Friday, April 13, 2012

"You say you want a revolution, well you know, we’d all like to see the plan"

Many skeptical doctors react to the mantra about revolutionizing health care delivery the same way John Lennon did when he wrote these lyrics for the 1968 Beatles anthem. Well you know, they’d all like to see the plan.

Well, you know, this week Medicare released two critical pieces of its plan to revolutionize health care delivery, naming the 27 medical organizations/groups selected for Medicare’s Shared Savings (Accountable Care Organization) program, and the geographic sites chosen for the Comprehensive Primary Care Initiative. (As I blogged in September, the Comprehensive Primary Care Initiative could be a game-changer for primary care, because it will provide sustained financial support and revenue opportunities from Medicare and private payers for participating practices.)

The Innovation Center’s announcements this week effectively counter two pernicious myths about the Affordable Care Act and physicians:

Myth # 1: That the government is trying to put independent physician practices out of business.

Myth # 2: That the government wants to put hospitals in control of physicians.

Actually, a majority of the organizations selected for the Shared Savings Program are "physician-led," as the AMA noted in praising the CMS announcement. But you don’t have to take the AMA’s (or my) word for it: just look at the descriptions from CMS and the physicians themselves of several of the 27 organizations who voluntarily agreed to join the Shared Savings Program:

The Atlantic Integrated Health Network "is one of the oldest self-sustaining physician-led networks in North Carolina."

The Coalition of Athens Area Physicians "represents 300 independent physicians from Athens, Georgia and surrounding counties."

Mississippi Coast Physicians "was founded by community physicians to offer accessible, cost effective and high quality healthcare services to employers and healthcare consumers along the Mississippi Gulf Coast."

North Country Physicians Organization "is a physician organization of 160 physicians" in upstate New York.

The Independent Physicians Network is "a Physician managed and controlled medical delivery network established in 1984" in the Milwaukee, WI community.

Accountable Care Coalition of Texas, Inc. is "an ACO created through a partnership between an affiliation of Independent Physician Associations, medical groups and health systems in the Houston/Beaumont area of Texas and Collaborative Health Systems."

"Owned and managed by physicians, AppleCare Medical ACO partners with more than 800 physicians in the region, as well as major hospitals and medical centers across Southern California to provide access to a full spectrum of facilities for receiving whatever care a patient may require."

"Located in Buffalo, NY, Catholic Medical Partners is a network of more than 900 independent practicing physicians."

"Coastal Carolina Health Care, the ACO’s sole participant, is a physician-owned and operated medical practice with over 50 providers."

There’s many more physician organizations in the 27 ACOs selected by CMS, but I think you get the point: physicians are the ones who will be leading the ACO revolution, through physician-controlled and owned organizations, ranging from tightly integrated group practices to looser coalitions and networks of independent smaller practices. The Comprehensive Primary Care Initiative will soon provide an opportunity for another 500 or so physician practices to lead the transition to the Patient-Centered Medical Home model, supported but not controlled by Medicare and other payers.

Well, you know, this is the way it should be: ACP has long argued that physicians are uniquely qualified to achieve the triple aim of better individual patient health outcomes, better population health, and lower per capita costs—not the government, not the hospitals, and not insurance companies. It is good to see this is Medicare’s plan as well.

Today’s question: What do you think CMS’s announcements say about its view of the role of independent, physician-owned organizations in revolutionizing health care delivery?


Jay Larson MD said...

The thing about myths is that there is some grain of truth in them.

I recently obtained a book from the Medical Group Managers Association (MGMA) with survey results for costs of primary care practices. They broke up each primary care specialty into non-hospital or Integrated Delivery System (IDS) owned (Independent) and hospital or IDS owned groups. The sad part is that there were inadequate numbers of surveys for the independent internal medicine practices to even have the category in the book. They only had 9 surveys completed and 10 were required. Using independent family practice as a surrogate for independent internal medicine, it was easily determined that independent general internists can not generated enough income from Medicare office visits to even cover overhead. Hospital or IDS owned practices using provider based billing were easily able to cover overhead and make a little extra income from Medicare office visits.

As a result of this unfair billing system, about 90% of outpatient general internists are now employed by hospitals or IDS’s. Because good primary care loses revenue for their employer, I have witnessed insane office schedules forced on the internists so they literally do not have the time to practice good primary care.

In an ACO, the incentive is to reduce costs compared to previous years of spending and projected spending. The resultant “savings” is then shared with the ACO. In this scenario, good primary care is then valued and supported.

So according to the Mythbusters…the 2 myths are plausible, it just not known if the government intended it to happen or if they were just didn’t care.

Steve Lucas said...

Adding to Jay’s thought I have always considered physicians to have a 30 year working life compared to a 40 year working life for the general public.

Additionally doctors are saddled with a horrendous student debt, a topic in itself. My personal feeling is schools have a desire to capture some of their students above average income long after they have graduated.

Moving forward doctors have to pay for their debt, care for their family, educate their children and provide for their retirement on a shortened work cycle.

We have to change the system.

Steve Lucas

BDoherty said...

Actually, Jay, although there has been a decline in small independent physician practices and growth in hospital owned practices, the most recent data I can find shows that the vast majoirty of physicians continue to be employed in physician owned, not hospital owned practices, see

I don't doubt that there is a trend to larger practices, and that hospital owned practices are becoming more common. I also don't question the ecpnomic struggles of physicians in smaller independent practices. The point of my blog post is that these trends, which were occuring long before Obamacare became law and continue today, are not by government intent or design to eliminate indepenedent practices--that is the myth part--but a consequence of market forces that have been buffeting small practices for a long time. ACOs and PCMHs offer the potential of helping physician owned practices by opening up funding and revenue--care coordination payments, shared savings--in addition to their usual FFS reimburesment. And Medicare's decision to select mostly physician owned practices for the ACO initiative, rather than hospital owned ones, suggests to me that at least some in government are betting that dcotors who own their own groups will do better than hospitals in increasing access and controlling cost.

Arvind said...

Thank you Bob, for quoting two organizations that have less than zero combined credibility in the minds of independent physicians - the AMA and CMS.

While I agree that the loss of independent IM practices started before Obamacare, this process will rapidly accelerate after the advent of ACOs. The myth that these organizations selected by CMS are "physician-led" is the biggest one you conveniently hide. You also forget what Dr. Emmanuel himself admitted in the now infamous article in the Annals a while ago....that disappearance of private practice of medicine was an inevitable outcome of Obamacare.

Jay Larson MD said...

I meant to say that about 90% of Montana general internists are hospital or IDS employed. 4 years ago it was about 60%. The market forces you commented on are more accutely felt in a rural environment. Intended or not, the average small group or solo practitioners who don't have lucrative ancillary services like diagnostic imaging can not generate enough income from Medicare office visits to cover practice expenses. So as the percentage of Medicare patients in an internist practice goes up, practice viability goes down. At some point the physician faces the options of leaving practice, becoming a hospitalist, or joining a hospital group.

You are correct that this is not due to the Affordable Care Act. This pernicious problem has been present for years. Because of provider based billing, hospitals (which already consume the lion's share of health care dollars)are given even more money from Medicare A if they employ physicians. Also hospital employed physicians tend to have their labs, referrals, and diagnostic imaging stay with in the hospital system, capturing that revenue also.

Steve Lucas said...

You may find this link of interest:

This link is part of a series on the situation in Pittsburgh, one that I find happening in my community and seen in other parts of the country as a business model and eliminating competition takes precedent to medical care.

Steve Lucas