Physician Leader Perspective of ACO Transition

Scott D. Hayworth, MD, FACOGPresident and CEO

Mount Kisco Medical Group, PC

• Multi-specialty group practice founded in 1946 and servicing Westchester, Dutchess and Putnam Counties in NYS

• 300 primary care and specialty physicians, 25 office locations servicing 300,000 patients

Mount Kisco Medical Group, PC

Mount Kisco Medical Group, PC

• Affiliated with 4 local community hospitals and academic affiliation with Massachusetts General Hospital

• Practice Data:o 760,000 patient visitso 2 million lab tests, 125K imaging testso $425 million in gross revenue• Recently implemented NextGen EMR; 3rd EMR in

over 15 years

Current Trends in Physician Practices• Consolidation of small

groups into larger group practices

• Acquisition of medical groups by hospitals & integrated delivery systems

• Imperative to capture market share

Current Trends in Physician Practices

• Risk-based contracting with payers• Pay for performance growing as adjunct to

usual payment • Blurring of roles between payers and

providers, i.e. groups become insurance plans and insurance companies are buying groups

Accountable Care Organizations(ACO)

• Established by federal government under Medical Shared Savings Program created by Section 3022 of Health Care Reform Law

• Initial guidelines published March 31, 2011

• Final guidelines published October 20,2011

Accountable Care Organizations• Definition: voluntary groups of physicians,

hospitals, and other health care providers willing to assume responsibility for care of a clearly defined population of eligible beneficiaries attributed to them on the basis of patient’s use of primary care services

Accountable Care Organizations

3 Types• Medicare • Commercial• Medicaid

Accountable Care Coalition of Mount Kisco (ACCMK)

• Signed “upside only” shared-risk contract with CMS in April, 2012

• Established partnership with Universal American to provide consulting services through Collaborative Health Systems, a wholly owned subsidiary

• Currently 14,000 lives in the ACO

Collaborative Health Systems (CHC)

• Facilitated key management committees• Provided requisite provider training• Established compliance program• Identified patient cohort and sent out “opt

out” letters to patients• Will provide necessary analytics to assist with

managing population

Care Management Services

• Staffing: PT Medical Director and six FTE care coordination staff

• Activities: - Identify high risk patients through CHC

analytics, hospital discharge/ER reports, PCP referrals, personal health assessments

- Link with affiliated hospital discharge planning departments

Care Management Services

• Work with PCP offices to provide services to high risk patients and insure appropriate follow up visits

• Telephonic follow up with patients• Facilitate appropriate point of service care:

home care, transitional care, etc.• Communicate with hospitalists re: discharge

planning

Challenges to Group Adoption of ACO Model

• Understanding the definition of an “ACO patient”

• Explaining “opt out” process to patients• Integrating ACO care management staff with

existing physician nursing staff• Involving physician staff in “transition of care”

process post-hospital discharge

Challenges to Group Adoption of ACO Model (cont’d)

• Achieving “buy-in” to maximizing quality metrics, i.e. “standardization of care”

• Encouraging referrals from physicians to case management staff

• Integrating case management notes into EMR• Distribution of savings to group participants• Making move from “volume” to “value”

“Brave New World” of Value

Volume Based• Payment: Fee For Service• Incentives: Volume• Focus: Acute episodes• Role of provider: single

episodes• Information: retrospective

Value Based• Outcomes• Value• Populations• Care Continuum

• Real-time & predictible

How Should Groups React to “Value Proposition”?

• Develop integrated care models using care managers partnering with providers

• Develop or contract with continuum of care providers: home health, SNF’s, etc.

• Optimize radiology and lab test ordering• Create patient-centered medical homes at

primary care office sites

How Should Groups React to “Value” Proposition

• Standardize care: evidence-based guidelines• Rationalize/consolidate clinical assets• Build Care Management Department with

imbedded case managers, transitions of care coordinators and telephonic outreach

What Do I Do If I Am In a Small Group?

Ethical Issues Associated with ACO

• Patient autonomy v. referral patterns within the ACO, i.e., leakage

• Unintended financial effects re: market share growth of ACO

• Distribution of savings fairly• Where to focus quality improvement efforts,

i.e. those closest or furthest from targets?• Potential loss of physician autonomy

Ethical Issues Associated with ACO

• Impact on risk management of reduced resource utilization

• Role of beneficiary on the ACO Governance Board: independence and strength of the role

• Comfort level with ACO referral patterns

Summary Points

• ACO’s with shared risk will be a significant venue for reimbursement in the future

• Medical groups must prepare for the transition from “pay for volume” to “pay for value” in the near future

• Group practices will need to standardize care, incorporate care coordination and respond to pay for performance metrics

• Medical groups must be prepared to address the ethical issues associated with ACO adoption

Thank you…questions?