As Massachusetts legislators seek to slow the rise of health care costs, neurologists in the state are likely to be paid in a new way.
Although the proposal is not yet finalized, the Massachusetts Special Commission on the Health Care Payment System plans to recommend that physicians, hospitals, and other providers be organized as accountable care organizations (ACOs) that provide a full range of services for patients in return for a so-called global payment to be divided among the participants.
The recommendation is important to physicians across the US because Massachusetts is widely viewed as a testing ground for health reform concepts being considered by the federal government. The ACO model is a key component of the leading health reform proposals being floated in Congress.
There's going to be a lot of angst among physicians around the country over this, and quite understandably so, Mario E. Motta, MD, president of the Massachusetts Medical Society, told Neurology Today. But we need to be part of the solution, and this is a potential part of the solution.
The ACO model is part of a plan to move away from today's fee-for-service payment system to a global payment system that incentivizes ACOs to provide high quality care at the lowest possible cost.
The term ACO was coined by Elliott Fisher, MD, an internist at the Dartmouth Institute for Health Policy and Clinical Practice. Dr. Fisher and his colleagues are behind the Dartmouth Atlas of Health Care, which for more than three decades has been documenting the tremendous variation in different areas of the country for physician practice patterns, health outcomes, and health care costs. Their research is generally used to make the point that the highest-cost health care in America is not associated with the best health outcomes and, indeed, there is a slightly negative association between cost and quality.
The ACO concept is showing up in many payment reform proposals around the country because many policy analysts believe that hospitals and physicians working together to coordinate a patient's care can strip billions of dollars of waste out of the system.
Figure. DR. ALAN H. ...Image Tools
A few limited pilots of the ACO model are emerging around the country. For example, Blue Cross and Blue Shield of Massachusetts this year signed a global payment contract with a hospital and an independent medical group.
Massachusetts, however, is the first state to actually start moving from theory to practice for its entire health care system. The state's payment reform commission, established by the legislature in 2008, issued its proposed ACO recommendation after a meeting on May 8.
The commission was slated to have its last meeting on July 16 and submit final recommendations to the state legislature after that, according to Jennifer Kritz, the commission's spokeswoman.
The Massachusetts vision is for global payments to provider networks to become the predominant form of reimbursement for health care services. A new independent board would be responsible for guiding implementation and monitoring for the new payment system. In fact, that board would flesh out the details for what an ACO looks like and does.
The AAN Professional Association (AANPA) has not taken a position on the Massachusetts recommendation, according to Joel M. Kaufman, MD, chair of the AANPA Payment Policy Subcommittee.
His own view is that the ACO concept could reward neurologists and other physicians who spend time diagnosing a patient's condition and developing an effective treatment plan that keeps patients from requiring more resource-intensive care.
A lot of the savings in this program is going to come from unnecessary emergency room visits, surgeries that might not be necessary, and fewer hospitalizations, he said. In the long term, we hope this will emphasize the cognitive services that neurologists should be doing anyhow without diminishing physician income. But he, and all other Massachusetts physicians, must wait for more details before they can assess how they might be affected.
Figure. DR. JOEL KAU...Image Tools
Gigi Girgis, MD, a solo neurology practitioner and immediate past president of the Massachusetts Neurological Association, says the ACO concept reminds her of the capitated risk physician-hospital organization (PHO) model, which generally has not been financially successful in Massachusetts. Hospitals and physicians have typically entered into PHO arrangements with the goal of increasing their negotiating power with health plans, only to find that the expense and managerial burdens of keeping the PHO together outweigh the benefits of the additional bargaining power.
Alan H. Kurland, MD, current Massachusetts Neurological Association president, said neurologists in Massachusetts are willing to participate in new health care models and work with other providers to encourage efficiency and coordination of care. However, the administrative burden currently associated with coordination of services - such as the need for prior authorization for imaging and medications - is already onerous, and Dr. Kurland wonders how that would change if an even higher priority is placed on efficiency and coordination.
He also thinks any overhaul of the health care model must include medical malpractice reform to reduce the practice of defensive medicine, which runs up the health care tab.
The Massachusetts payment reform commission has identified medical malpractice reform as one of several so-called complementary strategies to accompany payment changes. Other complementary strategies include administrative simplification, health plan design, and consumer engagement. In doing so, the commission acknowledges that payment reform alone will not solve the state's health care cost crisis. For example, health plan designs that encourage patients to choose cost-effective treatments - such as generics over brand-name drugs, when appropriate - and engaging consumers to curtail unhealthy habits like smoking and overeating are essential to saving the health care system.
The commission's ACO recommendation calls for patients to select a primary care provider to serve as their medical home to be responsible for coordination patient care. But Pushpa Narayanaswami, MD, an instructor in neurology at Harvard Medical School and Beth Israel Deaconess Medical Center, wonders whether that goes far enough. Primary care physicians cannot be expected to coordinate the care of patients with chronic neurological disorders, he said.
The AANPA is urging that the medical home concept, a tenet in many payment reform proposals nationwide, should be broadened beyond primary care providers to include neurologists and some other specialists who are the principal care providers for their patients.
It needs to be recognized that physicians other than those who practice primary care are often the primary care providers for patients with chronic medical illnesses, including several neurologic illnesses, and the role of the neurologist in coordinating care for these patients should be taken into account, said Dr. Narayanaswami, a member of the Massachusetts Neurological Association executive committee.
Dr. Motta said the Massachusetts Medical Society will support any new payment system that is fair and allows physicians the opportunity to succeed. The ACO model would require all physicians to have electronic medical record systems and antitrust laws that prohibit independent physicians from banding together to negotiate contracts, both of which take time.
If they try to implement it without the necessary steps to be successful, then we would have to oppose it because it would basically drive a lot of independent physicians out of practice, he said. If it's done properly and physicians voluntarily band together - 'voluntarily' is a key word here - and want to take part in it, then there is no reason to oppose it. But it has to be introduced gently.•
GUIDANCE ON ACCOUNTABLE CARE ORGANIZATIONS
The Massachusetts Special Commission on the Health Care Payment System's recommendation on accountable health organizations (ACO) suggests:
* Global payments should be adjusted for risk and other factors and incorporate common performance measures.
* Relationships among providers in an ACO could vary, including both ownership and contractual arrangements.
* The transition to a global payment system may take up to five years. During that time, a transitional payment model - shared savings for providing high-quality, low-cost care - would limit the risk to providers, if necessary, while providing financial incentives to ACOs that quickly position themselves to handle global payments.
* Support would be provided to help ACOs form and transition to a new way of life. These would include technical assistance, analysis of claims data for an ACO patient population, and education regarding the new payment system.•
© 2009 AAN Enterprises, Inc.