With more than $150 million in revenue and 128 physicians, a joint corporation made up of established orthopedic practices allows them to continue operating independently, but with more clout.
More than two dozen independent orthopedic physician practices have joined together to form one of the largest orthopedic groups in the country. With a footprint that spans 32 zip codes in metropolitan Washington D.C., Virginia, and Maryland, 128 physicians, and more than $150 million in revenue, The Centers for Advanced Orthopaedics (CAO), is hoping its size will ensure survival for physicians who do not want to sell their private practice to a hospital.
An expanding orthopedic practice is not news, but the business model CAO has embraced is different than adding physicians into an already existing practice or launching a new practice from the ground up with like-minded doctors. Rather, CAO is a joint corporation that allows established practices to continue operating independently, says Denny Tritinger, executive director of CAO.
"They maintain their own board structure within the group, and their pay structure is the same as it was before," says Tritinger. "This allowed them to feel that this wasn't a merger; this was a combination of practices under one tax ID number, which is a new corporation. But there's a lot more autonomy at the group level."
Being able to maintain independence was a key factor during the formation of the group, says CAO President, Nicholas Grosso, MD, an orthopedic surgeon whose three-location, 14-phyisician group is one of the largest practices within CAO.
"The writing was on the wall," he says, recalling the genesis of CAO three years ago. "We were reading the tea leaves saying, 'We need to get bigger in order to survive in the private practice model.' "
The concept of staying in private practice but forming a single company attracts practices because it offers economies of scale administratively. Already Tritinger says the CAO has already saved on medical malpractice insurance and medical supplies by at least 20 percent. CAO also has leveraged its size with payers, something none of the practices had been able to do on their own.
"They wouldn't negotiate with us, they dictated to us," says Louis Levitt, MD, Secretary Treasurer of CAO. Levitt's practice in Washington D.C. is made up of four "soon to be five" physicians in a single location, and represents the average size of practices that are part of CAO.
Grosso adds that pre-CAO his negotiations with payers were "like David and Goliath," but with 128 physicians behind him, payers were a lot more willing to talk. In fact, CAO negotiated two-year contracts with the major insurers with reimbursement rates that are 10–15 percent higher.
It is ironic that in order to stay in private practice, these physicians have formed a super-size entity—the very thing that hospitals represent and that these independents want to avoid. But Grosso, Tritinger, and Levitt—CAO's executive team—say the arrangement is very different.
For one, CAO has a one-vote-per-practice rule for its board, no matter how big or small the practice. Secondly, if a practice joins CAO, but has second thoughts and wants to back out, it can do so without much hassle.
"When you're getting large groups to form, you're warned not to have an easy 'unwind' agreement, meaning how do you get out of the group once you're in?" says Tritinger. "We knew the benefits of being in would be so overwhelming that we allowed the 'unwind' to be pretty easy … to allow for groups to leave."
There also aren't many strings attached for buy-in. Groups did have to agree to bill under one tax ID number, but physicians weren't required to change their practice management systems (there are 18). The logo and signage has changed to reflect CAO's affiliation, but office managers and secretaries stay the same at each practice, and the business pretty much runs just as it did without CAO.
But with the backing of a corporation, each practice has a louder voice and bigger presence. It's that concept that Levitt says resonates with this group of physicians.
"I spend a lot of my time trying to help groups think bigger than they see themselves as being," says Levitt. "Doctors have never seen themselves as a big company. I give them statistics that we are equivalent to the 60 largest private corporations in the metropolitan Washington area. When they see that … they begin to feel empowered and they see the benefit of the negotiations we had that were never possible before. Those are the wins."
There is currently no "litmus test" for other orthopedic groups wanting to join CAO, but that could change with its development of a Quality Committee they hope will establish best practices and clinical pathways. Grosso says they are trying out the committee process with easy diagnoses such as tennis elbow and sprained ankle, but he's hoping to move into total joint replacements, ACLs, and rotator cuffs soon.
Levitt offers another explanation for not having many barriers to joining CAO. He says it is because asking independent physicians to "conform" is against their philosophy.
"When the institution sets up best practices, I actually believe underlying all of it is, 'How do I save money, and how do I reduce services?'" he says. "One of the reasons we set up as we did is [because] we believe best practices actually improves the quality of healthcare and improves the quality of patient experience, and it's not driven by profit and so much efficiency. I really do believe that the difference between [this and] the hospital model is they do set up obstacles. The owners of this company are all physicians and they, in fact, will set up guidelines that truly benefit the patient and not as obstacles to the practice."
UnitedHealthcare is headed to federal court-ordered arbitration with two doctors groups in Connecticut over the insurer's decision to drop some physicians from its Medicare Advantage network.
A federal appeals court has ordered UnitedHealthcare, the Fairfield County Medical Association, and the Hartford County Medical Association to try to settle their differences over UnitedHealth's decision to drop 2,200 physicians from its Medicare Advantage (MA) network.
The three-judge panel of the 2nd Circuit Court of Appeals issued the order on Tuesday after hearing oral arguments from both sides. The medical associations filed suit in federal court against UnitedHealth claiming the insurer is violating federal law by dropping the physicians without cause and without the ability to appeal United's decision.
"We want the reasons why they are letting doctors go only for MA plans and not other plans," says Mark Thompson, executive director of the Fairfield County Medical Association, one of two plaintiffs. "We want doctors to have opportunity to arbitrate."
A judge issued a temporary restraining order against UnitedHealth in December, ordering it to halt the cuts. The hearing on Tuesday, expedited by the court, was in response to an appeal by UnitedHealth. The three-judge panel left the injunction against UnitedHealth in place, but ordered all parties to the court's Civil Appeals Management Plan, known as CAMP.
"We are pleased that the court recognized the importance of our appeal by expediting its review of the preliminary injunction," said Jessica Pappas, spokeswoman for UnitedHealth.
CAMP is a mediation process in the 2nd Circuit overseen by a court-appointed attorney and typically used before the court hears arguments. It's "unusual" that the court ordered the two sides to CAMP after oral arguments, but this week's hearing was expedited and mediation wasn't realistic, says attorney Roy Breitenbach, who is representing both the Fairfield & Hartford county medical associations.
"Mediation begins next week," says Breitenbach. "CAMP usually lasts about a day. The court-appointed attorney will then decide if it's worth having another session."
If there isn't room for agreement and a settlement seems unlikely, then the two sides will have to wait for the court's ruling, which Breitenbach estimates could be "one or two months."
The court's decisions may have an impact beyond Connecticut. The matter is being watched closely in New York, where the Medical Society of the State of New York has filed suit against the insurer for the same issue—dropping MA providers.
A Narrowing of Networks
UnitedHealth is narrowing its network of providers to deal with the 6.5% MA reimbursement rate reduction last year (and another cut expected this year) that helps pay for the Patient Protection and Affordable Care Act.
"The changes that we and other Medicare Advantage plans are making will bring better health outcomes and more affordable health care coverage to Medicare Advantage members," says Pappas.
"While these changes can be difficult for patients and their doctors, they are necessary to meet rising quality standards, slow the increase in health costs and sustain our plans in an era of Medicare Advantage funding cuts. Our focus remains on supporting our members and helping them access the care they need."
The providers are upset because they claim UnitedHealth's action limits patients' access to care. Beneficiaries are confused over why their longtime doctors are no longer part of their plan.
The issue has drawn in the American Medical Association and America's Health Insurance Plans. The AMA signed a brief in support of Connecticut's move to avert provider reductions, and AHIP sent a letter to the Centers for Medicare & Medicaid Services in November asking the federal agency to resist preventing insurers from cutting some providers loose.
"We are concerned that efforts are underway to encourage CMS to limit efforts by MA plans to establish more focused, high-performance networks …." wrote Karen Ignani, President and CEO of AHIP.
The physicians in Connecticut bolstered their case on Wednesday, the day after the federal appeals court listened to arguments, at a Senate Special Committee on Aging field hearing, which also took place in Connecticut, on the very issue of how Medicare Advantage changes affect consumers.
The committee heard from AHIP officials, a Medicare beneficiary, and Michael Saffir, MD, president of the Connecticut State Medical Society and a practicing physician who UnitedHealth cut from its MA network.
According to Saffir's testimony, "…United[Health] patients have received letters saying that they can switch to another doctor for their care, but when patients call this doctor's office, they are told that they can't be seen, or that they will have to wait weeks or even months for an appointment."
One of Saffir's patients, Richard Johnson, a retiree from Bridgeport, echoed Saffir's concerns, telling the committee he didn't understand why he couldn't see Saffir, who gave him "excellent care" for three years.
Because of the pending court case, UnitedHealth can't technically cut ties with Saffir just yet, but that message hasn't been made clear to beneficiaries like Johnson, who just wants to keep seeing his doctor.
"When you have health problems, you want to stay with the doctors who knows you personally and takes excellent care of you," said Johnson.
A provider of urgent and primary care is shining a spotlight on telemedicine's reach. This is more than just a way to reach patients in rural areas and cut healthcare costs. Early data shows that patients and physicians are finding other reasons to like virtual provider visits.
As a young medical student, Ben Green, MD, was a family physician in training at a typical primary care office. Rushing around to fit in as many as 20-30 patients per day, he realized quickly that this wasn't what he envisioned medicine to be, and became disillusioned.
"Ten minutes was the average face-to-face time with a patient," says Lee who is now one of the medical directors at Carena, a Seattle-based virtual telemedicine provider of urgent and primary care. "I don't feel like that's the right thing for patients in a primary care setting. I have a lot of respect for providers who do that, but for me, it didn't fit with my comfort level."
Green found the kind of care he wanted to provide patients at Carena, which in 2007 was providing traditional house calls 24/7 as a way to reduce emergency department visits for patients covered by Microsoft, Boeing, and other self-insured employers.
"They provided us as a service for employees, as a benefit to save on cost," says Green. Back then, visits at home were lasting an hour, but were up to 20% less expensive than an ED visit.
Not only was there was an immediate reduction in emergency department visits, but the company built on its success and started offering virtual visits via Skype in 2011. Green says virtual visits are 20 minutes, still longer than the traditional primary care or urgent care visit, and he likes it because he understands a patient's needs better.
"Intellectually, it's interesting," says Green. "We rely a lot on history and exploring a condition. In a clinic, I felt hurried and rushed."
Take Two Aspirin and Skype Me in the Morning
Green helps lead a team of 15 providers, each of whom works from home. As long as a contracted patient has a computer, a webcam, and an internet connection, they can visit with someone at Carena 24/7.
Green says the "always open" philosophy is easier to staff than some might think, and he's quick t clarify that 24/7 does not mean on-call.
"It's not that hard to schedule," he says. "You would think, 'How do you schedule that overnight shift?' But we have providers who prefer [it]. They're shifts, they're not on call."
Carena's model of telemedicine is slightly different because health systems, seeing the success Carena had with large employers, came calling. First came Franciscan Health System, an eight-hospital system headquartered in Tacoma, WA. It contracted with Carena in 2011 to provide its virtual visit service to its employees. Last year, the health system expanded its contract to include anyone in its service area for just $35.
"We tested the Franciscan Virtual Urgent Care with our own employees before expanding it to the public, so we know this model of care delivery works," says Cliff Robertson, MD, Franciscan Health System COO.
Green says the price point is close to the average amount of a co-pay and provides access for patients who would otherwise seek care in a more expensive setting.
Franciscan Health is affiliated with Catholic Health Initiatives, which led a $14 million round of investing about a year after Franciscan Health and Carena first began working together. The investment was used to expand to other states, and to date, Carena's virtual visits can be done in five states: Washington, California, Illinois, Missouri, and most recently Kentucky. In that state, another CHI-affiliated system, KentuckyOne Health, has launched the same virtual service that Franciscan Health offers.
With the weight of CHI and major employers behind it, Carena is shining a spotlight on telemedicine's reach. And the model is not just a way to reach patients in rural areas. Green says most of Carena's patients are near major metropolitan areas.
Initial Data Encouraging
"Telemedicine is giving patients care at the right time. It's [for] people who are looking for convenience," says Green. "A lot of patients could be treated over the phone or with a webcam. About 75% of the time when a patient calls us, they will not need to be seen in person. We can escalate patients to an ER, urgent care, or PCP office, but that happens only about 25% of the time."
Green also says that it follows up with patients five days after each virtual visit to find out if they sought care at another setting. He also wants to know if patients have gotten better or worse and whether or not they'd use Carena again. Those metrics have been measured monthly since 2013 – not long, but long enough for Green to see two leading indicators that show Carena is on the right track.
Patient satisfaction, measured after every visit via an automated survey developed by Carena, is high. Green says 98% of patients report they would use Carena again and recommend it to a friend. He also says that based on follow-up calls, patients seek care at a second site less than 5% of the time.
"We're proud of that, but we're waiting to gather more data with a larger sample size so that it is statistically significant."
Work/ Life Balance Opportunities
Telemedicine work is particularly attractive to a younger generation of providers, says Green."The virtual visit provider could help recruit more young physicians to be primary care," he says. "Nowadays you can do anything online. Now medicine is caught up to that and we're enabling that. Doing something new in medicine attracts me and some of the other providers."
Green measures provider satisfaction and says the nurses and physicians are happy. Carena physician Bob Bernstein, MD, says telemedicine offers work/ life balance opportunities.
"For me personally, I'm part of a two-career household with children, and the flexibility and scheduling shifts has been a great boon for my lifestyle" says Bernstein.
Telemedicine has significant reimbursement challenges as well as licensing and credential hurdles that are likely to complicate its universal acceptance for payment. But as health systems like Franciscan Health and KentuckyOne open up access to telemedicine, patients may drive the demand for it. That always tends to speed things up.
The Centers for Medicare & Medicaid Services has eagerly pushed EHRs onto healthcare providers without adequately addressing the risk of fraud, suggests a report from the Office of Inspector General.
Despite the increased focus on fraud and abuse of Medicare and Medicaid, the Office of Inspector General issued a report this month that found contractors for the Centers for Medicare & Medicaid Services need to do more to protect the integrity of electronic health records [PDF].
Among its findings and recommendations, the report notes that health officials have eagerly pushed EHRs without addressing the risk of fraud.
"The Department of Health and Human Services has spent considerable resources to promote widespread adoption of EHRs... It has directed less attention to addressing potential fraud and abuse vulnerabilities in EHRs despite the challenges they pose to the integrity of medical records."
CMS, OIG, the Department of Justice, and other government agencies have invested money and manpower to reduce Medicare and Medicaid fraud and abuse in recent years. In 2010, the Center for Public Integrity was created to align fraud and abuse prevention resources for both the Medicare and Medicaid programs.
Two years later, CMS unveiled a $3.6 million Program Integrity Command Center where investigators, analysts, and policy makers could work together physically in one space. And last year, CMS gave state-run Medicaid Fraud Control Units the power to data mine for fraudulent activity.
Their efforts seem to have paid off with multi-million dollar settlements and near-daily headlines touting the takedown of a fraudulent healthcare provider. According to CMS spokesperson, Rachel Maisler, the most recent figures available show year over year increases in penalties.
"Healthcare fraud prevention and enforcement efforts recovered a record $4.2 billion in taxpayer dollars in Fiscal Year (FY) 2012, up from nearly $4.1 billion in FY 2011, from individuals and companies who attempted to defraud federal health programs serving seniors and taxpayers or who sought payments to which they were not entitled," says Maisler.
But the OIG's new report exposes weaknesses of contractors who either do not understand or realize the risk of fraud that emerging technology carries when not protected properly. According to the OIG's findings, some contractors couldn't tell if a medical record contained too much information, which could lead to overbilling, or if a provider copied and pasted information, which could lead to improper billing.
In addition, OIG said in the report that "…CMS had provided limited guidance to Medicare contractors on EHR fraud vulnerabilities."
CMS primarily uses three types of contractors to help prevent fraudulent claims:
Zone Program Integrity Contractors (ZPICs)
Medicare Administrative Contractors (MACs)
Recovery Audit Contractors (RACs)
Using online questionnaires, OIG officials asked all three types of CMS contractors' questions aimed at determining how each one had modified its anti-fraud efforts for EHRs. A total of 18 CMS contractors participated, and the OIG report notes it had a 100% response rate from all 18.
According the report's findings, ZPICs were able to more often identify when a provider used the copy and paste function, as well as overdocumenting in an EHR. ZPICs are more focused on investigating Medicare fraud than MACs, which are claims processors and payers, and RACs, which identify improper payments; however, all three contractors play an important role in fighting fraud and abuse.
At issue is whether these CMS contractors are able to apply the same type of scrutiny to EHRs as paper claims. With EHR adoption increasing, it's important that these contractors be able find flaws easily, says Riza Dagli, a partner at New Jersey law firm, Brach Eichler. Dagli also previously held positions in New Jersey as the Director of the Medicaid Fraud Control Unit and Acting Insurance Fraud Prosecutor.
"In 2014, there will be more instances where insurers and the government are getting more sophisticated in trying to detect fraud by using electronic means," says Dagli.
The contractors, according the OIG report, want more guidance from CMS on how to identify fraud in an EHR. Specifically, all six ZPICs responded that CMS did not provide help on looking for instances of overdocumentation, electronic signatures, or copied language. The other two types of CMS contractors —MACs and RACs—indicated limited guidance on those three issues from the agency.
The OIG's recommendations were twofold:
Give guidance to contractors on detecting EHR fraud.
Use providers' audit logs to authenticate the medical record.
Audit logs capture time, date, and user information when an EHR is updated; using it to track the changes in the record was one of the recommendations suggested by RTI International, the nonprofit researcher based in North Carolina. The Office of the National Coordinator for Health Information Technology used RTI's expertise to help develop recommendation for EHR data safeguards. Audit logs were high on the list of anti-fraud tools within the EHR, but as the OIG report notes, that ability, as well as others can be bypassed by the user.
In a letter dated November 22, 2013, CMS Administrator Marilyn Tavenner, said that it would "develop appropriate guidelines to ensure the appropriate use of the copy paste feature in EHRs," but she stopped short of agreeing to use audit logs consistently because it would require that contractors receive special training in order to interpret the information.
Dagli believes that when it comes to physicians or hospitals developing their protocols in order to protect against fraud, technology works best when paired with consistent policies.
"When I was in government and private practice, I noted the detection and use and review of data to find red flags does not have to be sophisticated," says Dagli. "With hospital practices, a lot of it is a common sense—periodic review of billing procedures, review of office protocols, a system in place to review patient files. It doesn't require a lot of technology, but it does require management principle."
Kermit Crawford always knew he wanted to be a pharmacist. Now he's President of Walgreens' pharmacy, health and wellness division, and throughout his time at the drugstore giant, he's changed the company from a prescription filler to an important entity in serving medically underserved communities.
This profile was published in the December, 2013 issue of HealthLeaders magazine.
As a child, Kermit Crawford knew he wanted to be a pharmacist. He says he looked up to the man who ran the corner drugstore and knew Kermit and his family by name.
"He knew I was Harry Crawford's son, and I grew up saying, 'That's who I want to be,' " says Crawford, adding that his dream was to run his own drugstore someday.
Mission accomplished. As president of Walgreens' pharmacy, health, and wellness division, Crawford runs more than 8,000 drugstores, with sales last fiscal year of more than $72 billion. And they're not just drugstores—there are nearly 400 walk-in clinics integrated into the stores, which can administer healthcare services, such as vaccines, minor acute care, and back-to-school physicals.
Crawford's rise to be a top executive at one of the country's largest companies by revenue started in 1983, as a pharmacy intern at a Walgreens store in Houston. His subsequent roles as pharmacist, store manager, vice president of store operations, as well as his leadership as executive vice president of the company's pharmacy benefit management services gave him a broad view of a pharmacy during a fundamental shift in healthcare. The experience positioned him to transform Walgreens from prescription filler to now filling a void for medically underserved communities.
"There's clearly a shortage of physicians," says Crawford. "In the communities where we have our healthcare clinics, approximately 40% of the people who come in don't have a primary care physician. Our objective is to support and complement the traditional healthcare system. We believe we're well positioned to serve as an entry point."
Crawford's earliest attempt to modify Walgreens' value position to consumers and patients was in 2006 when the pharmacy chain started offering flu shots at its stores. His confidence was initially shaky.
"When we first began to think about really transforming the role of community pharmacists, our question was, 'Will the American consumer allow pharmacists do more than put pills in a bottle?' "
The other unanswered question Crawford faced at the time was getting pharmacists on board because they needed additional training to become certified immunizers.
"You don't graduate from pharmacy school as a certified immunizer," he says.
Crawford says the additional training appealed only to the early adopters, but two things happened that turned doubters into believers: No.1, consumers responded overwhelmingly to the convenience of getting a flu shot at a store they trusted and shopped; No. 2, the appearance of the H1N1 virus in the United States in 2009.
When the World Health Organization declared H1N1 a pandemic, the need for that vaccine spiked and production was rushed into high gear. Crawford says Walgreens' previous internal buildup to offer more flu shots and the immediate need for the H1N1 vaccine was "luck" that he leveraged into opportunity after the virus threat lessened.
In 2009, Walgreens had 17,000 certified immunizers, a retail footprint big enough to reach a signification portion of the population, and an electronic and logistics system that gave up-to-minute information on H1N1 vaccine inventory. The pandemic that scared consumers and health officials led Crawford to believe Walgreens could successfully expand its reach into healthcare even further, and today, all Walgreens pharmacists (27,000) are certified immunizers and they offer all 17 CDC-approved immunizations in approximately 40 states.
Walgreens also helped change the business side of flu shots with health insurers that didn't always include the flu vaccine as a covered benefit.
"When we first started, about 90% of all flu shots were paid for by cash," says Crawford. "Today, almost 90% are paid for by third-party payers. It's providing access to care that people didn't have before."
Crawford has also helped build a bridge with physicians, hospitals, and health systems so that the pharmacy chain would be viewed as a partner and not a threat. Among its clinical affiliations, Walgreens has collaborative care relations with Orlando Health, a nonprofit system of physician practices and hospitals that serves 1.6 million area residents; Community Health Network, another nonprofit system in central Indiana, and most notably Johns Hopkins Medicine in Baltimore.
Those collaborations build on Crawford's vision for Walgreens' newest strategy, which is managing chronic conditions, such as diabetes, hypertension, high cholesterol, and asthma. As a partner in those systems, Crawford says the objective is population health management and the role is to increase medication adherence, provide testing, and share information with patients' primary care physicians. To him, including chronic care in the business strategy is a "natural extension" of Walgreens' ever-expanding move beyond the pharmacy counter.
"Those patients are coming into our stores significantly more than they are seeing their physicians," says Crawford. "We don't see ourselves as owning that particular patient. We see it as enhancing the experience with a physician. We're helping manage it consistently, versus a patient who has diabetes and goes to their doctor every six months."
Crawford's goal of owning a single community pharmacy in a neighborhood where he can greet patients by name seems quaint and simple now, but he believes that Walgreens' strategy is returning pharmacists back to being the face of what he sees as a front door to healthcare.
"Our real purpose is not putting pills in a bottle. It's the outcome that you get from adherence to your medication," he says. "We've freed up our pharmacists to be out front interacting with patients, and they love it. Pharmacists are at the intersection of all healthcare relationships, and now with more than 70,000 healthcare professionals between our pharmacists and nurse practitioners, we are in a real sweet spot when it comes to healthcare reform and having convenient access to quality, affordable care."
The fate of the loathsome sustainable growth rate formula is one of two big unknowns that will have a large impact on how doctors are reimbursed in the New Year.
It is an easy exercise to begin 2014 by reviewing what happened the previous 12 months and then try to plan for a more appropriate path going forward.
That task, however, is nearly impossible for the tumultuous healthcare industry, especially for physicians. They won't get a true indication of what 2014 and their longer-term future will be like until the end of March, when we hit two key deadlines:
The three-month Sustainable Growth Rate (SGR) patch expires
HIX enrollment ends nationwide
The final number attached to both of these will largely determine how physicians practice in the remaining months of 2014 and beyond.
Last of the SGR Patches?
The bipartisanship on repealing the SGR in 2013 was not surprising. The threat to cut provider reimbursement has long been dogged by both Republicans and Democrats. But there is real hope that the band-aid box used to avert the cuts in years past will finally be put away with a draft proposal that is, in the words of American Medical Association President Ardis Dee Hoven, MD, "bipartisan, bicameral, and … enthusiastically supported".
Unfortunately, there is no agreement on how to pay for the SGR repeal, so the issue has, again, been kicked down the road for Congress to deal with in March. A three-month patch was included in the budget President Barack Obama signed in late December. Instead of a 20% payment reduction, physicians will receive a 0.5% bump for services provided through the end of March. The extension should give Congress enough time to reach an agreement on paying for permanent repeal.
The AMA and other groups are understandably unhappy with yet another so-called "doc fix." American Academy of Family Physicians President, Reid Blackwelder, MD, FAAFP, cites the SGR issue as a major challenge in developing physician-led teams, a trend that holds the promise of improving care, quality, and lowering cost in an era of diminishing primary care access.
An Issue for Medical Students "One of the biggest barriers is the reality that our current system pays for volume," says Blackwelder. "And that has created some significant challenges all over the country in that we're not used to recognizing the value of primary care especially in the setting that physician led teams can bring to the table. So as we transition from paying for volume (fee-for-service) to paying for value, the system we're trying to get away from doesn't have a way for me to easily document and be paid appropriately for it."
He also says that SGR uncertainty contributes to decisions medical students have to make now that affect patients and care in the future.
"When [medical students] are looking at four years down the road or even eight years down the road, we're still at the crossroads of… the SGR. We haven't repealed it, we don't know what the pay-fors will be, and that is actually a very important variable in the next steps this country takes toward the changes that have to happen in healthcare delivery and healthcare payment. The payment reform, incentivizing primary care, these are huge issues for medical student interest into becoming the physician leaders of their team," says Blackwelder.
Will HIX Enrollment Numbers Meet Expectations?
January 1, 2014, marked the beginning of what will be Obamacare's fourth, and arguably, most tested year. The massive volume of regulations included in the Patient Protection and Affordable Care Act has already changed the environment for all of healthcare's key players, but now previously uninsured patients are expecting delivery on the promise of access and care through a health insurance exchange (HIX).
The consumer protections, drastic payer changes, and drug discounts implemented in previous years were the run up to exchanges, which began with a whimper in federally facilitated exchange states (the majority). Exchanges are the most visible component of PPACA, and will become either a beacon or a relic. Critics could point to the troubled start of the exchanges as an indicator of it being the latter. But the real test is the end of March, when HIX enrollment ends.
By March 31, 2014, the Centers for Medicare & Medicaid Services (CMS) has projected 7 million Americans enrolled in the health insurance exchanges. There are numerous reports of how far behind estimations are.
High Anxiety
According to a September letter to the House Ways and Means committee [PDF], by December 2013, the agency believed 3.3 million would have enrolled. The number is close to, 2 million. The technical glitches barring some from enrolling in the federal HIX surely is to blame for the shortfall; however, there are three more months to get to the 7 million mark.
Of that number, 2.7 million people aged 18−34 need to enroll to ensure an adequate risk pool. It's not clear if young people are signing up, as hoped, as expected, and most importantly, as needed.
The effect of the surge of newly insured patients seeking out care is expected to put a strain on physicians, who are already being squeezed out of some insurance networks or being asked to take reduced reimbursement for new patients.
And, if the SGR three-month patch is extended to yet another temporary fix to be dealt with after the 2014 mid-term elections, physician groups may not be able to back burner or recapture their optimism for a permanent repeal in 2015.
The impact of these wildcards on how physicians care for patients and are paid for their services can't be underestimated. During the next three months of intense healthcare transformation, expect some anxiety among physicians.
Nurses and physicians are at odds over who is qualified to take the lead in caring for the expected surge of newly insured Americans that will strain primary care providers.
"We decided in the setting of everybody talking about patient-centered medical homes and transforming healthcare that it would be really important to go out and ask patients what they thought about how their healthcare is provided, says Reid Blackwelder, M.D., president of AAFP. The survey of 1,363 adults was taken in early November.
The American Association of Nurse Practitioners, also curious about what type of care patients want, released its own study last month showing that healthcare consumers are in favor of expanding responsibility for NPs.
The two surveys do not exactly contradict each other, but it does indicate the two sides—nurses and doctors—are digging in their heels over who is qualified to take the lead in caring for the expected surge of newly insured Americans that will strain primary care providers.
According the AAFP survey, only 7% of respondents said they would prefer a nurse practitioner over a physician while 16% indicated no preference and 5% said they didn't know.
The AANP is continuing its lobbying efforts for states to give NPs more authority to prescribe medication, order tests, provide some services for some Medicare patients, and practice without a physician's supervision. Easing scope-of-practice restrictions, would address the shortage of primary care physicians.
AANP Co-president, Ken Miller, in a statement last month, pointed to its own survey results showing that 70% of patients are supportive of NPs having more responsibility, as proof that patients' preferences skew favorably toward NPs.
"These results clearly confirm what we have known anecdotally for years: American healthcare consumers trust NPs and want greater access to the safe, effective services they provide. This is no surprise given that NP patients have health care outcomes that are consistent with those of physicians, and that patients consistently, and increasingly, prefer NPs as their primary health care provider."
Concluding that because Americans support legislation expanding NP authority, they also prefer an NP over a physician is a long leap. But patients, whether faced with access or insurance challenges, have been increasingly turning to NPs and other non-physician providers.
Take a look at the growth in retail clinics at pharmacy chains. What started out as stopping in to pick up a prescription or a flu shot has morphed into a convenience store with a healthcare department.
Now you can see someone (a non-physician provider) about a cold or minor ailment while also picking up a gallon of milk and your prescription and getting a flu shot. Consumers have become increasingly comfortable with this model, but physicians are uncomfortable with the lack of communication among the different parties providing care.
"The reality is that some medical issues can be provided in different locations, [such as] flu shots," says Blackwelder, who is also a practicing family physician in Kingsport, TN.
"The challenge is it goes back to the fragmentation of the system. I don't know, in Kingsport, if my patient has gotten the flu vaccine somewhere else. Part of this transformation to team-based care is making sure we have systems in place so that accessing healthcare is communicated back to my office because again, I'm the physician leader of the team and I want to know what's going on with my patients."
Blackwelder, and the AAFP, for that matter, are not anti-NP. Non-physician providers have an important role to play as part of a team, he says.
"The survey demonstrates patients overwhelmingly want to see physicians… almost three-quarters want to see a physician for their healthcare needs, and nine out of ten want a physician to be a leader of that team, and that's an aspect that's not usually a part of retail clinics," says Blackwelder.
He believes solving the problem of the primary doc shortage will come from payment reform and restructuring the healthcare system to a team-based approach. Doctors have been waiting on the former for nearly 10 years, and the latter is far off.
With more patients and healthcare consumers soon expected to fill providers' waiting rooms, demand may drive preference. And it is likely to happen before the industry is ready.
James Merlino, MD, FACS, FASCRS, has been at the helm of rethinking and redefining patient experience for the Cleveland Clinic since 2009. But, initially, it was a job he didn't want, in a hospital he never wanted to step foot in again.
This profile was published in the December, 2013 issue of HealthLeaders magazine.
Today, James Merlino, MD, FACS, FASCRS, is a go-to leader for hospitals and health systems looking for advice on how to improve their patients' experiences. In addition to his position as chief experience officer for the Cleveland Clinic, he also serves as president and founder of the board for the Association for Patient Experience, an independent nonprofit organization that grew out of discussions at the first Patient Experience Summit sponsored by Cleveland Clinic in 2010 and was established to support healthcare professionals, patients, and their families by improving the patient experience.
He has been at the helm of rethinking and redefining patient experience for the nonprofit academic medical center since 2009. But, initially, it was a job he didn't want, in a hospital he never wanted to step foot in again.
In the summer of 2005, Merlino walked out of the Cleveland Clinic after finishing his fellowship believing the world-renowned hospital was "the worst place in the world for patients." Six months earlier, Merlino's father had died there after a five-day stay related to an ambulatory procedure for bladder cancer. Merlino vowed never to return. Not because of the clinical care—complications that arose with his father's surgery were "nobody's fault," he says; rather, he was upset with the way his father was treated.
"The nurses didn't consistently round on him. His doctor didn't round on him. The communication with the family was terrible," says Merlino, who struggled with the decision to leave because he trained for his specialty in colorectal surgery at the hospital and considered it an honor to be there.
The experience on the other side of healthcare opened his eyes wide. Those five days, he says, redefined how he thought about taking care of patients.
"What I recognized pretty quickly was that we ignored the human side. We ignored the patient. We ignored the family," he says. "We spend hours and hours and lots of money on how to be at the top of our game in healthcare—nurses and physicians are doing continuing education, learning how medicine is evolving—but we spend nearly zero time on how we deliver that care."
Merlino says he returned to the Cleveland Clinic after a five-year hiatus because CEO Delos "Toby" Cosgrove, MD, assumed his title in 2005 and put a renewed focus on patient experience. Merlino says he and Cosgrove were unsure what patient experience meant, but they were both dedicated to making it a priority, something Merlino says is a must to move the needle at any hospital.
"There has to be passion around it," Cosgrove says of improving patient experience. "It's got to be a strategic priority. You have to put it front and center of everything you do in the organization. In terms of who leads it, it's got to come from the top person. It's not a nursing problem; it's not an operations problem. Anything you're doing to develop the culture has to be led by the top people otherwise it won't get the billing it deserves."
Leadership may be in charge of driving home the point that patient experience is core to the strategy at Cleveland Clinic, but Merlino is also quick to point out that it is a shared responsibility among every employee. He says he learned early on in Cleveland Clinic's patient experience journey that aligning staff was central to carrying out his vision of putting patients first. When a 43-year old patient, who was getting ready to leave after an uncomplicated surgery, showed Merlino the journal she'd kept while at the hospital, he was shocked to see how many different people had helped care for her during the five days since when was admitted.
"At the end of this hospital stay, eight physicians had signed the journal, 60 nurses, and so many other people … and she forgot to have three people sign the journal," he says. "What it said to me, in a very, critical stage of this career, was that it's not just the doctor or the nurse, it's everybody. If everybody's not aligned in thinking what we're doing and how they're interfacing with that human being, then we're not going to be successful at delivering what we're supposed to be doing, which is high-quality care."
Merlino believes communication is the fundamental building block of a patient experience that, if it is positive, will have a ripple effect in hospital safety, quality, experience, and value. The multipronged approach defines the Cleveland Clinic's "Patients First" initiative, a personal mission for Merlino, who says helping patients have a good experience is beyond "more smiling" by physicians or gimmicks that attempt to make a patient happier. To Merlino, high quality and safety flow from solid communication with everyone involved in the healthcare of a patient.
"When nurses communicate better at the bedside, medication errors are reduced, falls are reduced, pressure ulcers are reduced," he says. "Those are safety issues. When physicians communicate better with patients and nurses, compliance with treatment goes up and coordination of care improves. That's quality."
Intuitively, hospital leaders know that better communication will lead to better results, but Merlino says staff, including leadership, is tasked so heavily that it is easy to lose perspective, especially in a hospital with a lot of patients. He's not endorsing smaller hospitals, but rather a different approach to who is working in healthcare.
"I think that 90% of people who work in healthcare are there for the right reasons," he says. "I think there's probably a percentage who want to do the right thing, but don't know how to do it, and there's a small percentage of people who don't belong here."
Cutting out the small group of healthcare workers who hinder healthcare efforts is no small task, but identifying deficiencies through training and development around service excellence can help he says.
The other component of patient experience Merlino emphasizes is empathy and compassion for the caregivers, not just the patients. That idea is expressed in an emotional four-minute video Cleveland Clinic produced for its 2012 State of the Clinic Address. With only background music playing, patients, doctors, nurses, and family members are shown moving throughout a hospital setting with just a few words describing them and their situation.
For example, the words, "He has been dreading this appointment. Fears he waited too long," appear next to an elderly man in wheelchair. In another scene, a physician leans against an elevator wall with the words, "Recently Divorced." The video is effective at illustrating the humanity that can get lost between caregivers and patients. It's been downloaded nearly a million times.
"It just reminds me of why this is important," says Merlino. "You have to pay attention to little things because at the end of the day, they're human beings. They come to us at their most vulnerable, terrifying time in their life. We need to deliver care in a much more compassionate way."
The top issues on the Physicians Foundation Watch List for 2014 are related to healthcare reform. Some matters, such as health insurance exchanges, are no longer a theoretical concern, but an emergent and very real one.
Ambiguity around how various provisions of the Patient Protection and Affordable Care Act will be implemented is the core reason behind the top physician concerns on the Physicians Foundation 2014 Watch List.
The group released the list this week.
Last year, the Physicians Foundation used the word "nebulous" to describe the implementation of health insurance exchanges, fee schedules, accountable care organizations, and the Independent Payment Advisory Board. This year, significant uncertainty remains around all of those as well as the PPACA in general.
But heading into 2014 the issues are different because some, like health insurance exchanges, are no longer theory, they are being put into practice.
Last year's concern about exchanges centered on patient access to physicians. While that remains to be seen, it is more of a long-term worry that will take months, maybe years, to play out. Going forward, when HIX enrollees begin making appointments, physicians will face the potential problem of uncompensated care. It's a real issue, and there are two reasons why:
First, reports have surfaced that 1 in 4 files with information from exchange enrollees to insurers were incomplete or wrong. The Washington Post says, "The mistakes include failure to notify insurers about new customers, duplicate enrollments or cancellation notices for the same person, incorrect information about family members, and mistakes involving federal subsidies."
This has physicians worried that HIX patients who show up in their offices wanting services will unknowingly believe they are covered when in fact they are not. This is particularly a concern in states that have federally facilitated exchanges because of all the enrollment glitches and remaining back-end problems on the federal enrollment website.
Second, physicians have genuine reason to be concerned about the 90-day grace period that consumers have under PPACA when they don't pay their premiums. Under the healthcare reform law, certain individuals can't be terminated from coverage for failing to pay for 90 days. Health insurance plans pay claims for the first 30 days, but can deny or pend the claims for the remaining 60 days if the enrollees don't pay.
At issue for physicians is knowing when an enrollee has entered into the 90-day grace period.
"Providers are on the hook for services provided and everybody is very anxious about it," says Tom Holloway, executive vice president of the Missouri State Medical Association (MSMA), which, along with the Missouri Hospital Association, sent its second joint letter to the Center for Medicare & Medicaid Services asking the agency to address the 90-day grace period. CMS responded in September that it would publish "guidance" to establish notice parameters.
"We're waiting to see in the next three weeks if CMS addresses the issue," says Holloway.
So far, the only guidance from CMS remains an April directive to insurers requiring that they notify "all potentially affected providers as soon as is practicable," though that language is not strong enough for Missouri's provider associations or the American Medical Association.
The letter from Missouri's provider organizations states "practicable" doesn't go far enough, saying it is "an undefined standard that is subject to wide interpretation by the health plans."
The remaining four issues on the Physicians Foundation Watch List for 2014 include some other repeats from 2013, such as concern that industry consolidation could lead to monopolization. Again, this fear is a result, though indirectly, of healthcare reform.
As more healthcare organizations merge and/or partner to achieve business efficiencies, small physician practices feel pressure to align with larger groups or organizations because they can't achieve the same value proposition as the bigger guys in town.
The regulatory burden on physicians is listed in the second spot on the organization's watch list for next year. A survey from the Physicians Foundation in 2012 found that physicians spend nearly a quarter of their time on paperwork that isn't clinically related. ICD-10 rules that go into effect in October are listed as a significant source of the extra regulatory burden doctors will incur this year.
Technology is also listed as a watch list item for next year, though it is recognized separately from the regulatory burden, mainly because the issue for physicians is getting electronic health records to be interoperable with other providers.
The final issue for physicians to watch for is health system stalemates, a more direct result of PPACA. Included in this watch list item are several ongoing issues that physicians believed would be addressed in 2013: a resolution to the Sustainable Growth Rate issue, tort reform, and the practice of defensive medicine.
Repeal of the Medicare Sustainable Growth Rate has clear momentum, but with 2013 winding down and the $139 billion price tag still unresolved, physicians could be facing yet another short-term fix.
There is unmistakable momentum in Congress for repealing the Medicare Sustainable Growth Rate (SGR), but as 2013 winds down with Congress eyeing the holiday recess, physicians could be facing the possibility of yet another short-term fix.
Next week, the Senate Finance Committee holds an executive session to mark up the bipartisan draft proposal that would repeal the SGR and replace it with a mix of payment freezes and alternative payment models that reward physicians with bonuses for value and quality rather than volume. The draft proposal was crafted with the House Ways and Means committee and released at the end of October.
Repeal would be a landmark moment for Congress and physician groups, such as the American Medical Association (AMA) and the American College of Physicians (ACP), because it is the first time both chambers and parties agreed on a plan physicians say they can stomach.
"Clearly now we have a trajectory of activity that has never been seen before in the history of our work around the SGR," says AMA President Ardis Dee Hoven, MD. "It started with the House Energy and Commerce committee. They started running the ball down the field, and [House] Ways and Means and [Senate] Finance obviously are picking up on this. It's bipartisan, bicameral, and it's enthusiastically supported."
The proposal isn't without criticism from the AMA or other groups, but with repeal in view the focus is on getting a bill passed. In fact, the AMA and the ACP were among physician and provider groups that met with staff from both the Senate Finance and House Ways and Means committees on Wednesday to find out how the committees responded to their concerns in the draft proposal.
The ACP issued a statement after the meeting saying the newest proposal included two of the organization's suggestions:
Increase funding for performance measure development and validation
Increase funding for physicians in smaller practices—and expands eligibility to smaller practices that fall outside of health professional shortage areas—to assist them in making the transition to VBP programs and other alternative payment models.
However, despite the momentum behind repealing the broken physician payment system, the issue of paying the bill's $139 billion price tag remains.
Ken Perez, a healthcare policy consultant, says the atmosphere that exists in Washington, D.C., will make finding that much money difficult.
"People fight over $10 billion-$20 billion," he says. "Paying for the SGR repeal is the Achilles' heel. Because of the cost and the deficit reduction climate, [Congress] is not going to add to the deficit. It comes back to the numbers. That's the cold, hard reality."
The AMA stays strictly "on the policy side" of things, though Hoven admits the fiscal question of how to pay for the SGR repeal is significant and consistent.
"We hear this every time we visit with members of Congress," she says.
One plan that Perez believes is a realistic possibility is the Medicare Drug Savings Act sponsored by Sen. Jay Rockefeller (D-WV) who is also a member of the Senate Finance committee, which will be marking up the SGR repeal bill next week.
Rockefeller's bill extends discounted drug pricing to the dual-eligible population, saving an estimated $141 billion over 10 years. That makes the SGR fix more than budget-neutral. To drum up backing for the bill, Rockefeller sent letters (PDF) to 65 hospital, physician, and provider groups in November asking for their support.
But the AMA and other groups run the risk of weakening their Congressional clout if they take sides on a bill paying for the SGR, such as Rockefeller's. His bill has zero support among Republicans and is opposed by the powerful pharmaceuticals lobby.
Perez describes the juxtaposition of bipartisanship on a single issue in a session marked by partisan politics as "a day of reckoning" for the SGR.
"If you have Republican and Democratic agreement on the SGR, then the question is, 'Are the Republicans so in favor of that [that] they're willing to go along with a Democratic bill?'"
The answer remains unclear, though with the House set to recess for the holidays the day after the proposal markup, it is unlikely there will be any progress on the bipartisan legislation to end the SGR before the end of the calendar year.
Nicholas Manetto, vice president at the K Street lobbying firm FaegreBD Consulting, says the SGR repeal could move quickly, even with a narrow window. He says it depends on the progress at next week's mark-up meeting.
"The big issue is timing," says Manetto. "At next week's committee meeting, [groups] will be looking to see if the bill gets bogged down with a lot of amendments that make it harder to move."
Any budget offsets to pay for the SGR repeal will not be offered by Senate Finance committee chairman Max Baucus (D-Mont.). His office confirmed it would not identify any offsets prior to next week's hearing.
Talks about a temporary patch have resurfaced because of budgetary and debt ceiling constraints, which raises the hackles of the AMA.
"We've already spent $146 billion to patch over the last 10 years," says Hoven. Repealing the SGR "is the fiscally responsible thing to do, and members of Congress get it. They know it. If they don't repeal it and don't get us to a better model that is going to work, it is going to continue to cost this country billions and billions of dollars, and that's inappropriate."
The chairman of the House Ways and Means committee, Dave Camp (R-Mich), issued a statement Thursday that echoes the AMA’s position of forgoing another temporary workaround:
"SGR is an important issue for physicians and seniors alike who, for over a decade, have been hamstrung by short-term patches instead of the certainty of a permanent solution. The Committee has made real progress on a bipartisan and bicameral bill. If that progress continues, I expect the Committee to consider the legislation before the end of next week."