HOW SYSTEMS-BASED PRACTICE EFFECTS SPECIALISTS

Reasons that during the 1990’s, Specialists might seek retraining into primary care include:

  • Economic pressures – managed care organization’s efforts to lower specialist utilization
  • Shortage of Primary Care Physicians (PCPs) in a time when managed care which relies on PCP as coordinators of care or “gatekeepers” is mushrooming
  • Health care is moving in direction of ambulatory settings, community oriented care, non-institutional focus, managed care, and capitated payment – not in-patient, institutional, fee-for-service, tertiary care
  • Excess of specialists, in some areas twice as many as needed
  • Under Hippocratic school, the need for more physicians who care for the entire patient – Goal 50% of U.S. medical graduates entering primary care disciplines
  • Prepayment plans that use capitation stand to gain financially by keeping their subscribers healthy and away from specialists and hospitals
  • Focus on “health” rather than “Health care” places increasing emphasis on primary care

Under a managed care system specialists typically do not get the “walk-in’s” or routine referrals that they used to get under a traditional fee for service system. “Walk-in’s” are “self-pay” patients who arrange their own medical care appointments with whatever physician they desire whenever they so choose and are held personally responsible for payment for those services. Physicians may be required by contractual obligations to refer their patients only to certain specialists who are part of the contracted network of providers.

Originally, many MCO plans require their members to have a referral from the Primary Care Physician to a Specialist before that plan will pay for services rendered by the Specialist. Typically, PCP’s have a list of Specialists who are part of the network of providers the MCO’s allow to be used under their plan.  In the late 1990’s, early 2000’s, the referral may be some kind of standing, continuing referral, due to legislative managed care reform and also competition among health care plans.

Self Pay Example: If a physician is no longer a participating provider of a HMO

Patients covered by HMO plans can elect to continue receiving treatment from such provider and become “self pay” type of patients – meaning patients would pay for services rendered by such provider out of their own pocket as compared to being covered by HMO

A “self-pay” situation means a patient is responsible for payment of medical services rendered typically because the patient is not operating within the terms of the agreement with the MCO. For example, the patient may have gone to a specialist outside of the contracted network of providers or may not have complied with the plan’s requirement to obtain a referral form the PCP prior to the specialists’ services being rendered.

Any Willing Provider type of laws:

  • Created to protect Providers
  • Tend to require Managed Care Organization’s (MCOs) to offer same contracts to other Providers qualified and willing to comply with contractual provisions of participating providers
  • Practical questions about effectiveness of “Any Willing Provider” type of laws – From a MCOs perspective, MCO may attempt to tailor contract in way that only the provider that MCO actually wants to contract with could possibly meet requirements of contract provisions
  • From Providers perspective, applying “Any Willing Provider” type of laws may be a negotiating tool

In a developing managed care market, Specialists and other Providers may be eager to contract with developing MCO’s. These Providers tend to fear that if they fail to do so in a timely manner, then they will be locked out of the system and not be able to be part of the network of participating providers for these plans. Certain laws may apply to seemingly protect Providers in this regard, such as “Any Willing Provider” type of laws. These type of laws tend to require MCO’s to offer the same contracts to other Providers qualified and willing to comply with the contractual provisions of the participating providers. However, there are practical questions about the effectiveness of these type of laws. From a MCO perspective, the MCO may attempt to tailor the contract in a way that only the provider that the MCO actually wants to contract with could possibly meet the requirements of the contract provisions. For example, the contract might require participating providers to have certain locations, open at specific hours, and staffed in a certain manner. From a Providers perspective, applying these type of laws may be a negotiating tool.

Some say: With the aging baby-boomers and graying of America, more in-patient services will be needed.

Another reason Specialists may elect to participate in a broad range of MCO contracts is due to the concern that their patient base might begin to shift into the managed care system and then unless they are part of that system they would have a problem.  However, it is important to note that many physicians as of the late 1990’s and early 2000’s, are reevaluating their managed care contracts and terminating or not continuing with contracts that do not meet their needs.

Many of the various laws around the country involving Managed Care Reform and Patient Rights include provisions allowing access to specialists, such as having a standing referral to a specialist.

Many MCO plans deduct the cost of referrals for contractually defined primary-care services from capitation payments. Or the plan may refuse to pay the specialist, who then sends his bill to the primary doctor. Even if plans don’t cut PCP’s capitation, they may penalize PCP’s in other ways if they refer a patient for something the plan define as a primary care duty.

If the PCP’s referrals exceed the MCO’s plan’s quota, the PCP may see less return of the withhold money. Plans often consider all their contracted doctor’s referrals collectively, not individually. It may be difficult to get information on how plans calculate charges against withholds. So, it may be hard to tell whether the PCP’s referral of expanded primary care services have been deducted equitably. Many HMO’s have replaced the term “withholds” with the term “bonuses” so that for example providers do not think that they were entitled to this money.

Primary Care Physicians (“PCP’s”) as coordinators of care or “gatekeepers” acting to manage patients efficiently across the continuum of care focus on health rather than health care. This means that PCP’s have a financial incentive to keep their patients healthy and use preventive care. So that when PCP’s refer patients to specialists, it is on the basis they believe the patient has a condition requiring treatment. In other words, something needs to be fixed and they (as PCP’s) believe the specialist is in the best position to provide this type of service, with perhaps, the hospital backing up the specialist skills as needed. Prepayment plans that use capitation stand to gain financially by keeping their enrollees healthy and out of hands of specialists and hospital.

The following lists some reasons that during the 1990’s, Specialists might seek retraining into primary care:

  1. Economic pressures – managed care organization’s efforts to lower specialist utilization.
  2. Shortage of PCP’s in a time when managed care which relies on PCP as coordinators of care or “gatekeepers” is mushrooming.
  3. Health care is moving in the direction of ambulatory settings, community oriented care, non-institutional focus, managed care, and capitated payment – not in-patient, institutional, fee-for-service, tertiary care.
  4. Excess of specialists, in some areas twice as many as needed.
  5. Under Hippocratic school, the need for more physicians who care for the entire patient. Goal 50% of U.S. medical graduates entering primary care disciplines.
  6. Prepayment plans that use capitation stand to gain financially by keeping their subscribers healthy and out of hands of specialists and hospitals.
  7. Focusing on “health” rather than “Health care” places increasing emphasis on primary care.

There are various reasons some Specialists seek retraining. For example, there may be economic pressures such as managed care organizations efforts to lower specialist utilization. Some say there is a shortage of Primary Care Physicians (“PCP’s”) in a time when managed care that relies on PCP’s as coordinators of care or “gatekeepers” is mushrooming. Some say there is an excess of specialists, in some areas twice as many as needed.

Under Hippocratic school, it is claimed that there is the need for more physicians who care for the entire patient. Some claim that the goal for the United States should be that 50 percent (50%) of U.S. medical graduates must enter primary care disciplines.

Prepayment plans that use capitation stand to gain financially by keeping their enrollees healthy and out of hands of specialists and hospitals.

Communication with patients is key factor in risk management to help prevent medical malpractice lawsuits.

Until recently, health care seemed to have been moving in the direction of outpatient, group practice, and capitated settings. This movement toward ambulatory settings and community oriented care, is a movement away from the traditional institutional focus.  Depending on who one talks to, may either say managed care is growing and capitated payment is becoming more common or that the fee for service system is returning even though certain tools of managed care remain.  Currently, delivery of health care in the United States is not moving in the direction of in-patient, institutional, fee-for-service, tertiary care.  However, some say, that with the aging baby-boomers and graying of America, more in-patient services will be needed.

A Big Concern for Providers in multiple Managed Care Arrangements is how to handle the variety of rules that may apply.

An issue some Specialists are seeing more often as well as PCP’s is how to manage the variety of rules that might apply from health plan to health plan. For example, some plans might require certain kinds of referral (maybe its written, or it has to come from a certain department of the MCO). Another example could be the treatment procedures involved, such as how much communication and authorizations are necessary from plan to plan to render medical care.

By the year 2000’s, Providers are reevaluating their managed care contracts and terminating those that do not meet their needs.

Affordable Care Act

One of the main ways the Affordable Care Act seeks to reduce health care costs is by encouraging doctors, hospitals and other health care providers to form networks to coordinate care better, which could keep costs down.  To do that, the law is trying a carrot-and-stick approach in the Medicare program: Accountable Care Organizations (ACOs).  Providers get paid more if they keep their patients well.

ACOs are proposed as a way to help fix an inefficient payment system that rewards more, not better, care.  Some economists warn they could lead to greater consolidation in the health care industry, which could allow some providers to charge more, if there is no competition.

Some may say ACOs sound a lot like health maintenance organizations, but there are some critical differences.  For example, an ACO patient is not required to stay in the network.  ACOs strive to perform like a HMO in holding down the cost of care while avoiding the structural features that give the HMO control over patient referral patterns, which limited patient options and created a consumer backlash in the 1990s.

Further, the ACOs, unlike HMOs, must meet a long list of quality measures to ensure they are not saving money in place of necessary care.

On November 2, 2011, the Centers for Medicare & Medicaid Services (CMS) finalized new rules under the Patient Protection and Affordable Care Act (Affordable Care Act) to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs). ACOs create incentives for health care providers to work together to treat an individual patient across care settings—including doctor’s offices, hospitals, and long-term care facilities. The Medicare Shared Savings Program (Shared Savings Program) will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first. Participation in an ACO is purely voluntary.

An ACO refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the Medicare Fee-For-Service patients they serve. The goal of an ACO is to deliver seamless, high-quality care for Medicare beneficiaries, instead of the fragmented care that often results from a Fee-For-Service payment system in which different providers receive different, disconnected payments. The ACO will be a patient-centered organization where the patient and providers are true partners in care decisions. The ACO will be responsible for maintaining a patient-centered focus and developing processes to promote evidence-based medicine, promote patient engagement, internally and publicly report on quality and cost, and coordinate care.

ACO Quality Measures

Under the CMS ACO initiatives, before an ACO can share in any savings created, it must demonstrate that it met the quality performance standard for that year. CMS will measure quality of care using nationally recognized measures in four key domains:

  1. Patient/caregiver experience (7 measures)
  2. Care coordination/patient safety (6 measures)
  3. Preventive health (8 measures)
  4. At-risk population:
    • Diabetes (1 measure and 1 composite consisting of five measures)
    • Hypertension (1 measure)
    • Ischemic Vascular Disease (2 measures)
    • Heart Failure (1 measure)
    • Coronary Artery Disease (1 composite consisting of 2 measures)

Recently, about one-third of the Pioneer ACOs announced they were dropping out of the advanced program, some because they didn’t save enough money, though seven are moving into a second Medicare ACO model with less risk of losing money.

All 32 Pioneers succeeded in improving quality and performed better than fee-for-service Medicare in 15 quality measures, according to CMS. And they generated a gross savings of $87.6 million in the 2012, the first year of the program.

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