February 21, 2017
February 21, 2017
Originally published at: www.physicianspractice.com
For many physicians and practices, their introduction to “value based” contracts will come in the form of understanding Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). However, if you are getting paid on a “pay for performance” basis from the commercial payers, you are already participating in value-based contracts.
The “value-based purchasing” model evolved from work done by the University of Michigan Center for Value-Based Insurance Design, a non-profit that was established in 2005 to develop, evaluate, and promote value-based insurance initiatives. Their initial research studied the impact of healthcare costs and paying for care “events,” rather than outcomes. Eventually value-based reform helped to shape the Patient Protection and Affordable Care Act (the ACA) signed into law in 2010.
So what does all that mean to you? The bottom line is that “payers” — insurance companies, employers, and now consumers themselves — are looking for more value for the money they spend on healthcare.
September 1, 2016
July 11, 2016
October 30, 2015
Originally published at: http://www.physicianspractice.com/payers/physicians-contract-self-funded-employers
Some medical practices are cutting out insurance companies and providing services directly to employers (direct care), thereby reducing overhead and cost to patients.
First, let me define what is meant by “direct care.” Similar to charging patients cash for your services, the difference here is that you are charging employers directly for services delivered to their employees. There is no middle-man insurance company; simply two parties exchanging cash for services. So “direct” here means that you, the physician, are selling your services directly to the purchaser of healthcare, the employer.
This is not as novel an approach as you might think. Employers, particularly those that are “self-funded” (meaning those that carry the financial risk for employee claims rather than the insurance company), have already been investing in medical tourism for years. They contract directly with providers of care overseas (or through medical tourism companies) and send employees for such services as bariatric surgery, knee and hip replacements, and hernia operations, which are far less expensive than here in the United States. Even some insurers, like Anthem Blue Cross and Blue Shield, are exploring the idea of including medical tourism as a part of their coverage.
September 3, 2015
What is PCSP?
Patient-Centered Specialty Practice (PCSP) is a recognition program from the National Committee for Quality Assurance (NCQA) that went into effect in 2013. The PCSP program was designed in many ways to complement the success of NCQA’s Patient-Centered Medical Home (PCMH) program and expand its reach. The goal of the program is to encourage excellent care coordination by specialty practices in the outpatient setting, leading to less duplication of procedures and fewer hospitalizations.
Much like the PCMH program, the PCSP program focuses on proactive coordination of care, information sharing among clinicians involved in a patient’s care, and a centering of care around the patient (versus around the care setting).
According to the NCQA, “Specialists who achieve NCQA PCSP Recognition will show purchasers (consumers, health plans, employers and government agencies) that they have undergone a rigorous and independent review to assess their capabilities and commitment to excellence in sharing and using information to coordinate care.” What this means practically is that practices that undergo the process will be better placed to meet the challenges of the marketplace.
August 27, 2015
Patient education programs have been around for a long time, but typically these programs have been geared toward only the chronically ill and those that needed extensive management. In this era of the Patient-Centered Medical Home patients and insurers are looking more to physician practices to provide effective patient education in all aspects of their care. In fact, many insurance companies are actively measuring physicians’ performance on quality metrics. Current accountable care models factor in patient utilization of emergency rooms, hospital visits, and prescriptions, and attribute that cost to the patient’s primary-care doctor, which may also include specialties such as cardiology.
So what does this mean to your practice? With more accountability comes the need to manage patient populations more effectively to be able to hold the line on costs. If you are not doing a good job in actively engaging patients to “self manage” their own care, and utilizing lower-cost opportunities for managing your patients’ care, then you may soon find yourself failing to achieve a targeted level of care and cost utilization, and that will cost you money.
July 2, 2015
Many physicians are by now familiar with such terms as “clinically integrated networks” (also known as CINs), but a slightly different model is beginning to emerge as independent practices resist being swallowed up by hospital systems, and physician organizations become more savvy. You can think of this model as a hybrid between the “super group” (or clinically integrated practice) model and the more familiar hospital-based offering whereby care coordination and data is managed centrally there. Rather, these independent integrated networks (IINs) are being driven by independent physician organizations, coalitions, and alliances between physicians themselves.
What is “clinical integration” anyway?
The Department of Justice and the FTC define clinical integration as an active and ongoing program to evaluate and modify practice patterns by the CIN’s physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality. Generally, the FTC considers a program to be clinically integrated if it performs the following:
1. Establishes mechanisms to monitor and control utilization of healthcare services that are designed to control costs and ensure quality of care;
2. Selectively chooses CIN physicians who are likely to further these efficiency objectives; and
3. Utilizes investment of significant capital, both monetary and human, in the necessary infrastructure and capability to realize the claimed efficiencies.
April 24, 2015
By learning about ongoing pediatric medical home initiatives in your state, pediatric clinicians, practices, state Title V agencies, American Academy of Pediatrics chapters, and others can gain insights on how to integrate their work and coordinate efforts across multiple systems.