over that time period.
“So we’re at risk both clinically and fiscally for the health of those members,” he says. “As we generate appropriate savings based on quality and HEDIS measures, we can create pools of savings to incent physicians.”
A new structure
One of Strauss’s first priorities in creating an ACO was hiring someone who got the concept and who had a track record of building an accountable care model. Michael Hillman, MD, was that person for Strauss. Hillman is Summa’s chief medical and quality officer, and his key role is in reaching out to independent physicians in Summa’s service area to encourage them to join the ACO. A neurologist, Hillman developed his accountable care skills during his years at Marshfield (WI) Clinic, an all-ambulatory health system that also owns a health plan.
“We designed Marshfield’s group practice initiative with CMS,” he says, “before anyone really knew what an ACO was. It made economic as well as patient sense.”
Marshfield’s initiative included an EMR and call center strategy that provided patients 24-hour access to care. They might not be able to see their doctor at all hours, but the point was to provide expert medical advice to patients with severe or chronic illnesses in part in an attempt to save them unnecessary and—costly—trips to the emergency department. It evolved into a program that reduced hospitalizations for all causes by about 30%, according to a study funded by the Agency for Healthcare Research and Quality.
That experience gave Hillman a certain credibility with Akron-area physicians when he arrived in September 2009, but a formidable challenge was alleviating fear from independent community practices about working as a partner with a hospital-centric system.
“They are competing with each other, and us, in many ways,” he says of independent physicians. “And it’s tough to get them to actually believe in something other than their day-to-day survival.”
Hillman started with transparency. Summa chose as initial partners the top five largest primary care groups in the area that were offering the best quality and good leadership, and brought them in immediately to explain Summa’s vision and the critical nature of their participation in the ACO. The goal was to align providers along the continuum of care to systematically anticipate and address the health needs of the population they serve.
With representatives from each group, the ACO board set up four committees to help with project management: an IT group, a care model group, a finance group, and a physician network group.
Summa invested in call centers. It invested in IT with the idea that it would yield not just an EMR for the doctors in the ACO, but would offer tools that help identify patient populations. But the affiliated physicians, he says, also needed “skin in the game” to galvanize their investment in the ACO’s goals of achieving better and less costly patient care.
“This is not all funded by Summa,” Hillman says. “We had to develop a way where physicians really learn how to take risk—and not just insurance risk.”
As their contribution, affiliated doctors in the ACO give a small percentage of their fee-for-service revenue to defray the administrative costs of the ACO.
“Convincing these independent physicians to commit to it has been a challenging thing,” he says, “but it has to be done because the most dangerous part of healthcare is the handoffs.”
Cautious optimism
Rodney Ison, MD, was elected as the chairman of the ACO board. A family doctor with 28-physician, 10-location Community Health Care Inc., in Akron, he says the ACO developed out of what was originally a physician–hospital organization tasked with helping area physicians with their technology needs.
The ACO represented a more formal structure with clearly articulated goals about shared risk, savings, and patient care goals. But he was cautious at first, as were many of his colleagues who were involved in the discussions.
“We had been looking at the medical home model, but no one’s supporting that financially in our area,” he says.
With Summa’s financial backing, the ACO was a better alternative. “This takes collaboration to a whole new level, and was the right step for patients.”
That focus on the patient has helped with framing the collaboration around a “moral imperative” to do what’s best for the patient, which Ison says Hillman is fond of bringing up.
Since forming the ACO earlier this year, the groups and Summa have worked on bringing best practices to all from a variety of techniques each has implemented over the years to better treat high-risk patients. For example, Ison’s practice has implemented evening hours and sophisticated EMR data-mining techniques to monitor patients who have congestive heart failure or diabetes.
“We’ve been working on these for a long time at our organization, but with the ACO’s help we will broaden them,” he says. “My board actually is considering opening Sunday hours because it prevents readmissions.”
Though Ison concedes there is a very small financial risk from affiliated physicians to support the ACO, in the long run those risks could be substantial through the ACO’s plans to contract with insurers as a single entity.
However, there are other risks besides the financial.
“The bigger risk is you’re aligning with a single partner in the market more openly than in the past,” he says. “That will lead to some potential retaliation from others in the market who don’t want to see that level of collaboration. Another risk is it fails and you’ve spent a lot of time and effort and risked your reputation. So many people say this can’t be done in a nonintegrated system. We’ve got a long way to go, but so far it’s working pretty smoothly.”
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