Practice Economics

As Medicare celebrates its 50th anniversary, federal officials are beginning one of the most significant shifts in the program’s history – paying physicians based on quality and efficiency rather than for the volume of services they provide. The shift to so-called value-based payment will be phased in, but it is coming soon.

Earlier this year, federal officials announced their goal to tie 85% of all Medicare fee-for-service payments to quality or value by 2016 and 90% by 2018, relying heavily on the use of alternative payment models such as Accountable Care Organizations (ACOs) and bundled payments. The shift also is being driven by the recent repeal of Medicare’s Sustainable Growth Rate formula. The law that removed the SGR from physicians’ lives also created alternative payment pathways that tie payments to performance on certain quality metrics or successful participation as part of an ACO.

How will these changes affect how physicians deliver care in the future? We invited physicians in various practice settings to offer their perspectives on how the new payment paradigm will drive practice changes.

‘Value’ payment system is arbitrary

BY JOSEPH S. EASTERN, M.D.

While much has been written about the Centers for Medicare & Medicaid Services’ plan to shift its payment system away from fee-for-service and toward a “value-based” structure, most physicians in small and solo private settings have given little if any thought to its potential impact on their practices. That is about to change.

The principal vehicle for the CMS’s plan is something called the value-based payment modifier (VBPM), a component of the Affordable Care Act. The VBPM has not been on the radar of smaller private practices because up until now it has only applied to groups with more than 10 providers. Beginning this year, it applies to everyone. If you accept Medicare patients, regardless of the size of your practice, VBPM will become part of your life – because your 2017 Medicare payments will be adjusted based on your 2015 VBPM “score.”

It will adjust your reimbursements based on quality of care as defined by the CMS and cost, compared to other physicians. Your “score” will have a quality component and a cost component, and will be calculated based on measures reported through the Physician Quality Reporting System (PQRS). And the ACA requires that the program be budget neutral, which means that all rewards to physicians who pull the highest scores must be offset by penalties, or “negative adjustments,” to those who don’t score as well. In essence, the VBPM establishes arbitrary practice standards and spending ceilings; physicians who have the temerity to practice medicine as they see fit, or spend too much relative to their peers, will be punished.

Beyond the obvious and very real possibility of significant financial hardship, there are serious potential consequences inherent in this unprecedented new system. Health care is already among the most regulated industries in the country; the VBPM creates new incentives to practice “cookbook” medicine, and new disincentives to order tests, consults, or medications, even when doing so would clearly be in a patient’s best interest. The inevitable result will be compromised care and further limitation of patient access.

The VBPM’s potential effects on physician-patient relations and legal liability are additional serious concerns. Many patients will object to their physicians’ new reluctance to recommend appropriate interventions for fear of generating excessive costs; and should a less-than-thorough work-up lead to a missed diagnosis, the ACA offers no protection at all from any resulting malpractice litigation.

The already strained relationship between physicians and their hospitals will likely deteriorate as well. Hospital administrators will be scrutinizing each medical decision from admission to discharge, particularly in those institutions already in financial trouble, as is all too often the case. The constant necessity of justifying every significant order and consult will not be in anyone’s best interest, least of all that of patients.

For all the talk that the transition from fee-for-service to value-based reimbursement would result in better care at a lower cost, there is little evidence that care is improving, and even less that costs are decreasing. Conversely, there are plenty of warning signs that physicians in small private practices who can’t meet the new performance standards may face a significant financial burden because of the resulting penalties and lower reimbursements.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News.

Staying independent may prove costly

BY PETER M.G. DEANE, M.D.

The changes announced for Medicare and Medicaid, to be implemented over the next few years, are breathtaking in scope and ambition. A system based on payment for services is to become a system based on payment for individual health and population health outcomes. This will require enormous changes in the way health care is delivered, and this is an intended effect. Private payers will certainly desire the same results and savings.

I am a partner in a multiphysician, single-specialty private group practice. We have two hospital systems locally. Both of these are now health systems, in that they either employ or closely interact with many physicians.

Just a few years ago, our practice could comfortably make decisions about how we went about delivering care without much consideration of the plans of larger local institutions. Then came the rise of our local accountable care networks. These were created by the local health care systems to provide the overall organizational infrastructure to move from the current payment model to the coming one. We delayed for awhile but have now signed up with both. It can only be a matter of months before each of them pursues a meaningful degree of clinical integration. In other words, they will be analyzing data from our electronic medical record about our individual practice patterns and results, and giving us the results along with feedback on how to improve care.

For this to happen, our EMR system needs to be up to the task. We are unsure it will be. It has been difficult for some of us to adapt to electronic records systems. Now we need to see if our existing system can interoperate effectively. If not, we may be paying quite a bit for another one soon.

Our physicians are not accustomed to seeing report cards about their practice patterns. It will be a shock to see comparisons and rankings. But patients will be enrolled in and referred to us by the networks, and it will not be possible to ignore the reports we get.

Likely this radical change in the practice of medicine will drive some to retire, affecting the size of our group. We intend to remain in private practice, but independence may prove increasingly costly.

Already, patients see that their physicians make less eye contact with them and more time documenting care. This will likely get worse. We worry that if increased expenses cause staff cuts, the personal service we provide will suffer.

Redesigning medical practice will be a serious challenge for us. But our goal has always been to provide the best care, and in a value-based system, that should be what sustains us all.

Dr. Deane specializes in allergy, immunology, and rheumatology and is a partner in a private group practice with eight physicians and five offices in greater Rochester, N.Y. He is also the chief of allergy, immunology, and rheumatology at Unity Hospital in Rochester.

Value shift brings irreparable change to private practice

BY ROBERT SHOR, M.D.

The simple truth is that we are in transition. The current health system, for the most part, rewards “making widgets” (volume). That is, being paid for units of work actually being done. The more patients you see, the more procedures you do, the more you are compensated. We are moving from “volume” to “value” as we try to move away from “widgets” to management of population health. How do we get there? What can we as physicians and providers do?

I am part of a 40-person, single-specialty private cardiology practice in the Washington, D.C., suburbs. In the coming years, the CMS will reward (the euphemism for payment) practices that meet their definitions for quality and penalize those that don’t meet those metrics.

We have participated in PQRS/PQRI, Meaningful Use (MU), and other Medicare programs for which we are compensated. But how do you truly determine what are quality metrics and what is truly meaningful use of health system resources? How do we impact health on an individual and population view?

For us to be compliant with the Medicare rules and get paid, we have had to heavily invest in not only EHRs (we were an early adopter around 2000), but personnel costs to make sure all of the paperwork is completed appropriately for submission and for the audit that precedes the CMS payment for MU.

So how do we proceed going forward? In my opinion, what is clear is that private practice has been irreparably changed. The notion of an individual physician or a small practice surviving without some arrangement with a health system, an ACO, or a Clinical Integrated Network (CIN) is rapidly dwindling.

I have seen a variety of actions taken as providers try to survive and jockey for position to their advantage and we have explored a wide range of options. For an ACO to succeed in the shared risk model, it usually is part of a larger health care system. Thus many practices – primary care and subspecialty – have integrated with these health systems. Indeed, about 70% of the cardiology community is now integrated. To manage costs, you need to know your costs and most of the cost remains in the hospital care.

What do you do if you want to stay independent or do not feel you have a reliable health system with which you can integrate? Many practices may merge in a formal or looser network of practices to create a CIN where EHR access to patient records within the network is streamlined and care can be more effectively given. This has benefits, but also limitations. I believe that any future in which cost is contained on a larger scale will require close collaboration with hospitals given the disproportionate cost incurred during hospital care. Some practices have decided to form Physician Service Agreements with hospital systems to help manage product lines within the health system and to establish more meaningful relationships in an effort to coordinate care more effectively. This provides an opportunity to impact inpatient care, to contribute to programs that reduce hospital readmissions, and to reach the holy grail of preventing disease by better outpatient care. This would truly help with population health care management.

Some of the challenges, at least in large metropolitan areas, are that practices may work at several hospitals with different health systems. They may want to continue providing care at all of the hospitals in their community, but may be forced to choose. This does not appear to me to be in the best interest of our patients, many of whom we have cared for many years. However, the choice may be forced upon them as the health systems force the issue and make the decision for us.

The future holds much uncertainty, but also opportunity. Will our practice survive in its current form in 5 years? For now we are trying to read the tea leaves, like so many others, to make the best decisions on behalf of our patients to allow us to be able to continue to provide care in our community.

We are still reading the tea leaves.

Dr. Shor is vice president of Virginia Heart, which has nine offices in the northern Virginia region. He is the chair of the board of governors of the American College of Cardiology.

Leaving behind fee-for-service battles

BY ROBERT FIELDS, M.D.

Many of us in health care received with a mix of excitement and fear the recent news from the CMS regarding the transition to 90% value-based payments by 2018. For me, an employed family medicine physician and medical director of a new ACO in western North Carolina, I applaud the ambitious goal and understand the sentiment behind it. But, I also worry about the ability of most providers to adapt to this change in such a short time span.

The rationale behind value-based payments couldn’t be clearer – we spend too much on health care. Way too much. So much, that if we continue on this track our country will break under the financial pressures of providing care in a fee-for-service system. In addition, U.S. medical outcomes lag behind most other industrialized nations, which leads to the conclusion that the system at large is not providing the value it should.

As I put on my rose-colored glasses, I hope this restructuring encourages the system at large to coordinate care better, to improve our information systems to share relevant clinical data, and to encourage quality improvement at the practice level so that we move toward improved outcomes for our patient populations.

When talking to providers about our ACO and adding value in health care, they think we are saying that THEY are not delivering high value care. I keep reiterating, and will continue to do so, that value-based payments are not a criticism of our individual abilities as physicians or a comment on our interactions with our patients, but acknowledgment that how we communicate with and manage our populations as a network of hospitals, providers, and agencies lacks the efficiencies and coordination of services that patients deserve.

Ultimately, we are moving toward a patient-centered health care system that requires a fundamental transformation in how we pay for and deliver care. Measurement and quality improvement, although new to health care, has existed in every other industry for years.

In the end, I hope patients feel they are getting more efficient, coordinated care and that providers can start to see improvements in outcomes without the daily battle of the fee-for-service world.

Dr. Fields is a family physician and the medical director of Mission Health Partners, a physician led ACO in Asheville, N.C.

As Medicare celebrates its 50th anniversary, federal officials are beginning one of the most significant shifts in the program’s history – paying physicians based on quality and efficiency rather than for the volume of services they provide. The shift to so-called value-based payment will be phased in, but it is coming soon.

Earlier this year, federal officials announced their goal to tie 85% of all Medicare fee-for-service payments to quality or value by 2016 and 90% by 2018, relying heavily on the use of alternative payment models such as Accountable Care Organizations (ACOs) and bundled payments. The shift also is being driven by the recent repeal of Medicare’s Sustainable Growth Rate formula. The law that removed the SGR from physicians’ lives also created alternative payment pathways that tie payments to performance on certain quality metrics or successful participation as part of an ACO.

How will these changes affect how physicians deliver care in the future? We invited physicians in various practice settings to offer their perspectives on how the new payment paradigm will drive practice changes.

‘Value’ payment system is arbitrary

BY JOSEPH S. EASTERN, M.D.

While much has been written about the Centers for Medicare & Medicaid Services’ plan to shift its payment system away from fee-for-service and toward a “value-based” structure, most physicians in small and solo private settings have given little if any thought to its potential impact on their practices. That is about to change.

The principal vehicle for the CMS’s plan is something called the value-based payment modifier (VBPM), a component of the Affordable Care Act. The VBPM has not been on the radar of smaller private practices because up until now it has only applied to groups with more than 10 providers. Beginning this year, it applies to everyone. If you accept Medicare patients, regardless of the size of your practice, VBPM will become part of your life – because your 2017 Medicare payments will be adjusted based on your 2015 VBPM “score.”

It will adjust your reimbursements based on quality of care as defined by the CMS and cost, compared to other physicians. Your “score” will have a quality component and a cost component, and will be calculated based on measures reported through the Physician Quality Reporting System (PQRS). And the ACA requires that the program be budget neutral, which means that all rewards to physicians who pull the highest scores must be offset by penalties, or “negative adjustments,” to those who don’t score as well. In essence, the VBPM establishes arbitrary practice standards and spending ceilings; physicians who have the temerity to practice medicine as they see fit, or spend too much relative to their peers, will be punished.

Beyond the obvious and very real possibility of significant financial hardship, there are serious potential consequences inherent in this unprecedented new system. Health care is already among the most regulated industries in the country; the VBPM creates new incentives to practice “cookbook” medicine, and new disincentives to order tests, consults, or medications, even when doing so would clearly be in a patient’s best interest. The inevitable result will be compromised care and further limitation of patient access.

The VBPM’s potential effects on physician-patient relations and legal liability are additional serious concerns. Many patients will object to their physicians’ new reluctance to recommend appropriate interventions for fear of generating excessive costs; and should a less-than-thorough work-up lead to a missed diagnosis, the ACA offers no protection at all from any resulting malpractice litigation.

The already strained relationship between physicians and their hospitals will likely deteriorate as well. Hospital administrators will be scrutinizing each medical decision from admission to discharge, particularly in those institutions already in financial trouble, as is all too often the case. The constant necessity of justifying every significant order and consult will not be in anyone’s best interest, least of all that of patients.

For all the talk that the transition from fee-for-service to value-based reimbursement would result in better care at a lower cost, there is little evidence that care is improving, and even less that costs are decreasing. Conversely, there are plenty of warning signs that physicians in small private practices who can’t meet the new performance standards may face a significant financial burden because of the resulting penalties and lower reimbursements.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News.

Staying independent may prove costly

BY PETER M.G. DEANE, M.D.

The changes announced for Medicare and Medicaid, to be implemented over the next few years, are breathtaking in scope and ambition. A system based on payment for services is to become a system based on payment for individual health and population health outcomes. This will require enormous changes in the way health care is delivered, and this is an intended effect. Private payers will certainly desire the same results and savings.

I am a partner in a multiphysician, single-specialty private group practice. We have two hospital systems locally. Both of these are now health systems, in that they either employ or closely interact with many physicians.

Just a few years ago, our practice could comfortably make decisions about how we went about delivering care without much consideration of the plans of larger local institutions. Then came the rise of our local accountable care networks. These were created by the local health care systems to provide the overall organizational infrastructure to move from the current payment model to the coming one. We delayed for awhile but have now signed up with both. It can only be a matter of months before each of them pursues a meaningful degree of clinical integration. In other words, they will be analyzing data from our electronic medical record about our individual practice patterns and results, and giving us the results along with feedback on how to improve care.

For this to happen, our EMR system needs to be up to the task. We are unsure it will be. It has been difficult for some of us to adapt to electronic records systems. Now we need to see if our existing system can interoperate effectively. If not, we may be paying quite a bit for another one soon.

Our physicians are not accustomed to seeing report cards about their practice patterns. It will be a shock to see comparisons and rankings. But patients will be enrolled in and referred to us by the networks, and it will not be possible to ignore the reports we get.

Likely this radical change in the practice of medicine will drive some to retire, affecting the size of our group. We intend to remain in private practice, but independence may prove increasingly costly.

Already, patients see that their physicians make less eye contact with them and more time documenting care. This will likely get worse. We worry that if increased expenses cause staff cuts, the personal service we provide will suffer.

Redesigning medical practice will be a serious challenge for us. But our goal has always been to provide the best care, and in a value-based system, that should be what sustains us all.

Dr. Deane specializes in allergy, immunology, and rheumatology and is a partner in a private group practice with eight physicians and five offices in greater Rochester, N.Y. He is also the chief of allergy, immunology, and rheumatology at Unity Hospital in Rochester.

Value shift brings irreparable change to private practice

BY ROBERT SHOR, M.D.

The simple truth is that we are in transition. The current health system, for the most part, rewards “making widgets” (volume). That is, being paid for units of work actually being done. The more patients you see, the more procedures you do, the more you are compensated. We are moving from “volume” to “value” as we try to move away from “widgets” to management of population health. How do we get there? What can we as physicians and providers do?

I am part of a 40-person, single-specialty private cardiology practice in the Washington, D.C., suburbs. In the coming years, the CMS will reward (the euphemism for payment) practices that meet their definitions for quality and penalize those that don’t meet those metrics.

We have participated in PQRS/PQRI, Meaningful Use (MU), and other Medicare programs for which we are compensated. But how do you truly determine what are quality metrics and what is truly meaningful use of health system resources? How do we impact health on an individual and population view?

For us to be compliant with the Medicare rules and get paid, we have had to heavily invest in not only EHRs (we were an early adopter around 2000), but personnel costs to make sure all of the paperwork is completed appropriately for submission and for the audit that precedes the CMS payment for MU.

So how do we proceed going forward? In my opinion, what is clear is that private practice has been irreparably changed. The notion of an individual physician or a small practice surviving without some arrangement with a health system, an ACO, or a Clinical Integrated Network (CIN) is rapidly dwindling.

I have seen a variety of actions taken as providers try to survive and jockey for position to their advantage and we have explored a wide range of options. For an ACO to succeed in the shared risk model, it usually is part of a larger health care system. Thus many practices – primary care and subspecialty – have integrated with these health systems. Indeed, about 70% of the cardiology community is now integrated. To manage costs, you need to know your costs and most of the cost remains in the hospital care.

What do you do if you want to stay independent or do not feel you have a reliable health system with which you can integrate? Many practices may merge in a formal or looser network of practices to create a CIN where EHR access to patient records within the network is streamlined and care can be more effectively given. This has benefits, but also limitations. I believe that any future in which cost is contained on a larger scale will require close collaboration with hospitals given the disproportionate cost incurred during hospital care. Some practices have decided to form Physician Service Agreements with hospital systems to help manage product lines within the health system and to establish more meaningful relationships in an effort to coordinate care more effectively. This provides an opportunity to impact inpatient care, to contribute to programs that reduce hospital readmissions, and to reach the holy grail of preventing disease by better outpatient care. This would truly help with population health care management.

Some of the challenges, at least in large metropolitan areas, are that practices may work at several hospitals with different health systems. They may want to continue providing care at all of the hospitals in their community, but may be forced to choose. This does not appear to me to be in the best interest of our patients, many of whom we have cared for many years. However, the choice may be forced upon them as the health systems force the issue and make the decision for us.

The future holds much uncertainty, but also opportunity. Will our practice survive in its current form in 5 years? For now we are trying to read the tea leaves, like so many others, to make the best decisions on behalf of our patients to allow us to be able to continue to provide care in our community.

We are still reading the tea leaves.

Dr. Shor is vice president of Virginia Heart, which has nine offices in the northern Virginia region. He is the chair of the board of governors of the American College of Cardiology.

Leaving behind fee-for-service battles

BY ROBERT FIELDS, M.D.

Many of us in health care received with a mix of excitement and fear the recent news from the CMS regarding the transition to 90% value-based payments by 2018. For me, an employed family medicine physician and medical director of a new ACO in western North Carolina, I applaud the ambitious goal and understand the sentiment behind it. But, I also worry about the ability of most providers to adapt to this change in such a short time span.

The rationale behind value-based payments couldn’t be clearer – we spend too much on health care. Way too much. So much, that if we continue on this track our country will break under the financial pressures of providing care in a fee-for-service system. In addition, U.S. medical outcomes lag behind most other industrialized nations, which leads to the conclusion that the system at large is not providing the value it should.

As I put on my rose-colored glasses, I hope this restructuring encourages the system at large to coordinate care better, to improve our information systems to share relevant clinical data, and to encourage quality improvement at the practice level so that we move toward improved outcomes for our patient populations.

When talking to providers about our ACO and adding value in health care, they think we are saying that THEY are not delivering high value care. I keep reiterating, and will continue to do so, that value-based payments are not a criticism of our individual abilities as physicians or a comment on our interactions with our patients, but acknowledgment that how we communicate with and manage our populations as a network of hospitals, providers, and agencies lacks the efficiencies and coordination of services that patients deserve.

Ultimately, we are moving toward a patient-centered health care system that requires a fundamental transformation in how we pay for and deliver care. Measurement and quality improvement, although new to health care, has existed in every other industry for years.

In the end, I hope patients feel they are getting more efficient, coordinated care and that providers can start to see improvements in outcomes without the daily battle of the fee-for-service world.

Dr. Fields is a family physician and the medical director of Mission Health Partners, a physician led ACO in Asheville, N.C.

As Medicare celebrates its 50th anniversary, federal officials are beginning one of the most significant shifts in the program’s history – paying physicians based on quality and efficiency rather than for the volume of services they provide. The shift to so-called value-based payment will be phased in, but it is coming soon.

Earlier this year, federal officials announced their goal to tie 85% of all Medicare fee-for-service payments to quality or value by 2016 and 90% by 2018, relying heavily on the use of alternative payment models such as Accountable Care Organizations (ACOs) and bundled payments. The shift also is being driven by the recent repeal of Medicare’s Sustainable Growth Rate formula. The law that removed the SGR from physicians’ lives also created alternative payment pathways that tie payments to performance on certain quality metrics or successful participation as part of an ACO.

How will these changes affect how physicians deliver care in the future? We invited physicians in various practice settings to offer their perspectives on how the new payment paradigm will drive practice changes.

‘Value’ payment system is arbitrary

BY JOSEPH S. EASTERN, M.D.

While much has been written about the Centers for Medicare & Medicaid Services’ plan to shift its payment system away from fee-for-service and toward a “value-based” structure, most physicians in small and solo private settings have given little if any thought to its potential impact on their practices. That is about to change.

The principal vehicle for the CMS’s plan is something called the value-based payment modifier (VBPM), a component of the Affordable Care Act. The VBPM has not been on the radar of smaller private practices because up until now it has only applied to groups with more than 10 providers. Beginning this year, it applies to everyone. If you accept Medicare patients, regardless of the size of your practice, VBPM will become part of your life – because your 2017 Medicare payments will be adjusted based on your 2015 VBPM “score.”

It will adjust your reimbursements based on quality of care as defined by the CMS and cost, compared to other physicians. Your “score” will have a quality component and a cost component, and will be calculated based on measures reported through the Physician Quality Reporting System (PQRS). And the ACA requires that the program be budget neutral, which means that all rewards to physicians who pull the highest scores must be offset by penalties, or “negative adjustments,” to those who don’t score as well. In essence, the VBPM establishes arbitrary practice standards and spending ceilings; physicians who have the temerity to practice medicine as they see fit, or spend too much relative to their peers, will be punished.

Beyond the obvious and very real possibility of significant financial hardship, there are serious potential consequences inherent in this unprecedented new system. Health care is already among the most regulated industries in the country; the VBPM creates new incentives to practice “cookbook” medicine, and new disincentives to order tests, consults, or medications, even when doing so would clearly be in a patient’s best interest. The inevitable result will be compromised care and further limitation of patient access.

The VBPM’s potential effects on physician-patient relations and legal liability are additional serious concerns. Many patients will object to their physicians’ new reluctance to recommend appropriate interventions for fear of generating excessive costs; and should a less-than-thorough work-up lead to a missed diagnosis, the ACA offers no protection at all from any resulting malpractice litigation.

The already strained relationship between physicians and their hospitals will likely deteriorate as well. Hospital administrators will be scrutinizing each medical decision from admission to discharge, particularly in those institutions already in financial trouble, as is all too often the case. The constant necessity of justifying every significant order and consult will not be in anyone’s best interest, least of all that of patients.

For all the talk that the transition from fee-for-service to value-based reimbursement would result in better care at a lower cost, there is little evidence that care is improving, and even less that costs are decreasing. Conversely, there are plenty of warning signs that physicians in small private practices who can’t meet the new performance standards may face a significant financial burden because of the resulting penalties and lower reimbursements.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News.

Staying independent may prove costly

BY PETER M.G. DEANE, M.D.

The changes announced for Medicare and Medicaid, to be implemented over the next few years, are breathtaking in scope and ambition. A system based on payment for services is to become a system based on payment for individual health and population health outcomes. This will require enormous changes in the way health care is delivered, and this is an intended effect. Private payers will certainly desire the same results and savings.

I am a partner in a multiphysician, single-specialty private group practice. We have two hospital systems locally. Both of these are now health systems, in that they either employ or closely interact with many physicians.

Just a few years ago, our practice could comfortably make decisions about how we went about delivering care without much consideration of the plans of larger local institutions. Then came the rise of our local accountable care networks. These were created by the local health care systems to provide the overall organizational infrastructure to move from the current payment model to the coming one. We delayed for awhile but have now signed up with both. It can only be a matter of months before each of them pursues a meaningful degree of clinical integration. In other words, they will be analyzing data from our electronic medical record about our individual practice patterns and results, and giving us the results along with feedback on how to improve care.

For this to happen, our EMR system needs to be up to the task. We are unsure it will be. It has been difficult for some of us to adapt to electronic records systems. Now we need to see if our existing system can interoperate effectively. If not, we may be paying quite a bit for another one soon.

Our physicians are not accustomed to seeing report cards about their practice patterns. It will be a shock to see comparisons and rankings. But patients will be enrolled in and referred to us by the networks, and it will not be possible to ignore the reports we get.

Likely this radical change in the practice of medicine will drive some to retire, affecting the size of our group. We intend to remain in private practice, but independence may prove increasingly costly.

Already, patients see that their physicians make less eye contact with them and more time documenting care. This will likely get worse. We worry that if increased expenses cause staff cuts, the personal service we provide will suffer.

Redesigning medical practice will be a serious challenge for us. But our goal has always been to provide the best care, and in a value-based system, that should be what sustains us all.

Dr. Deane specializes in allergy, immunology, and rheumatology and is a partner in a private group practice with eight physicians and five offices in greater Rochester, N.Y. He is also the chief of allergy, immunology, and rheumatology at Unity Hospital in Rochester.

Value shift brings irreparable change to private practice

BY ROBERT SHOR, M.D.

The simple truth is that we are in transition. The current health system, for the most part, rewards “making widgets” (volume). That is, being paid for units of work actually being done. The more patients you see, the more procedures you do, the more you are compensated. We are moving from “volume” to “value” as we try to move away from “widgets” to management of population health. How do we get there? What can we as physicians and providers do?

I am part of a 40-person, single-specialty private cardiology practice in the Washington, D.C., suburbs. In the coming years, the CMS will reward (the euphemism for payment) practices that meet their definitions for quality and penalize those that don’t meet those metrics.

We have participated in PQRS/PQRI, Meaningful Use (MU), and other Medicare programs for which we are compensated. But how do you truly determine what are quality metrics and what is truly meaningful use of health system resources? How do we impact health on an individual and population view?

For us to be compliant with the Medicare rules and get paid, we have had to heavily invest in not only EHRs (we were an early adopter around 2000), but personnel costs to make sure all of the paperwork is completed appropriately for submission and for the audit that precedes the CMS payment for MU.

So how do we proceed going forward? In my opinion, what is clear is that private practice has been irreparably changed. The notion of an individual physician or a small practice surviving without some arrangement with a health system, an ACO, or a Clinical Integrated Network (CIN) is rapidly dwindling.

I have seen a variety of actions taken as providers try to survive and jockey for position to their advantage and we have explored a wide range of options. For an ACO to succeed in the shared risk model, it usually is part of a larger health care system. Thus many practices – primary care and subspecialty – have integrated with these health systems. Indeed, about 70% of the cardiology community is now integrated. To manage costs, you need to know your costs and most of the cost remains in the hospital care.

What do you do if you want to stay independent or do not feel you have a reliable health system with which you can integrate? Many practices may merge in a formal or looser network of practices to create a CIN where EHR access to patient records within the network is streamlined and care can be more effectively given. This has benefits, but also limitations. I believe that any future in which cost is contained on a larger scale will require close collaboration with hospitals given the disproportionate cost incurred during hospital care. Some practices have decided to form Physician Service Agreements with hospital systems to help manage product lines within the health system and to establish more meaningful relationships in an effort to coordinate care more effectively. This provides an opportunity to impact inpatient care, to contribute to programs that reduce hospital readmissions, and to reach the holy grail of preventing disease by better outpatient care. This would truly help with population health care management.

Some of the challenges, at least in large metropolitan areas, are that practices may work at several hospitals with different health systems. They may want to continue providing care at all of the hospitals in their community, but may be forced to choose. This does not appear to me to be in the best interest of our patients, many of whom we have cared for many years. However, the choice may be forced upon them as the health systems force the issue and make the decision for us.

The future holds much uncertainty, but also opportunity. Will our practice survive in its current form in 5 years? For now we are trying to read the tea leaves, like so many others, to make the best decisions on behalf of our patients to allow us to be able to continue to provide care in our community.

We are still reading the tea leaves.

Dr. Shor is vice president of Virginia Heart, which has nine offices in the northern Virginia region. He is the chair of the board of governors of the American College of Cardiology.

Leaving behind fee-for-service battles

BY ROBERT FIELDS, M.D.

Many of us in health care received with a mix of excitement and fear the recent news from the CMS regarding the transition to 90% value-based payments by 2018. For me, an employed family medicine physician and medical director of a new ACO in western North Carolina, I applaud the ambitious goal and understand the sentiment behind it. But, I also worry about the ability of most providers to adapt to this change in such a short time span.

The rationale behind value-based payments couldn’t be clearer – we spend too much on health care. Way too much. So much, that if we continue on this track our country will break under the financial pressures of providing care in a fee-for-service system. In addition, U.S. medical outcomes lag behind most other industrialized nations, which leads to the conclusion that the system at large is not providing the value it should.

As I put on my rose-colored glasses, I hope this restructuring encourages the system at large to coordinate care better, to improve our information systems to share relevant clinical data, and to encourage quality improvement at the practice level so that we move toward improved outcomes for our patient populations.

When talking to providers about our ACO and adding value in health care, they think we are saying that THEY are not delivering high value care. I keep reiterating, and will continue to do so, that value-based payments are not a criticism of our individual abilities as physicians or a comment on our interactions with our patients, but acknowledgment that how we communicate with and manage our populations as a network of hospitals, providers, and agencies lacks the efficiencies and coordination of services that patients deserve.

Ultimately, we are moving toward a patient-centered health care system that requires a fundamental transformation in how we pay for and deliver care. Measurement and quality improvement, although new to health care, has existed in every other industry for years.

In the end, I hope patients feel they are getting more efficient, coordinated care and that providers can start to see improvements in outcomes without the daily battle of the fee-for-service world.

Dr. Fields is a family physician and the medical director of Mission Health Partners, a physician led ACO in Asheville, N.C.

In a May 2, 2015 editorial “Stroke of Fate,” respected Times columnist Maureen Dowd wrote about her niece’s experience after suffering a vertebral artery dissection that had been “diagnosed correctly and acted on in the ED,” according to a subsequent letter written by neurologist Louis R. Caplan, MD, who was quoted extensively in the column. Noting that the incidence of strokes has been rising among younger adults, the column took issue with the advice of doctors who told her niece to cut back on physical activity. Dr Caplan was consulted for a second opinion and determined that the imaging studies had been misinterpreted and that the vertebral artery had only narrowed, not closed, allowing the patient to resume her active lifestyle.

Though the column did not specify which doctors had misinterpreted the studies or who had given the unnecessarily restrictive advice, it is difficult to imagine that EPs were responsible for either. Nevertheless, Dr Caplan was subsequently quoted as saying that “stroke experts have had a hard time getting the message across to ER personnel that if a stroke is suspected, a vascular image must be taken as well as a brain image” and that going to an “ER” because of a neurological problem is similar to “run[ning] your Rolls-Royce into the local gas station.” He also said that he is afraid to go to the “emergency room” because he thinks it’s dangerous, and that patients have to “worry about the quality of treatment” there.

In a letter to emergency medicine colleagues after the column appeared, Dr Caplan apologized for quotes taken out of context, and wrote “feel free to convey…to your colleagues” that he did not mean to throw stones at EPs, but wanted to point out that undue limitations on activities can become more disabling than the stroke itself and that system issues, such as long waits and lack of access to past records, not the competency of EPs, made patients afraid. He added that he did “not think being in an ED is dangerous, but is frightening to many patients.”

Clearly, we can all agree on the need for vascular as well as other types of imaging for certain stroke presentations, and that statements in the column were not intended to be understood exactly as written— though to date, no clarifications have since appeared in the column or newspaper. But when such criticism appears in a powerful, respected, and widely disseminated media source, it is almost impossible to undo whatever damage may have been done to public perceptions of ED safety and quality of care. Although many EPs have read or learned of the subsequent clarifying letter, few nonphysicians will ever see or appreciate the disclaimers and clarifications.

To avoid such unfortunate situations in the future, all physicians must be very, very careful in framing statements to the media, and should assume that their remarks will not be placed “in context,” or nuanced as they intended. Most important, is to not disparage entire specialties or use slang terms such as “ER docs” to indicate lesser expertise than one’s own specialty. Doing so can only unnecessarily heighten patients’ fears.  

In a May 2, 2015 editorial “Stroke of Fate,” respected Times columnist Maureen Dowd wrote about her niece’s experience after suffering a vertebral artery dissection that had been “diagnosed correctly and acted on in the ED,” according to a subsequent letter written by neurologist Louis R. Caplan, MD, who was quoted extensively in the column. Noting that the incidence of strokes has been rising among younger adults, the column took issue with the advice of doctors who told her niece to cut back on physical activity. Dr Caplan was consulted for a second opinion and determined that the imaging studies had been misinterpreted and that the vertebral artery had only narrowed, not closed, allowing the patient to resume her active lifestyle.

Though the column did not specify which doctors had misinterpreted the studies or who had given the unnecessarily restrictive advice, it is difficult to imagine that EPs were responsible for either. Nevertheless, Dr Caplan was subsequently quoted as saying that “stroke experts have had a hard time getting the message across to ER personnel that if a stroke is suspected, a vascular image must be taken as well as a brain image” and that going to an “ER” because of a neurological problem is similar to “run[ning] your Rolls-Royce into the local gas station.” He also said that he is afraid to go to the “emergency room” because he thinks it’s dangerous, and that patients have to “worry about the quality of treatment” there.

In a letter to emergency medicine colleagues after the column appeared, Dr Caplan apologized for quotes taken out of context, and wrote “feel free to convey…to your colleagues” that he did not mean to throw stones at EPs, but wanted to point out that undue limitations on activities can become more disabling than the stroke itself and that system issues, such as long waits and lack of access to past records, not the competency of EPs, made patients afraid. He added that he did “not think being in an ED is dangerous, but is frightening to many patients.”

Clearly, we can all agree on the need for vascular as well as other types of imaging for certain stroke presentations, and that statements in the column were not intended to be understood exactly as written— though to date, no clarifications have since appeared in the column or newspaper. But when such criticism appears in a powerful, respected, and widely disseminated media source, it is almost impossible to undo whatever damage may have been done to public perceptions of ED safety and quality of care. Although many EPs have read or learned of the subsequent clarifying letter, few nonphysicians will ever see or appreciate the disclaimers and clarifications.

To avoid such unfortunate situations in the future, all physicians must be very, very careful in framing statements to the media, and should assume that their remarks will not be placed “in context,” or nuanced as they intended. Most important, is to not disparage entire specialties or use slang terms such as “ER docs” to indicate lesser expertise than one’s own specialty. Doing so can only unnecessarily heighten patients’ fears.  

In a May 2, 2015 editorial “Stroke of Fate,” respected Times columnist Maureen Dowd wrote about her niece’s experience after suffering a vertebral artery dissection that had been “diagnosed correctly and acted on in the ED,” according to a subsequent letter written by neurologist Louis R. Caplan, MD, who was quoted extensively in the column. Noting that the incidence of strokes has been rising among younger adults, the column took issue with the advice of doctors who told her niece to cut back on physical activity. Dr Caplan was consulted for a second opinion and determined that the imaging studies had been misinterpreted and that the vertebral artery had only narrowed, not closed, allowing the patient to resume her active lifestyle.

Though the column did not specify which doctors had misinterpreted the studies or who had given the unnecessarily restrictive advice, it is difficult to imagine that EPs were responsible for either. Nevertheless, Dr Caplan was subsequently quoted as saying that “stroke experts have had a hard time getting the message across to ER personnel that if a stroke is suspected, a vascular image must be taken as well as a brain image” and that going to an “ER” because of a neurological problem is similar to “run[ning] your Rolls-Royce into the local gas station.” He also said that he is afraid to go to the “emergency room” because he thinks it’s dangerous, and that patients have to “worry about the quality of treatment” there.

In a letter to emergency medicine colleagues after the column appeared, Dr Caplan apologized for quotes taken out of context, and wrote “feel free to convey…to your colleagues” that he did not mean to throw stones at EPs, but wanted to point out that undue limitations on activities can become more disabling than the stroke itself and that system issues, such as long waits and lack of access to past records, not the competency of EPs, made patients afraid. He added that he did “not think being in an ED is dangerous, but is frightening to many patients.”

Clearly, we can all agree on the need for vascular as well as other types of imaging for certain stroke presentations, and that statements in the column were not intended to be understood exactly as written— though to date, no clarifications have since appeared in the column or newspaper. But when such criticism appears in a powerful, respected, and widely disseminated media source, it is almost impossible to undo whatever damage may have been done to public perceptions of ED safety and quality of care. Although many EPs have read or learned of the subsequent clarifying letter, few nonphysicians will ever see or appreciate the disclaimers and clarifications.

To avoid such unfortunate situations in the future, all physicians must be very, very careful in framing statements to the media, and should assume that their remarks will not be placed “in context,” or nuanced as they intended. Most important, is to not disparage entire specialties or use slang terms such as “ER docs” to indicate lesser expertise than one’s own specialty. Doing so can only unnecessarily heighten patients’ fears.  

Sweeping proposals disclosed late May would create profit guidelines for private Medicaid plans as well as new standards for the plans’ doctor and hospital networks and rules to coordinate Medicaid insurance more closely with other coverage.

“We are taking steps to align how these programs work,” said Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services.

©sripphoto/Thinkstock

Privatized Medicaid has grown rapidly as budget-pinched states have responded to commercial insurers’ promise to deliver care for a fixed price. Most beneficiaries of Medicaid – state programs for the poor run partly with federal dollars – now get care through contracted insurers.

The 653-page rule, which also would require states to establish quality ratings for Medicaid plans, constitutes the biggest regulation change to Medicaid managed care in more than a decade. The National Association of Medicaid Directors, a group of state officials, called it a “milestone.”

One proposal would require plans to assume, for rate-setting purposes, that they will spend at least 85% of their revenue on medical care.

Such a “medical loss ratio” target is similar to that required under the Affordable Care Act for other plans, but with a key difference: Unlike health plans sold through the law’s online marketplaces and elsewhere, Medicaid plans wouldn’t have to rebate the difference if they spend less than 85%.

But states would still “need to take that into account the next year” when they set new rates, thus limiting profits later, said Vikki Wachino, CMS deputy administrator.

Jeff Myers, CEO of Medicaid Health Plans of America, an industry group, criticized the inclusion of the medical loss ratio (MLR) standard, which supporters promote as ensuring that plans spend a minimum amount on care instead of executive salaries and shareholder profits.

“We don’t believe a nationwide MLR is appropriate,” Mr. Myers said. A uniform profit standard across diverse states could limit plans’ ability to spend administrative dollars to fine-tune care coordination and quality, he said.

Generally, however, “we are very supportive of the direction they are going,” he said of the CMS. He particularly praised the proposal to better align the Children’s Health Insurance Program (CHIP) with Medicaid.

Led by giants such as UnitedHealthcare, Anthem, Aetna and Centene, private Medicaid plans generated nationwide operating profits of $2.4 billion last year, according to regulatory data compiled by Mark Farrah Associates and analyzed by Kaiser Health News.

Advocates for the poor have said that the U.S. Department of Health & Human Services’ regulation of Medicaid managed care has lagged behind the industry’s growth. Industry profits have sometimes come at the expense of denied care and inadequate doctor networks, they say.

A study last year by the HHS’ inspector general found that half the doctors listed in official plan directories weren’t taking new Medicaid patients. Among doctors who were, one fourth couldn’t see patients for a month.

In rules, the CMS proposed new standards for network adequacy that also allow wide flexibility to states. States would have to certify at least annually that Medicaid managed-care patients have sufficient access to doctors and hospitals, based on standards for numbers of medical providers per member, maximum distances required to travel for care, and other criteria.

“This latest proposed guidance ensures that health plans and states have the flexibility to structure their programs and benefits to meet the unique health needs of their enrollees,” Dan Durham, interim CEO of America’s Health Insurance Plans, said in a statement.

Sarah Somers, an attorney with the National Health Law Program, which has long urged updates to federal regulations, praised proposed safeguards for Medicaid members with disabilities and limited English ability.

“The regulations governing network adequacy have some positive aspects,” she added. “But we are concerned that they do not contain the specificity that we recommended.”

The proposal also would establish a quality-rating system, perhaps similar to the star scores assigned to Medicare coverage for seniors, so members could compare plan performance. However, Ms. Wachino said, it was too early to tell what the ratings would look like.

Margaret Murray, CEO of the Association for Community Affiliated Plans, a group of not-for-profit Medicaid companies, said she was disappointed that the quality standards wouldn’t apply to traditional Medicaid run by the states as well as private Medicaid plans.

“We think that managed care will come out ahead in that comparison,” she said.

In a victory for industry, the rules also propose to loosen marketing restrictions on insurers that offer Medicaid coverage as well as plans sold through the ACA marketplaces.

Some companies are counting on capturing customers moving from Medicaid to commercial plans or vice versa as the members’ incomes fluctuate. The new regulation would make it easier for insurers to let Medicaid beneficiaries know that the same company sells a plan through the marketplace.

The rules published May 26 are proposals. The HHS will take comments until late July and issue final rules later.

Kaiser Health News (KHN) is a nonprofit national health policy news service.

Sweeping proposals disclosed late May would create profit guidelines for private Medicaid plans as well as new standards for the plans’ doctor and hospital networks and rules to coordinate Medicaid insurance more closely with other coverage.

“We are taking steps to align how these programs work,” said Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services.

©sripphoto/Thinkstock

Privatized Medicaid has grown rapidly as budget-pinched states have responded to commercial insurers’ promise to deliver care for a fixed price. Most beneficiaries of Medicaid – state programs for the poor run partly with federal dollars – now get care through contracted insurers.

The 653-page rule, which also would require states to establish quality ratings for Medicaid plans, constitutes the biggest regulation change to Medicaid managed care in more than a decade. The National Association of Medicaid Directors, a group of state officials, called it a “milestone.”

One proposal would require plans to assume, for rate-setting purposes, that they will spend at least 85% of their revenue on medical care.

Such a “medical loss ratio” target is similar to that required under the Affordable Care Act for other plans, but with a key difference: Unlike health plans sold through the law’s online marketplaces and elsewhere, Medicaid plans wouldn’t have to rebate the difference if they spend less than 85%.

But states would still “need to take that into account the next year” when they set new rates, thus limiting profits later, said Vikki Wachino, CMS deputy administrator.

Jeff Myers, CEO of Medicaid Health Plans of America, an industry group, criticized the inclusion of the medical loss ratio (MLR) standard, which supporters promote as ensuring that plans spend a minimum amount on care instead of executive salaries and shareholder profits.

“We don’t believe a nationwide MLR is appropriate,” Mr. Myers said. A uniform profit standard across diverse states could limit plans’ ability to spend administrative dollars to fine-tune care coordination and quality, he said.

Generally, however, “we are very supportive of the direction they are going,” he said of the CMS. He particularly praised the proposal to better align the Children’s Health Insurance Program (CHIP) with Medicaid.

Led by giants such as UnitedHealthcare, Anthem, Aetna and Centene, private Medicaid plans generated nationwide operating profits of $2.4 billion last year, according to regulatory data compiled by Mark Farrah Associates and analyzed by Kaiser Health News.

Advocates for the poor have said that the U.S. Department of Health & Human Services’ regulation of Medicaid managed care has lagged behind the industry’s growth. Industry profits have sometimes come at the expense of denied care and inadequate doctor networks, they say.

A study last year by the HHS’ inspector general found that half the doctors listed in official plan directories weren’t taking new Medicaid patients. Among doctors who were, one fourth couldn’t see patients for a month.

In rules, the CMS proposed new standards for network adequacy that also allow wide flexibility to states. States would have to certify at least annually that Medicaid managed-care patients have sufficient access to doctors and hospitals, based on standards for numbers of medical providers per member, maximum distances required to travel for care, and other criteria.

“This latest proposed guidance ensures that health plans and states have the flexibility to structure their programs and benefits to meet the unique health needs of their enrollees,” Dan Durham, interim CEO of America’s Health Insurance Plans, said in a statement.

Sarah Somers, an attorney with the National Health Law Program, which has long urged updates to federal regulations, praised proposed safeguards for Medicaid members with disabilities and limited English ability.

“The regulations governing network adequacy have some positive aspects,” she added. “But we are concerned that they do not contain the specificity that we recommended.”

The proposal also would establish a quality-rating system, perhaps similar to the star scores assigned to Medicare coverage for seniors, so members could compare plan performance. However, Ms. Wachino said, it was too early to tell what the ratings would look like.

Margaret Murray, CEO of the Association for Community Affiliated Plans, a group of not-for-profit Medicaid companies, said she was disappointed that the quality standards wouldn’t apply to traditional Medicaid run by the states as well as private Medicaid plans.

“We think that managed care will come out ahead in that comparison,” she said.

In a victory for industry, the rules also propose to loosen marketing restrictions on insurers that offer Medicaid coverage as well as plans sold through the ACA marketplaces.

Some companies are counting on capturing customers moving from Medicaid to commercial plans or vice versa as the members’ incomes fluctuate. The new regulation would make it easier for insurers to let Medicaid beneficiaries know that the same company sells a plan through the marketplace.

The rules published May 26 are proposals. The HHS will take comments until late July and issue final rules later.

Kaiser Health News (KHN) is a nonprofit national health policy news service.

Sweeping proposals disclosed late May would create profit guidelines for private Medicaid plans as well as new standards for the plans’ doctor and hospital networks and rules to coordinate Medicaid insurance more closely with other coverage.

“We are taking steps to align how these programs work,” said Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services.

©sripphoto/Thinkstock

Privatized Medicaid has grown rapidly as budget-pinched states have responded to commercial insurers’ promise to deliver care for a fixed price. Most beneficiaries of Medicaid – state programs for the poor run partly with federal dollars – now get care through contracted insurers.

The 653-page rule, which also would require states to establish quality ratings for Medicaid plans, constitutes the biggest regulation change to Medicaid managed care in more than a decade. The National Association of Medicaid Directors, a group of state officials, called it a “milestone.”

One proposal would require plans to assume, for rate-setting purposes, that they will spend at least 85% of their revenue on medical care.

Such a “medical loss ratio” target is similar to that required under the Affordable Care Act for other plans, but with a key difference: Unlike health plans sold through the law’s online marketplaces and elsewhere, Medicaid plans wouldn’t have to rebate the difference if they spend less than 85%.

But states would still “need to take that into account the next year” when they set new rates, thus limiting profits later, said Vikki Wachino, CMS deputy administrator.

Jeff Myers, CEO of Medicaid Health Plans of America, an industry group, criticized the inclusion of the medical loss ratio (MLR) standard, which supporters promote as ensuring that plans spend a minimum amount on care instead of executive salaries and shareholder profits.

“We don’t believe a nationwide MLR is appropriate,” Mr. Myers said. A uniform profit standard across diverse states could limit plans’ ability to spend administrative dollars to fine-tune care coordination and quality, he said.

Generally, however, “we are very supportive of the direction they are going,” he said of the CMS. He particularly praised the proposal to better align the Children’s Health Insurance Program (CHIP) with Medicaid.

Led by giants such as UnitedHealthcare, Anthem, Aetna and Centene, private Medicaid plans generated nationwide operating profits of $2.4 billion last year, according to regulatory data compiled by Mark Farrah Associates and analyzed by Kaiser Health News.

Advocates for the poor have said that the U.S. Department of Health & Human Services’ regulation of Medicaid managed care has lagged behind the industry’s growth. Industry profits have sometimes come at the expense of denied care and inadequate doctor networks, they say.

A study last year by the HHS’ inspector general found that half the doctors listed in official plan directories weren’t taking new Medicaid patients. Among doctors who were, one fourth couldn’t see patients for a month.

In rules, the CMS proposed new standards for network adequacy that also allow wide flexibility to states. States would have to certify at least annually that Medicaid managed-care patients have sufficient access to doctors and hospitals, based on standards for numbers of medical providers per member, maximum distances required to travel for care, and other criteria.

“This latest proposed guidance ensures that health plans and states have the flexibility to structure their programs and benefits to meet the unique health needs of their enrollees,” Dan Durham, interim CEO of America’s Health Insurance Plans, said in a statement.

Sarah Somers, an attorney with the National Health Law Program, which has long urged updates to federal regulations, praised proposed safeguards for Medicaid members with disabilities and limited English ability.

“The regulations governing network adequacy have some positive aspects,” she added. “But we are concerned that they do not contain the specificity that we recommended.”

The proposal also would establish a quality-rating system, perhaps similar to the star scores assigned to Medicare coverage for seniors, so members could compare plan performance. However, Ms. Wachino said, it was too early to tell what the ratings would look like.

Margaret Murray, CEO of the Association for Community Affiliated Plans, a group of not-for-profit Medicaid companies, said she was disappointed that the quality standards wouldn’t apply to traditional Medicaid run by the states as well as private Medicaid plans.

“We think that managed care will come out ahead in that comparison,” she said.

In a victory for industry, the rules also propose to loosen marketing restrictions on insurers that offer Medicaid coverage as well as plans sold through the ACA marketplaces.

Some companies are counting on capturing customers moving from Medicaid to commercial plans or vice versa as the members’ incomes fluctuate. The new regulation would make it easier for insurers to let Medicaid beneficiaries know that the same company sells a plan through the marketplace.

The rules published May 26 are proposals. The HHS will take comments until late July and issue final rules later.

Kaiser Health News (KHN) is a nonprofit national health policy news service.

Minnesota and Alabama have joined six other states in enacting a law that aims to expand the practice of telemedicine by streamlining physician licensure. Alabama Gov. Robert Bentley (R) and Minnesota Gov. Mark Dayton (D) on May 19 each signed into law the Interstate Medical Licensure Compact, model legislation developed by the Federation of State Medical Boards (FSMB).

Larry D. Dixon, executive director for the Alabama Board of Medical Examiners, said the law will help ease the physician shortage in rural and other underserved areas.

©Brigitte Wodicka/thinkstockphotos.com

“Now that [eight] states have enacted the compact legislation, we can begin the real work of establishing the compact to ensure patients have access to quality health care services, while maintaining the highest level of patient protections,” Mr. Dixon said in a statement.

The FSMB also announced the creation of a commission that will meet later this year to discuss the management and administration of the compact. Members of the commission will include two voting representatives appointed by each member state. Commissioners will be selected from physicians appointed to a member board, executives of a member board, or members of the public appointed to a member board.

Under the compact legislation approved physicians would be under the jurisdiction of the state medical board in which the patient is located at the time of the medical interaction. State boards of medicine would retain their individual authority for discipline and oversight. Interested physicians would also need to complete a background check including biometric data (such as fingerprints) and pass all components of either the U.S. Medical Licensing Examination or the Comprehensive Osteopathic Medicine Licensing Examination within three attempts.

The model legislation has been introduced in nearly 20 state legislatures. Alabama and Minnesota join Idaho, Montana, South Dakota, Utah, West Virginia, and Wyoming in enacting the law.

[email protected]

@legal_med

Minnesota and Alabama have joined six other states in enacting a law that aims to expand the practice of telemedicine by streamlining physician licensure. Alabama Gov. Robert Bentley (R) and Minnesota Gov. Mark Dayton (D) on May 19 each signed into law the Interstate Medical Licensure Compact, model legislation developed by the Federation of State Medical Boards (FSMB).

Larry D. Dixon, executive director for the Alabama Board of Medical Examiners, said the law will help ease the physician shortage in rural and other underserved areas.

©Brigitte Wodicka/thinkstockphotos.com

“Now that [eight] states have enacted the compact legislation, we can begin the real work of establishing the compact to ensure patients have access to quality health care services, while maintaining the highest level of patient protections,” Mr. Dixon said in a statement.

The FSMB also announced the creation of a commission that will meet later this year to discuss the management and administration of the compact. Members of the commission will include two voting representatives appointed by each member state. Commissioners will be selected from physicians appointed to a member board, executives of a member board, or members of the public appointed to a member board.

Under the compact legislation approved physicians would be under the jurisdiction of the state medical board in which the patient is located at the time of the medical interaction. State boards of medicine would retain their individual authority for discipline and oversight. Interested physicians would also need to complete a background check including biometric data (such as fingerprints) and pass all components of either the U.S. Medical Licensing Examination or the Comprehensive Osteopathic Medicine Licensing Examination within three attempts.

The model legislation has been introduced in nearly 20 state legislatures. Alabama and Minnesota join Idaho, Montana, South Dakota, Utah, West Virginia, and Wyoming in enacting the law.

[email protected]

@legal_med

Minnesota and Alabama have joined six other states in enacting a law that aims to expand the practice of telemedicine by streamlining physician licensure. Alabama Gov. Robert Bentley (R) and Minnesota Gov. Mark Dayton (D) on May 19 each signed into law the Interstate Medical Licensure Compact, model legislation developed by the Federation of State Medical Boards (FSMB).

Larry D. Dixon, executive director for the Alabama Board of Medical Examiners, said the law will help ease the physician shortage in rural and other underserved areas.

©Brigitte Wodicka/thinkstockphotos.com

“Now that [eight] states have enacted the compact legislation, we can begin the real work of establishing the compact to ensure patients have access to quality health care services, while maintaining the highest level of patient protections,” Mr. Dixon said in a statement.

The FSMB also announced the creation of a commission that will meet later this year to discuss the management and administration of the compact. Members of the commission will include two voting representatives appointed by each member state. Commissioners will be selected from physicians appointed to a member board, executives of a member board, or members of the public appointed to a member board.

Under the compact legislation approved physicians would be under the jurisdiction of the state medical board in which the patient is located at the time of the medical interaction. State boards of medicine would retain their individual authority for discipline and oversight. Interested physicians would also need to complete a background check including biometric data (such as fingerprints) and pass all components of either the U.S. Medical Licensing Examination or the Comprehensive Osteopathic Medicine Licensing Examination within three attempts.

The model legislation has been introduced in nearly 20 state legislatures. Alabama and Minnesota join Idaho, Montana, South Dakota, Utah, West Virginia, and Wyoming in enacting the law.

[email protected]

@legal_med

After nearly 15 years of litigation between UnitedHealth Group Inc. and a group of physicians, the health insurance giant agreed to pay $11.5 million to resolve allegations that it incorrectly paid and managed doctors’ billing claims.

UnitedHealth Group and its subsidiaries agreed to spend at least $9 million in enhancements to its provider self-service website to increase efficiency and reduce delays in managing of claims. The additional funds will go toward educational programs for medical society members pertaining to ICD-10-CM coding, CPT coding, medical review audits, appeals, and claims submission and processing. The settlement stems from lawsuits filed in 2001 by the Medical Society of the State of New York, the Connecticut State Medical Society, the North Carolina Medical Society, the Tennessee Medical Association, and several individual physicians.

Daryl Richard, UnitedHealth Group spokesman, said that the insurer was pleased to finally be ending the litigation, and that the company looks forward to new ways of collaborating with doctors.

“Physicians will have simpler and more comprehensive access to claims management information through enhancements we are making to our physician website,” Mr. Richard said in a statement.

Dr. Joseph Maldonado, president of the New York medical society, said the settlement was a significant victory for physicians.

©jsmith/iStockphoto

“This settlement will improve access to information and the ability to adjust claims for all in-network physicians contracting with United and submitting claims, while providing certain benefits to member physicians,” he said in a statement.

The case was part of a series of lawsuits filed in the early 2000s alleging illegal business practices and corruption by Aetna, Cigna, UnitedHealthcare, Healthnet, Humana, PacifiCare, Prudential, and WellPoint. The suits alleged that the defendants engaged in a conspiracy to wrongfully and fraudulently pay doctors less than the amounts to which they were entitled. Several of the cases were consolidated into what is referred to in court documents as “the lead case.”

The medical societies’ litigation was halted pending the outcome of the lead case, according to the UnitedHealth Group settlement documents. Following a 2007 ruling for defendants in the lead case, plaintiffs in the medical societies’ case attempted to revive their litigation, and a lengthy court battle ensued. The parties tried unsuccessfully to negotiate a settlement for years.

Meanwhile, settlements were eventually reached in the lead case with insurers agreeing to change their business practices and reimburse the plaintiff physicians for hundreds of million dollars, according to a summary by the American Medical Association, a plaintiff in one of the original cases. In addition, the settlements required the insurers to disclose their coding edits, adopt certain CPT conventions, and clarify the criteria under which medical procedures will be deemed medically necessary.

In its settlement with the medical societies, UnitedHealth Group denied all allegations in the suit and admitted no wrongdoing. For their part, the medical societies stated the claims have merit, but that they will dismiss the suit following payment of the settlement, according to court documents.

The settlement will offer significant relief in the areas of claims management and claims resolution, said Edith Kallas, a New York–based attorney and legal counsel for plaintiffs.

“We applaud the medical societies and individual physicians for their commitment to obtaining a meaningful resolution of these issues,” she said in a statement.

[email protected]

On Twitter @legal_med

After nearly 15 years of litigation between UnitedHealth Group Inc. and a group of physicians, the health insurance giant agreed to pay $11.5 million to resolve allegations that it incorrectly paid and managed doctors’ billing claims.

UnitedHealth Group and its subsidiaries agreed to spend at least $9 million in enhancements to its provider self-service website to increase efficiency and reduce delays in managing of claims. The additional funds will go toward educational programs for medical society members pertaining to ICD-10-CM coding, CPT coding, medical review audits, appeals, and claims submission and processing. The settlement stems from lawsuits filed in 2001 by the Medical Society of the State of New York, the Connecticut State Medical Society, the North Carolina Medical Society, the Tennessee Medical Association, and several individual physicians.

Daryl Richard, UnitedHealth Group spokesman, said that the insurer was pleased to finally be ending the litigation, and that the company looks forward to new ways of collaborating with doctors.

“Physicians will have simpler and more comprehensive access to claims management information through enhancements we are making to our physician website,” Mr. Richard said in a statement.

Dr. Joseph Maldonado, president of the New York medical society, said the settlement was a significant victory for physicians.

©jsmith/iStockphoto

“This settlement will improve access to information and the ability to adjust claims for all in-network physicians contracting with United and submitting claims, while providing certain benefits to member physicians,” he said in a statement.

The case was part of a series of lawsuits filed in the early 2000s alleging illegal business practices and corruption by Aetna, Cigna, UnitedHealthcare, Healthnet, Humana, PacifiCare, Prudential, and WellPoint. The suits alleged that the defendants engaged in a conspiracy to wrongfully and fraudulently pay doctors less than the amounts to which they were entitled. Several of the cases were consolidated into what is referred to in court documents as “the lead case.”

The medical societies’ litigation was halted pending the outcome of the lead case, according to the UnitedHealth Group settlement documents. Following a 2007 ruling for defendants in the lead case, plaintiffs in the medical societies’ case attempted to revive their litigation, and a lengthy court battle ensued. The parties tried unsuccessfully to negotiate a settlement for years.

Meanwhile, settlements were eventually reached in the lead case with insurers agreeing to change their business practices and reimburse the plaintiff physicians for hundreds of million dollars, according to a summary by the American Medical Association, a plaintiff in one of the original cases. In addition, the settlements required the insurers to disclose their coding edits, adopt certain CPT conventions, and clarify the criteria under which medical procedures will be deemed medically necessary.

In its settlement with the medical societies, UnitedHealth Group denied all allegations in the suit and admitted no wrongdoing. For their part, the medical societies stated the claims have merit, but that they will dismiss the suit following payment of the settlement, according to court documents.

The settlement will offer significant relief in the areas of claims management and claims resolution, said Edith Kallas, a New York–based attorney and legal counsel for plaintiffs.

“We applaud the medical societies and individual physicians for their commitment to obtaining a meaningful resolution of these issues,” she said in a statement.

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On Twitter @legal_med

After nearly 15 years of litigation between UnitedHealth Group Inc. and a group of physicians, the health insurance giant agreed to pay $11.5 million to resolve allegations that it incorrectly paid and managed doctors’ billing claims.

UnitedHealth Group and its subsidiaries agreed to spend at least $9 million in enhancements to its provider self-service website to increase efficiency and reduce delays in managing of claims. The additional funds will go toward educational programs for medical society members pertaining to ICD-10-CM coding, CPT coding, medical review audits, appeals, and claims submission and processing. The settlement stems from lawsuits filed in 2001 by the Medical Society of the State of New York, the Connecticut State Medical Society, the North Carolina Medical Society, the Tennessee Medical Association, and several individual physicians.

Daryl Richard, UnitedHealth Group spokesman, said that the insurer was pleased to finally be ending the litigation, and that the company looks forward to new ways of collaborating with doctors.

“Physicians will have simpler and more comprehensive access to claims management information through enhancements we are making to our physician website,” Mr. Richard said in a statement.

Dr. Joseph Maldonado, president of the New York medical society, said the settlement was a significant victory for physicians.

©jsmith/iStockphoto

“This settlement will improve access to information and the ability to adjust claims for all in-network physicians contracting with United and submitting claims, while providing certain benefits to member physicians,” he said in a statement.

The case was part of a series of lawsuits filed in the early 2000s alleging illegal business practices and corruption by Aetna, Cigna, UnitedHealthcare, Healthnet, Humana, PacifiCare, Prudential, and WellPoint. The suits alleged that the defendants engaged in a conspiracy to wrongfully and fraudulently pay doctors less than the amounts to which they were entitled. Several of the cases were consolidated into what is referred to in court documents as “the lead case.”

The medical societies’ litigation was halted pending the outcome of the lead case, according to the UnitedHealth Group settlement documents. Following a 2007 ruling for defendants in the lead case, plaintiffs in the medical societies’ case attempted to revive their litigation, and a lengthy court battle ensued. The parties tried unsuccessfully to negotiate a settlement for years.

Meanwhile, settlements were eventually reached in the lead case with insurers agreeing to change their business practices and reimburse the plaintiff physicians for hundreds of million dollars, according to a summary by the American Medical Association, a plaintiff in one of the original cases. In addition, the settlements required the insurers to disclose their coding edits, adopt certain CPT conventions, and clarify the criteria under which medical procedures will be deemed medically necessary.

In its settlement with the medical societies, UnitedHealth Group denied all allegations in the suit and admitted no wrongdoing. For their part, the medical societies stated the claims have merit, but that they will dismiss the suit following payment of the settlement, according to court documents.

The settlement will offer significant relief in the areas of claims management and claims resolution, said Edith Kallas, a New York–based attorney and legal counsel for plaintiffs.

“We applaud the medical societies and individual physicians for their commitment to obtaining a meaningful resolution of these issues,” she said in a statement.

[email protected]

On Twitter @legal_med

CHICAGO – Technology advances are giving patients direct access to myriad health tests and their own health data, but what role do physicians have in responding to such patient-generated assessments?

Dr. Marc Triola of New York University in New York says that the growing reach of health care technology presents both challenges and opportunities for the physician-patient relationship. Dr. Triola spoke at the annual meeting of the American Medical Women’s Association about how physicians can embrace technology and use advancements to improve quality of care.

In this video interview, Dr. Triola speaks about the new ways in which patients can assess their own health data and how doctors should address the test results. He also discusses barriers posed by new technology and how physicians can help shape the changing delivery of health care.

[email protected]

On Twitter @legal_med

CHICAGO – Technology advances are giving patients direct access to myriad health tests and their own health data, but what role do physicians have in responding to such patient-generated assessments?

Dr. Marc Triola of New York University in New York says that the growing reach of health care technology presents both challenges and opportunities for the physician-patient relationship. Dr. Triola spoke at the annual meeting of the American Medical Women’s Association about how physicians can embrace technology and use advancements to improve quality of care.

In this video interview, Dr. Triola speaks about the new ways in which patients can assess their own health data and how doctors should address the test results. He also discusses barriers posed by new technology and how physicians can help shape the changing delivery of health care.

[email protected]

On Twitter @legal_med

CHICAGO – Technology advances are giving patients direct access to myriad health tests and their own health data, but what role do physicians have in responding to such patient-generated assessments?

Dr. Marc Triola of New York University in New York says that the growing reach of health care technology presents both challenges and opportunities for the physician-patient relationship. Dr. Triola spoke at the annual meeting of the American Medical Women’s Association about how physicians can embrace technology and use advancements to improve quality of care.

In this video interview, Dr. Triola speaks about the new ways in which patients can assess their own health data and how doctors should address the test results. He also discusses barriers posed by new technology and how physicians can help shape the changing delivery of health care.

[email protected]

On Twitter @legal_med