California
FAMILY PHYSICIAN VOL. 62 NO. 4 Fall 2011
WHAT ACOS MUST DO … 17 AND WHAT THAT MEANS FOR YOU ACO S OPERATE LIKE A NEIGHBORHOOD 18 FOR YOUR PATIENT CENTERED MEDICAL HOME ACO S PLAY A BIG ROLE IN CALIFORNIA’S 20 QUALITY IMPROVEMENT HOW ARE PRIVATE ORGANIZATIONS 21 PREPARING FOR ACOS? HOW ARE COMMUNITIES RESPONDING 22 TO ALL THIS ACO TALK?
ACCOUNTABLE CARE ORGANIZATIONS (ACOS) What do unicorns have to do with accountable care organizations? . . . . . . .
T H E C A L I F O R N I A A C A D E M Y O F F A M I LY P H Y S I C I A N S • S T R O N G M E D I C I N E F O R C A L I F O R N I A
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We relentlessly defend, protect, and reward the practice of good medicine. Robert D. Francis Chief Operating Officer, The Doctors Company
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Version 5010 Deadline:
JAN 1st, 2012 ICD-10 Deadline:
OCT 1st, 2013
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1520 Pacific Avenue • San Francisco, California 94109 • www.familydocs.org Phone (415) 345-8667 • Fax (415) 345-8668 • E-mail: cafp@familydocs.org
Officers and Board
Staff
President Carol Havens, MD
Cecilia Awayan
Susan Hogeland, CAE
Cody Mitcheltree
Receptionist and Membership Administrator
Executive Vice President
Student and Resident Coordinator
Karisa Juachon, CPA
Chris Navalta
Chief Financial Officer
Manager, Publications and Marketing
jcho@familydocs.org
Cynthia Kear, CCMEP
Adam Francis
ckear@familydocs.org
Leah Newkirk Director, Health Policy lnewkirk@familydocs.org
President-Elect Steven Green, MD Immediate Past President Jack Chou, MD Speaker Mark Dressner, MD Vice-Speaker Delbert Morris, MD Secretary/Treasurer Jay Lee, MD, MPH Executive Vice President Susan Hogeland, CAE Foundation President Robert Bourne, MD AAFP Delegates Jack Chou, MD Carla Kakutani, MD AAFP Alternates Jeffrey Luther, MD Eric Ramos, MD CMA Delegation Steve Green, MD Nathan Hitzeman, MD Carla Kakutani, MD Kevin Rossi, MD Patricia Samuelson, MD Ashby Wolfe, MD
cafp@familydocs.org Jane Cho Manager, Medical Practice Affairs
shogeland@familydocs.org
ktop@familydocs.org Senior Vice President
Assistant Director, Government Relations
Callie Langton, PhD
Sophia Henry
clangton@familydocs.org
afrancis@familydocs.org
Associate Director, Health Care Workforce Policy
Membership Manager
cmitcheltree@familydocs.org
cnavalta@familydocs.org
Tom Riley Director, Government Relations triley@familydocs.org Shelly Rodrigues, CAE, CCMEP Deputy Executive Vice President CAFP Foundation Executive Director
shenry@familydocs.org
srodrigues@familydocs.org
California FAMILY PHYSICIAN Quarterly publication of the California Academy of Family Physicians
Michelle Quiogue, MD, Editor Chris Navalta, Managing Editor
Communications Committee: Michelle Quiogue, MD, Chair • Julia Blank, MD • Nathan Hitzeman, MD
• Jeffrey Luther, MD • Jay Mongiardo, MD
• Albert Ray, MD • Lindsay Larson, DO
The California Family Physician (CFP) is published quarterly by the California Academy of Family Physicians (CAFP). Opinions are those of the authors and not necessarily those of the members and staff of the CAFP. Non-member subscriptions are $35 per year. Call 415-345-8667 to subscribe. Advertising and publication management, Publishing Concepts Inc., 14109 Taylor Loop Road, Little Rock, Arkansas 72223. Phone (800) 561-4686. For ads: David Brown, dbrown@pcipublishing.com. Web address: www.pcipublishing.com Cover Illustration: Accountable Care Organizations (ACOs) can be compared to unicorns: You can describe what they look like, but nobody has actually seen one. This issue of California Family Physician provides information on what ACOs really are and how this will affect family medicine. Illustration by Julie Eriksen, ValForms, Inc.
Looking for a job? Go to www.fpjobsonline.com where you can: • search jobs for free • post a résumé • be visible to employers • receive e-mail alerts of new job postings Questions? Call 888-884-8242and a HEALTHeCAREERS representative will help you.
A C C O U N TA B L E C A R E O R G A N I Z AT I O N S 17 What ACOs Must Do … and What That Means for You
Bruce Bagley, MD
18 ACOs Operate Like a Neighborhood for Your Patient Centered Medical Home 20 ACOs Play a Big Role in California’s Quality Improvement
Leah Newkirk David D. O’Neill, JD, MPH
21 How Are Private Organizations Preparing for ACOs? 22 How Are Communities Responding to All this ACO Talk?
Steven Green, MD Joseph E. Scherger, MD, MPH
6 Editorial
Time for a Reality Check; DON’T Leave Change to Chance
7 President’s Message
Will YOU Be Ready for Accountable Care Organizations?
8 Political Pulse
CAFP Continues to Flex Its Muscles in Sacramento
10 Student News
California Reception Offers Hope for a “Better Tomorrow” Kareen Espino Residency Fair Makes Decisions a Lot Easier David English and David Piccinati
11 Resident News
Superheroes Descend on Kansas City
12 QI Corner
Approaching Diabetes Care is a Team Effort
14 Practice Management News Protect Your Practice from Embezzlement 16 News in Brief
Michelle Quiogue, MD Carol Havens, MD Tom Riley
Alisha Dyer, DO Jane Cho
Barbara Hensleigh
25 Executive Vice President's Forum Is a Checklist Necessary for Patient Care?
For the upcoming CME calendar go to www.familydocs.org
Susan Hogeland, CAE
Michelle Quiogue, MD
EDITORIAL
Time for a Reality Check; DON’T Leave Change to Chance You know what is happening in health care. You know what is working and you know what doesn’t work. Can you allow lawmakers to make important decisions about health care without your input? This message from AAFP leadership is my favorite souvenir from this year’s Family Medicine Congressional Conference. As I climbed the marble steps and walked the symmetrical maze-like hallways of our nation’s capital, I never felt more connected to our history of democracy. I learned so much about delivering the promise of family medicine to our representatives from our professional lobbyists and veteran physician-advocates. At the second annual National Accountable Care Organization Summit held this past June, Health and Human Services (HHS) Secretary Kathleen Sebelius reported that HHS is sifting through more than 1,200 comments submitted by stakeholders in the health care industry on HHS' recently released proposed rules that would implement the Medicare Shared Savings Program and Accountable Care Organization (ACO) provisions of the Patient Protection and Affordable Care Act (PPACA). The goal of the review process is to find a balance among the needs of patients, health care providers and payors while also improving costs and health care quality. Among those comments are the AAFP and CAFP analysis of the proposed rules. This valuable reality check sent to your lawmakers by your Academy is worth much more than your membership dues. CAFP and AAFP key recommendations include urging that the Centers for Medicare and Medicaid Services (CMS): • Identify alternative policies so that primary care physicians are able to participate in multiple Medicare ACOs; • Not confine its payment method to the current, traditional Medicare fee-for-service payments to ACO participants but instead employ a variety of payment approaches, such as blended fee-for-service payments, prospective payments, episode/case rate payments and partial capitation payments; • Reconsider its proposed Medicare ACO policies and instead offer greater flexibility so that more small- to
6 California Family Physician Fall 2011
medium-sized primary care practices will be eligible to participate; • Consider proposing additional tracks that are tailored for smaller medical practices less familiar with assuming financial risk; • Specify that the Medicare ACO governance structure must utilize primary care physicians in the top leadership positions to ensure that Medicare ACOs are primary care driven; and • Outline quality reporting requirements for the full three-year program; significantly reduce the number of required quality measures; and only require reporting on quality measures that improve population health outcomes and efficiency. The importance of feedback from family physicians to all levels of government cannot be overstated. The lasting impression from my advocacy trips to Sacramento and Washington, DC is how we can never take for granted that lawmakers understand our work and our patients. Just as we know best those patients whom we see most often, our representatives understand issues that they hear about most often. A system that is primary care-driven will not emerge by accident and the stakes are too high to leave this to chance. The challenge of achieving better care at lower costs has never been more important or more urgent, and the serious challenges of getting from here to there have never been more daunting. I am proud of our Academy for being the strong voice of family medicine to policymakers and regulators. I urge each of us to contribute what we can to this group effort. With more than 7,000 California members we can be the strongest primary care force in Sacramento. Your active participation is the missing catalytic enzyme that converts ideology to reality. Where should you go to contribute your input? A great place to start is the CAFP Congress of Delegates, held March 3-5, 2012 in Sacramento – where words turn into action.
PRESIDENT'S MESSAGE
Carol Havens, MD
Will YOU Be Ready for Accountable Care Organizations? Accountable Care Organizations (ACOs) sound like a great idea. Who wouldn’t want organizations to be more accountable? However, in this context, ACO refers to a specific type of organization. There is a lot of confusion about what that is, however. At its most basic, an ACO is a group of health care providers who agree to take responsibility for both the quality and cost of care for a defined group of patients. We already take on the responsibility for the quality of care we deliver, so the added part here is the responsibility for costs. There are a variety of models of ACOs, though the Medicare Shared Savings Program is the one that has the potential to affect most of us. New regulations were released earlier this year, and will go into effect on January 1, 2012. So is this the second coming of the managed care of the 1990s? Not really … although there are some similarities. In the original version, it was mainly a capitated system, with much of the financial risk falling on primary care providers. We were often seen as “gatekeepers” to prevent patients from seeing the more highly compensated specialists, rather than as active participants in providing care. And it was all about controlling costs rather than improving quality. The ACO model is very different, both in payment, as well as philosophy. The current ACO model has the potential to be a huge boon to family medicine and to family physicians. It rewards care management, which is currently not being paid. It requires that a majority of the governing body must be ACO providers. And ACOs that can reduce their costs while reaching quality targets will be eligible for additional revenue. In the demonstration projects to date, the greatest savings have been in reduced hospitalization costs, reduced imaging and actively managing chronic diseases, including improved transitions of
care between outpatient, hospital and skilled nursing care. The Patient Centered Medical Home (PCMH) is perfect for ACOs. The PCMH includes alternatives to office visits to provide care, use of electronic health records (EHRs), registries, chronic disease management and team-based care. All of these will also support ACOs. The challenge for us is to figure out how to incorporate those things into our practices – but once we do, we will be in a position to decide whether or not we would benefit from joining an ACO. In the current regulations, at least 50 percent of an ACO’s primary care physicians must be meaningful users of EHRs. If you are, you will be in a better position to negotiate. Whether or not you choose to join an ACO or even agree with the concept, it is clear there will be changes to our current payment system as well as increased pressure to demonstrate quality of care and provision of evidence-based medicine. While we all have some concerns about the actual implementation of the new (and future) regulations, I am confident that there will be more changes coming. It is important that you are educated about these changes as they occur so you are making informed decisions. CAFP Director of Health Policy Leah Newkirk gave a nice overview in the last issue of this magazine, and now this whole issue is dedicated to the topic. So we can either be active participants in the process – in developing, designing and implementing the regulations – or we can hope that nothing changes to adversely affect us. Your academy is actively pursuing the former strategy. Your choice is to prepare yourself and your practice for change or be willing to take what you are given. Which will you choose?
California Family Physician Fall 2011 7
Tom Riley
CAFP Continues to Flex Its Muscles in Sacramento The California State Legislature is made up of 120 individuals, each having a different responsibility to his or her constituents. This means during every two-year legislative session, each legislator makes tough choices about which bills he or she authors. Despite this selection process, of the several thousand bills introduced each session, most will not make it to the Governor’s desk — even fewer will become law. CAFP’s Legislative Affairs Committee also makes tough decisions about which bills CAFP will help to become law and which bills CAFP will oppose. This involves supporting or opposing more than 30 bills, then lobbying members of the Legislature in Sacramento, their home districts and in the press. CAFP members play the crucial role of not only setting priorities for legislation, but also taking time out of their busy days to meet with senators or
assemblymembers, testify in hearings and speak to reporters. As we prepare to enter the second half of the 2011-12 legislative session, three trends have emerged: First, with few exceptions, nothing that costs the state money will move beyond fiscal committees. Second, bills that could change payment incentives within health care, either in anticipation of federal health care reform or independently from it, have proved controversial. Finally, because several pending decisions in Washington, DC and in the courts could change the health care dynamic within California, leaders here have adopted a “go slow” policy to let federal laws and regulations be settled before taking state action. What follows are a few bills on which CAFP has been active. To read more go to: http://www.familydocs.org/advocacy/ cafp-positions-on-legislation.php
CAFP Wins in Sacramento CAFP's advocacy team is working hard to improve health care in California. Here are some recent "wins" for CAFP, family physicians and patients. Twelve CAFP-Supported Bills Await Governor's Signature As of this writing, 12 CAFP-supported bills have made it through the entire legislative process and await Governor Jerry Brown's signature or veto. These bills include AB 210 (Hernández) and SB 222 (Evans) which would require insurance companies to provide maternity coverage for women with group or individual health plans; SB 866 (Hernández) which requires regulators to develop a standardized prescription drug benefit prior authorization form for use by all providers and plans, and stipulates that upon a failure to accept the prior authorization form or to respond to a physician within two business days, the bill would deem the prior authorization request granted; and SB 746 (Lieu) which would prohibit persons under 18 years of age from using ultraviolet tanning devices in tanning salons. FP-PAC On Pace to Break Single Year Fundraising Record Family physicians are showing their support for the Family Physicians Political Action Committee (FP-PAC) in record numbers. Heading into the important 2012 election year, it is crucial that we maintain this momentum so that FP-PAC can support family physician friendly candidates running for state office. If you have yet to contribute, please go to www.familydocs.org/fppac and give today!
8 California Family Physician Fall 2011
SB 393 (Hernández) Medical Homes Authored by the Chair of the Senate Health Committee, Ed Hernández (D-Los Angeles), this CAFP-sponsored bill would add a more functional definition of “Patient Centered Medical Home” to California law. Joining CAFP in co-sponsorship of the bill are the American Academy of Pediatrics-California chapters, California Psychiatric Association, Osteopathic Physicians and Surgeons of California, American College of Physicians-California chapters, California Association of Physician Assistants, California Association for Nurse Practitioners, California Association of Physicians Groups, and California Primary Care Association. Position: Sponsor AB 1059 (Huffman) Health Care Service Plans This bill requires health plans to pay a provider the amount owed to them, plus interest, if it has been determined to have underpaid or failed to pay a provider. Position: Support AB 669 (Monning) Taxation: Sweetened Beverage Tax: Children’s Health Promotion Fund This bill would have imposed a tax on sweetened beverages to help combat obesity and diabetes. Position: Support SB 635 (Hernandez) Health Care: Workforce Training Currently, the first $1 million in fines and penalties assessed against health insurers is deposited into the Stephen M. Thompson Physician Corp Loan Repayment Program. Any amount over the first $1 million, including accrued interest, is deposited in the Major Risk Medical Insurance Fund. This fund helps provide major risk medical coverage to individuals who were denied coverage by at least one private health plan. Due to the coverage expansion in federal health care reform, this fund will be obsolete in 2014. This bill would instead transfer funds over the first $1 million each year to support family medicine training in the Song-Brown Workforce Training program. Position: Support
AB 52 (Feuer) Health Care Coverage: Rate Approval The bill would authorize the Department of Managed Health Care and the Department of Insurance to approve, deny or modify an insurance premium increase found to be excessive, inadequate or unfairly discriminatory. Despite the sponsor’s (Insurance Commissioner Dave Jones) request that CAFP support Assemblyman Feuer’s “rate regulation” bill, CAFP has opted to remain neutral on the subject for the following reasons: • CAFP membership opinion has been mixed on the issue. Some CAFP members have argued that payment, including payment for primary care services delivered in the context of the Patient Centered Medical Home (PCMH), may be fairer in those states where insurance commissioners have such discretion;
POLITICAL PULSE
services beginning in 2012. Position: Support
tanning device in a tanning salon. Position: Support
SB 486 (Dutton) California Children and Families Program: Funding: Abolishes the California Children and Families Commission and the county children and families commissions and would require that its provisions be submitted to the voters for approval at the next statewide election. Position: Oppose
AJR 10 (Brownley) School-based Health Centers This bill declares the legislature’s support for the school-based health center program authorized by the federal health care reform law, including support for school-based health centers as partners in creating medical homes for all children. The bill was signed by the Governor. Position: Support
SB 746 (Lieu) Tanning Facilities This bill prohibits persons younger than 18 years of age from using an ultraviolet
Tom Riley is CAFP’s Director of Government Relations.
• Other CAFP members are concerned that supporting such regulation could hurt large medical groups; • Many of our allies are opposed to it; and • There is concern that while the current Insurance Commissioner has been supportive of primary care and PCMH, such power in a future commissioner could be used against physicians. As of this writing (September), the bill has been made into a two-year bill after strong opposition from the California Medical Association, health insurers and the California Hospital Association. Position: Watch Carefully AJR 13 (Lara) Graduate Medical Education This bill urges the President and Congress to continue providing resources to increase the supply of physicians in California and to consider solutions that would increase the number of graduate medical education residency positions. Position: Support SB 155 (Evans) Maternity Services This bill requires every individual and group health insurance policy to provide coverage for maternity California Family Physician Fall 2011 9
California Reception Offers Hope for a “Better Tomorrow”
STUDENT NEWS
Residency Fair Makes Decisions a Lot Easier By David English and David Piccinati
By Kareen Espino
Part of the beauty of family medicine When I started medical school, I
wanted to be an emergency physician. Fortunately, by the end of my first year, I met some amazing mentors who made me realize that my calling was to become a family physician. I got involved in UC Irvine’s Family Medicine Interest Group and Family Medicine Scholars program and attended CAFP’s annual student and resident conferences. These experiences have enriched my path toward becoming a family physician. However, I knew I was still missing an event that no medical student (much less a future family physician) should leave school without experiencing — the AAFP National Conference for Medical Students and Family Medicine Residents in Kansas City, MO. I was fortunate to receive a scholarship from AAFP to attend this year’s conference (held July 28-30). After attending three days of practical workshops and relevant lectures on various topics, and having opportunities to interact with more than 300 family medicine residency programs, I understood the importance of going to this conference. Not only was it the perfect chance to learn from renowned family medicine and public health leaders and familiarize myself with different residency programs, it was also a chance to interact with passionate medical students from all over the country. It’s not every day that I get to be surrounded by so many family medicine enthusiasts whose mission is to change the world one community at a time, regardless of the myriad challenges. The energy and dedication each of these students exudes is not only admirable, but contagious. In addition to the great events and people at this year’s conference, CAFP hosted its annual California Reception. This was a great opportunity to network with physicians, residents and medical students from all over California. During the reception, I was inspired by New Family Physician Director Jay W. Lee, MD’s message for family physicians and other primary care providers to “embrace the idea that [they] are better than how [they] are currently valued and that we need to 'revolt' against the fragmented health care delivery machine that exists right now.” It is refreshing to know there are people such as Dr. Lee who are leading the way to a better tomorrow, in which family physicians are put on an equal footing with other specialties, and medical students are not told that they are “too smart” to become family physicians. And while I join the ‘revolt’ known as the “Family Medicine Revolution,” I realize I can find many different ways to contribute. One clear way is to get involved with AAFP and CAFP as well as going to next year’s AAFP National Conference in Kansas City. Kareen Espino is a fourth year PRIME-LC student at UC Irvine School of Medicine currently pursuing a MPH at UCLA. 10 California Family Physician Fall 2011
David English
residency programs is that they are extremely diverse. This is also part of the intricacy when it comes time to apply. Where to begin? How does one decide what the right fit is? Is it possible to know what a program’s culture is before a rank list can be made? The AAFP National Conference for Medical Students and Family Medicine Residents makes approaching the looming application process a much less terrifying prospect. After attending the conference, we came away with a clearer idea of what programs could offer (not to mention what we students can offer to these programs). After all, residency is a “match” and we are making an enormous career choice.
The most efficient way to learn about a program is to spend time with its residents. In fact while strolling through the seemingly David Piccinati never-ending aisles of displays – admittedly in search of a free pen or two in some cases – we stumbled across programs we never would have considered. And this isn’t because they are not well-respected, reputable programs offering excellent and broad training, but rather because it’s terribly complicated to judge a program’s feel based on a website, pamphlet or word of mouth. We were so surprised by some of these experiences we are now applying to programs we weren’t even considering. Spending time chatting at the booths in the exhibition hall on topics from global health rotations to what procedural services are offered in the clinics, to whether or not the local community is dog-friendly, is the best way to find a match. On top of this, friends are made, your presence is known and you may even enjoy a complimentary dinner or two with residents and program directors. This year’s AAFP conference was an invaluable experience. We were able to effectively confirm or deny previous notions regarding various programs, learn from superb talks, catch up with old friends from across the country and make a few new ones while we were at it. It’s also more about what we can give back than what we can get from the conference. From the various speakers’ inspiring presentations to seeing what other student leaders are doing to shape the face of family medicine, to hearing about what residents are doing for the communities they serve, we return home to the wards, clinics, communities and classrooms filled with new hope and ideas. At our school’s next Family Medicine Interest Group meeting, we will laud the many wonders that were this year’s national conference, and we look forward to returning as residents! David English is a fourth year student at the UC Davis School of Medicine. David Piccinati is a fourth year student at UC San Diego School of Medicine.
RESIDENT NEWS
Alisha Dyer, DO
Superheroes Descend on Kansas City They come from all over the country,
UC Irvine said “Most medical students train in subspecialty-driven academic descending upon downtown Kansas City, medical centers where the value of MO. They’re together to collaborate, family medicine goes unrecognized. learn and celebrate becoming the next We are told, ‘You are too smart to be generation of “superheroes.” Each with a family doctor’ a different story or, ‘Don’t you and background, “I am proud to be a part want to do more they possess unique of such a special group than treat colds?’ powers to fight Students need to for the rights of that strives to deliver see the true value patients, physiof family medicine, cians and medical comprehensive, to see that family students. They have compassionate and physicians are the strengths to the whole demand high quality affordable high-quality treating patient, that we are and affordable care transforming our for all. These new health care.” communities and “superheroes” are are at the center of health care reform. otherwise known as the residents and Medical students need to learn from medical students of family medicine. these family physicians.” Family medicine residents and medical At the NCSR the students and residents students from across the nation attended can break free, join together, share their AAFP’s 2011 National Conference for superhero stories and find their power. Medical Students and Family Medicine This year’s event featured engaging Residents (NCSR) on July 28-30. This keynote speakers such as AAFP President year’s conference drew 798 students and 1,026 residents, a steady increase from previous years’ conferences. For the past 38 years, students, residents and family physicians have come to this conference to network, prepare for practice, enhance clinical skills, listen to keynote speakers and advocate for health care and education reform.1 It is a place where family medicine superheroes with common interests and goals can reenergize and build their power. This was my third time attending (my first as a resident). I enjoyed the conference from a different perspective, but the energy and excitement remained the same. Interacting with the next generation of superheroes reminded me of being a discouraged student and how wonderful and inspiring it was to be around people who love family medicine just as much as I do. Edwin Kwon, MSIV and CAFP’s Student Council Chair from
Roland Goertz, MD, MBA and Chief Medical Officer, Assistant to the Surgeon General, Rear Admiral Clare Helminiak MD, MPH. CAFP New Physician Director Jay W. Lee, MD, who introduced me to the concept of family physicians as superheroes, talked about his advocacy efforts and told his superhero story of being a new physician. The most impressive sessions during the conference were the Student and Resident Congresses. The congresses are where residents and students can explore important issues on education, health care and future practice. They can join forces to write resolutions that ultimately come to influence a wide range of AAFP policy. As the California delegate to the Resident Congress, I was amazed and honored to take part in the debates and listen to my colleagues discuss the pros and cons of key issues under the rules of parliamentary procedure. The end product of our efforts, i.e., the passing of resolutions Resident News, continued on page 26
From left to right: Nate Hitzeman, MD; Christie Romo, MD; Lisa Sprowl, MD and Alisha Dyer, DO at the AAFP National Conference for Medical Students and Family Medicine Residents this past July in Kansas City, MO.
California Family Physician Fall 2011 11
Jane Cho
QI CORNER
Approaching Diabetes Care is a Team Effort Five Bay Area practice teams gathered this past May in San Francisco to participate in CAFP’s newest quality improvement (QI) project, “The Team Approach to Diabetes Care.” CAFP recruited practices interested in improving diabetes care and building a culture of team-based care. The four-month project was designed to increase familiarity with the Patient Centered Medical Home (PCMH) and enhance the teams’ ability to care for chronic care patients. Why teams? CAFP developed the project because it was clear that physicians can no longer care for patients alone. On average, a primary care physician has a panel of 2,500 patients and provides both preventive and chronic care. High quality primary care requires the involvement of the entire team including physicians, physician assistants, nurse practitioners, medical assistants, health educators and other health care workers. The goal of CAFP’s initiative is to build a team approach to diabetes care. Participation in the project includes a pre-work practice assessment survey, mandatory workshop attendance at our Annual Scientific Assembly (ASA), one-on-one faculty advisor time, resources and staff technical support. Each team will also receive a $2,000 stipend for their commitment to working with their practice team to improve diabetes care. The project launched at this year’s ASA with the following practice teams: Bay Valley Medical Group, Tripdy Gandhi, MD, Street Level Health Project, Prima Medical Group and Livermore Medical Clinic. Each physician participated with his or her core team members and met all day with staff and faculty in San Francisco. The meeting was led by faculty: Bo Greaves, MD; Chris Sadler, PA-C; and Lauren Lorenzo, APRN. Faculty provided a brief introduction to the concept of team building and introduced a broad selection of activities that are most effective in improving teamwork and optimizing workflow and efficiency.
12 California Family Physician Fall 2011
Teams had time for strategic planning. Given a menu of resources and activities such as developing a “teamlet,” implementing daily huddles and flow mapping, each team identified key processes to work on and collaborated with faculty to fine-tune their aim statements. After individual team time, the practices shared what they planned to do back at the office to build a team culture. The sharing and discussion among the five practices proved valuable as they offered tips to one another based on what worked for them. Staff shared an effective flow sheet, described clinical measures on which to focus and discussed sharing job responsibilities and cross training to optimize work space. Staff summarized the lessons learned to wrap up the first in-person meeting. We are more than halfway through this project and will describe goals accomplished and lessons learned in the next issue of this magazine (Winter 2011). In the meantime, whether starting a registry, training a diabetes care coordinator or launching group visits, CAFP is here to help. This QI project is just one example of the work we are doing to spread innovations and quality improvement in health care. We have myriad resources on our website (www.familydocs.org) and invite you to browse through our New Directions in Diabetes Care Resource Center and Patient Centered Medical Home page for more information. Please contact me at jcho@familydocs.org with questions. This project is part of a larger Team Approach to Diabetes initiative supported by unrestricted educational grants from Boehringer Ingleheim, Sanofi Aventis, Lilly and Merck. Our partners in the overall initiative are the American Academy of Physician Assistants, American Academy of Nurse Practitioners and Medscape. Jane Cho is CAFP’s Manager of Medical Practice Affairs.
PRAC TICE MANAGEMENT NEWS
Protect Your Practice from Embezzlement By Barbara Hensleigh
Doreen started out as a front office clerk in a physician’s practice earning minimum wage. Within three years she was promoted to office manager because she was smart, competent and reliable As office manager, Doreen spent many nights after hours performing various clinic functions: depositing cash, ordering supplies, reviewing QuickBooks entries and balancing the practice’s computer ledger Because the physician was so busy, the trusted Doreen also was given checksigning authority. Doreen is now in Lompoc State Prison. A police officer pulled Doreen over for a burned out tail light and noticed boxes of controlled drugs in her back seat. Doreen’s arrest led to an inquiry at the physician’s office. Doreen had embezzled nearly $200,000 in five years, not counting the drugs she sold on the street that were ordered for the medical group and paid for out of the group’s bank account. Among other things, Doreen took cash
damage caused by Doreen’s crime spree as it stopped reviewing records after going back five years. A November 2010 Medical Group Management Association survey revealed nearly 85 percent of practices had been the victim of employee theft or embezzlement. Of course, every embezzled dollar reduces a practice’s net profit and large embezzlements can even bankrupt a practice.
Ways to Embezzle What are the ways to steal from a medical practice? Here are a few particularly vulnerable targets in medical practices: •
•
Cash via patients’ payments, copayments and deductible payments (especially at the start of the year when deductibles are being paid). Excessive drugs or supplies ordered for the medical group, taken and resold.
A November 2010 Medical Group Management Association survey revealed nearly 85 percent of practices had been the victim of employee theft or embezzlement. Of course, every embezzled dollar reduces a practice’s net profit and large embezzlements can even bankrupt a practice. co-pays. She opened an account in the name of the group, deposited payments to the group in the account and then withdrew the money for her personal use. Doreen spent her evenings at the clinic “balancing” the general ledger to hide her embezzlement. As with most embezzlers, Doreen started small, “borrowing” $10, for example, because she wanted to pick up dinner on the way home. Once Doreen realized that no one noticed she had taken small amounts, she started taking more. The practice does not know the full 14 California Family Physician Fall 2011
•
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A bank account opened in the name of the medical group. Payment s to the group are deposited in the account, and then withdrawn by the employee for personal use. Bogus refunds recorded as having been paid to patients or fictitious patients and instead taken by the employee. Payments made for “medical supplies” to a company formed by the employee for embezzlement
purposes. Supplies are either sold to the group at a grossly inflated price or never delivered.
Signs of Embezzlement Keeping a “heads up” attitude about your practice lets you observe signs of potential vulnerability and embezzlement. It is rare case that the police inform a physician that his or her employee may be embezzling from the practice, as in Doreen’s case. What are the clues that an employee may be embezzling or stealing? Some, as with Doreen, are also characteristics of hard workers. Here are a few signs an employee may be stealing from you. The employee: •
Does not want help with his or her tasks to avoid having someone examining his or her work.
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Takes little or no vacation because someone may find out that, for example, co-pay collections increase 50 percent while he or she is gone.
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Makes his or herself indispensible.
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Stays late or comes in early regularly.
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Does not want others to open the mail or make bank deposits.
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Has an overly friendly relationship with drug representatives.
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Has a lifestyle that appears beyond his or her means (e.g., an expensive car, boat or home).
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Has a problematic financial history (e.g., very poor credit rating, multiple bankruptcies or jailed family members).
At the practice where Doreen worked, there were clear signs something was wrong. Take note of such signs while managing your practice. Trust an overall impression that the business should have more income than it does (i.e., do not
PRAC TICE MANAGEMENT NEWS ignore your gut instinct). Do not ignore complaints by patients about billing errors or excessive unpaid patient charges in the system. It is also important to follow up on non-descript or vague purchases entered into the general ledger, payments to companies you do not recognize. Beware of overhead costs for supplies or medications exceeding the average for the size of the practice. Finally, if your books frequently do not balance (e.g., the off-ledger’s recorded amounts for cash payments are greater than the deposits recorded on multiple occasions) take control of them and determine what is happening.
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Preventing Embezzlement
check references Pay for a credit check.
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Encourage employees to report conduct that appear suspicious.
Divide tasks, called “segregation of duties” by auditors. For example, one person collects cash, co-pays and deductibles. Another person posts the amount each day to the general ledger and another person makes the deposit. Reconcile numbers daily. One person can order supplies and another person can check on deliveries and stock the supplies. In small offices, this can be challenging, but it can be done.
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Stay involved in the financial aspects of your practice. Spot check entries into computer records, accounts receivable balances and the overall cost and breakdown of supplies.
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Hire a specialized firm to perform a spot check audit.
Require employees to trade tasks so no one person handles the money all the time. Task trading makes it easier for an employee to find something not quite right in the books. It also has the benefit of cross-training your staff in case an employee calls in sick.
Small practices often use a spouse as an office manager Such oversight, even if part-time, can deter potential embezzlers. Other good practice methods include:
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Require employees to take vacation.
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Require two signatures on all checks.
Hire carefully Check for prior bankruptcies and criminal records and
Barbara Hensleigh, a former NICU nurse, has practiced law for more than 20 years. Her statewide practice is with the law firm of Andrews & Hensleigh, LLP, in Los Angeles, California Ms. Hensleigh’s practice is devoted to the representation of physicians, physician groups and health care entities in litigation, arbitration and administrative proceedings She may be reached at bhensleigh@ahlaw.us.
DISCLAIMER The articles provided in Practice Management News are general. They do not constitute legal, practice management or coding advice in any particular factual situation or create an attorney-client relationship. Consult your attorney or other professional for advice in your particular situation.
California Family Physician Fall 2011 15
NEWS IN BRIEF Physicians’ Medi-Cal Cuts Fight in Washington Gains National Attention On August 4, CAFP member Kara Odom Walker, MD traveled to Washington, DC to represent CAFP in meetings with Donald Berwick, MD, Administrator of the Centers for Medicare and Medicaid Services (CMS), Senators Dianne Feinstein and Barbara Boxer and the California Congressional delegation to urge them to halt state cuts to the Medi-Cal Program. CAFP is dedicated to fighting these cuts and, particularly the 10 percent cut to Medi-Cal provider payments. In addition to work in Sacramento, CAFP has supported litigation, pending in the US Supreme Court, which would stop the cuts. CAFP urged CMS to reject the state cuts because of the likely impact on Medi-Cal beneficiaries’ access to quality care, as well as on long-term costs. Dr. Odom Walker attested to the difficulty her Medi-Cal patients have obtaining health care and the likelihood this will worsen should the cuts take effect. CAFP has long asserted that repeated short-sighted state efforts to reduce costs
will make it impossible for providers to participate in the Medi-Cal program. Press coverage calling attention to the state’s proposed 10 percent cut to Medi-Cal payments and the trip to Washington by Dr. Odom Walker and representatives of the Patient Care Coalition, organized by the California Medical Association, was extensive.
Executive Vice President Susan Hogeland Celebrates 20 Years with CAFP Twenty years ago last month, Susan Hogeland, CAE joined CAFP as its new Executive Director. At the time of her hiring, she was thrilled about the opportunity. Today, with Susan still at the helm, CAFP remains at the forefront in advancing the specialty of family medicine through its efforts in advocacy, education and practice enhancement. Susan took some time to reflect on her past 20 years and had this to offer: “Hackneyed, yes, but it seems as if it were just yesterday that I interviewed for this position with a search committee headed by
John Crivaro, MD, as well as with the entire then-CAFP staff. My friend, Jane Hogg, former CAFP Executive Director, told me I "had to apply for her position." I couldn't be happier that I did. I'm grateful for the opportunity to help grow your Academy, to work with the best physicians on the planet (those with the greatest social consciousness and concern for their patients) and for the collegiality of outstanding Academy staffs over the years. Thank you.”
Stanford Professor Selected as Puffer/IOM Fellow The Institute of Medicine has selected CAFP member Sean P. David, MD, Clinical Associate Professor of Family and Community Medicine at Stanford University School of Medicine, as the 2011-2013 James C. Puffer, MD/American Board of Family Medicine Fellow at the Institute of Medicine. Dr. David was selected from an outstanding group of nominees because of his accomplishments in family medicine, specifically his work on smoking cessation and health promotion. Congratulations, Dr. David!
CAFP Members: Interested in Discounts for your Vaccines? Sign up with Atlantic Health Partners As you know, the California Academy of Family Physicians has strong support in helping our members lower their vaccine costs. Atlantic Health Partners helps thousands of physicians save money and advocates on your behalf with payers and manufacturers. In addition to offering our members the lowest prices for Sanofi Pasteur and Merck vaccines, Atlantic also provides the best terms for Sanofi’s Fluzone and High Dose Fluzone. Atlantic Health Partners can save you money on pediatric, adolescent and adult vaccines when purchased directly from Sanofi and Merck. Our members who joined Atlantic reported strong satisfaction with the program, most notably for the savings, ability to make smaller purchases, and customer support. Additional benefits offered by Atlantic: • Medical supply discount program • Office and business supply discounts with Staples Advantage • MedImmune Flumist discounts • Discounted patient recall program Jeff Winokur and Cindy Berenson are the primary contact persons at Atlantic, and we encourage you to contact them at 800-741-2044 (9am – 5:30 pm Eastern Time) or at info@atlantichealthpartners.com for more information and details about how your practice can benefit from participation.
16 California Family Physician Fall 2011
AC C O U N TA B L E C A R E O R G A N I Z AT I O N S
What ACOs Must Do … and What That Means for You By Bruce Bagley, MD
With all the buzz about Accountable Care Organizations (ACOs), it is important for family physicians to know what an ACO is and what it is not. Simply stated, an ACO is a group of health care providers who agree to take on a shared responsibility for the care of a defined population of patients while assuring active management of both the quality and cost of that care. The reality is a little more complicated than that, however. Any group preparing to form an ACO must have a level of organization and infrastructure to support the clinical, financial and information technology integration required for success. Vertically integrated health systems clearly have an advantage, but may also have difficulty adapting; they will need to change their mission from optimizing revenue to optimizing value for patients and payers. Existing physician-sponsored independent practice associations or large multi-specialty groups may also have the necessary resources and capability to staff an ACO. In general, the ACO must be able to accept global payments and distribute resources through internal incentives that reward those providers who contribute to the overall quality and efficiency of the enterprise. Many California family physicians are already on a journey toward the Patient Centered Medical Home (PCMH). These practices, with enhanced primary care capabilities, will be ideally suited to participate in an ACO. Any ACO must provide patients ready access to primary care so patients can have their needs met without the premature escalation of the level of intervention that so often occurs at the hospital and, in particular, in the emergency department. Unfortunately, some physicians assume that since there is no current effort to form an ACO in their geographic area or market, they do not have to make any changes. It is clear to most health plans, politicians and policy makers that the basic way we pay for health services must change. The heavy reliance on fee-forservice payments, as fashioned using the Resource Based Relative Value System, has created an environment in which volume is valued over quality and necessity, care is fragmented as opposed to continuous and integrated and patients are left to fend for themselves when it comes to navigating a complex system. If we are to do better as a society and as a nation in caring for the health of our people, we must change the structure and financing of medical care. An ACO could accomplish the transformation with a number of strategies. First, there must be more emphasis on prevention, primary care services and coordination of care for efficiency. These are key characteristics of the PCMH. Next, care teams working in the PCMH must be able to help patients obtain the care they need beyond primary care in the most timely, efficient and effective way. This requires ongoing relationships with specialists, imaging facilities, hospital labs etc., so that service expecta-
tions, costs and quality can all be part of the agreement to send these patients to another arm of the ACO. Finally, ACO leaders must be able to support the required infrastructure and information exchange to make it all work. They must measure and monitor the efficiency and effectiveness of the ACO with a focus on value for patients. The US health care system is clearly complex and adaptive. For ACOs to be successful, they must focus on their aims and change the playing rules to get better results. ACOs should have the following aims: 1) Aspire to safe, effective care for individual patients; 2) Have a commitment to the health of the community or population health; 3) Operate with efficient systems that reduce waste; 4) Ensure a shared responsibility for cost and quality; and 5) Possess a structure to assure long-term financial viability. To accomplish these aims, the new rules of the game must do the following: 1) Foster patient/family engagement and partnership; 2) Align payment and incentives with the aims; 3) Value primary care that is central and capable; 4) Create a culture of measurement and quality improvement; 5) Support clinical, financial and information technology integration; and 6) Create a financing environment designed for long-term stability and financial viability. It is hard to know if the current flurry of activity around practice acquisition, system consolidation and positioning for better market share will yield the desired results. For family physicians, the path is clear. Create, develop or join a practice that values primary care for its contribution to the overall efficiency and effectiveness of the larger system. As our nation moves to purchasing health care based on its value to patients, comprehensive and capable family medicine will have an essential role to play. Bruce Bagley, MD is the Medical Director for Quality Improvement for the American Academy of Family Physicians (AAFP).
RESOURCES American Academy of Family Physicians website: www.aafp.org/aco. See FAQs about ACOs California Academy of Family Physicians website: http://www.familydocs.org/pcmh/acos.php. See the Family Physicians ACO Blueprint for Success The Center for Healthcare Quality and Payment Reform: www.chqpr.org See “How to Create an ACO” and “Transition Strategies”
California Family Physician Fall 2011 17
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ACOs Operate Like a Neighborhood for Your Patient Centered Medical Home By Leah Newkirk
or similar models an explicit The Patientrequirement of the Medicare Centered Medical relationship between primary care Shared Savings Program.” Home (PCMH) is physician and patient. ACO emphasizes a model for the CAFP urges family physicians and thinking beyond individual patients to delivery of primary other health care providers, payers and populations, increased accountability care; it describes policymakers to think about the PCMH how a primary care for quality and payment models that as an essential component of any ACO. physician’s practice incentivize high-value care. There is The bottom line is that every ACO must currently a great deal of flexibility in should operate. have a plan for achieving higher quality both models; it is expected that there According to the and better population health and that will be some differences in how both Joint Principles of the PCMH, every plan should be to transform primary are put into operation in differing health patient should have a personal physician care practices into medical homes. care markets. who directs a practice team and There is significant evidence that the coordinates care across an integrated CAFP is committed to ensuring that ACO clinical improvements and overall cost health care system, using best available development in California advances savings necessary to ACOs are outcomes evidence and appropriate technology PCMH development in family physician of implementing medical to ensure high quality care and homes. patient safety. The Joint Principles “We will be working to incorporate CAFP is not alone in its also emphasize that the value commitment to ensuring PCMH with ACOs and examining of PCMH services (e.g., care the symbiotic relationship of coordination, increased access various payment methods to support ACOs and medical homes. to the primary care team and medical home expansion through the Representatives of CMS have availability of technology) must repeatedly expressed their be recognized by payment. CMS Center for Medicare and commitment to join the two The Accountable Care models. Donald Berwick, Medicaid Innovation.” Organization (ACO) is a model for MD, CMS Administrator, has managing the quality and cost of Donald Berwick, MD, CMS Administrator written “We will be working care through clinical and financial to incorporate PCMH with practices. In CAFP’s June 6 letter to the integration. It integrates the health care ACOs and examining various payment Centers for Medicare and Medicaid system – primary care, non-primary care methods to support medical home Services (CMS) commenting on the specialties and hospitals – to increase expansion through the CMS Center for proposed regulations governing ACOs, access to high-value care and improve Medicare and Medicaid Innovation.” we wrote: care coordination. It is also a means of The Patient-Centered Primary Care assuring both capital investment in the “CAFP believes that ACOs will be Collaborative (PCPCC), with its strategic PCMH and payment for PCMH services. most successful where there is a mission of advancing the PCMH, has this The ACO can be conceptualized as the PCMH or similar primary careyear created the Center for Accountable “medical neighborhood” to the medical centered model at its foundation. Care to serve as a bridge between home. Such a foundation offers great the various PCMH and ACO learning promise in moving America to a networks, collaboratives and pilots to Embodied in both models is a shared value-driven health care system foster and align the shared principles of vision frequently called the “triple aim”: that will improve the health of the models. In turn, this commitment higher quality, better population health American communities, while from leading policymakers is seeing and lower costs. PCMH emphasizes also facilitating cost savings. We results. In a recent HealthLeaders the role of primary care and the urge CMS to make the connection between the ACO and the PCMH 18 California Family Physician Fall 2011
AC C O U N TA B L E C A R E O R G A N I Z AT I O N S Media Intelligence survey of 275 health care leaders about ACOs, 70 percent responded that they are planning to implement a medical home as part of their ACO. In summary, California family physicians looking to ready themselves for a health care environment increasingly populated by ACOs should consider implementing the PCMH model or offering more PCMH services. This will make your practice more attractive to ACOs and increase your leverage in contract negotiations, should you consider joining an ACO. Moving toward the PCMH model is a great way to assure that you can demonstrate both quality and efficiency to any ACO in your community seeking primary care services. Leah Newkirk is CAFP’s Director of Health Policy. RESOURCES http://www.familydocs.org/pcmh/acos.php http://www.pcpcc.net/center-accountable-care
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Centers for Medicare and Medicaid Services and ACOs: A Regulatory Update In June, CAFP submitted comments to the Centers for Medicare and Medicaid Services (CMS) on the proposed regulations governing the Medicare Shared Savings Program (MSSP). The MSSP, a product of federal health care reform, was designed to encourage Medicare providers to create ACOs. The complex proposed regulations may have the opposite result: Providers have been almost uniformly critical of the MSSP as conceptualized by the proposed regulations. In our comments, CAFP urged changes to the MSSP that would make it more beneficial to family physicians. We addressed concerns that the program excludes small and rural physicians and, because of an overly complex regulatory scheme and low potential shared savings, may not be worth the effort for larger, more sophisticated groups. CAFP recommended simplifying the requirements, including more explicit references to models of care such as the Patient Centered Medical Home, requiring primary care physicians in the ACO’s governing body, offering additional payment options, permitting primary care physicians to participate in more than one ACO and more. If you have any questions about ACOs or the MSSP, please contact CAFP Director of Health Policy Leah Newkirk at lnewkirk@ familydocs.org or 415-345-8667. After issuing the proposed regulations, the Department of Health and Human Services announced three initiatives designed to help providers transform to ACOs. Run through the Center for Medicare and Medicaid Innovation (CMMI), these are meant to supplement the MSSP. The “Pioneer ACO Model” program is supposed to give groups that are already far along in developing into ACOs a faster path to achieving shared savings. CMMI offers as an incentive the opportunity to pocket more of the expected savings in exchange for taking on greater financial risk. These ACOs also will be able to work with private insurers and, eventually, Medicaid. CMMI announced it is considering helping less-developed provider groups form ACOs by giving them some of their share of anticipated savings upfront. If established, the “Advanced Payment ACO Initiative” would be available to providers who currently lack resources to form an ACO. It would offer certain Medicare ACOs access to a portion of their shared savings up front for infrastructure and staff investments.
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CMMI will also run four free “Accelerated Development Learning Sessions” for providers interested in finding out more about starting an ACO.
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AC C O U N TA B L E C A R E O R G A N I Z AT I O N S
ACOs Play a Big Role in California's Quality Improvement By David D. O’Neill, JD, MPH
Are Accountable Care Organizations (ACOs) this year’s hot topic – or a real solution to providing quality care to a designated population of patients while lowering the growth of health care expenditures? Is there a way to sort out the numerous reports of ACO development in California? Will the ACOs that do develop affect the quality of care? There are two broad categories of ACOs: 1) federal ACOs, which will include Medicare Shared Savings Program (MSSP) ACOs and Pioneer ACOs; and 2) ACO-like organizations or commercial ACOs. No federal ACOs have been designated, but several may be in 2012. They will be easy to identify and track; on the other hand, commercial ACOs are a challenge because there are no objective criteria by which to identify them. Unless commercial ACOs are risk-bearing organizations that fall under the regulatory authority of the California Department of Managed Health Care (DHMC), they are largely self-defined. As a result, it is difficult to populate a scorecard to track existing or nascent ACOs in California; nevertheless, even the most casual observer knows that the ACO concept has gained significant traction. Although many emerging commercial ACOs may not pursue federal designation, the ACO provisions of the Affordable Care Act provided the impetus and the framework for their development. Leadership in these organizations has emerged from many different sources including independent practice associations (IPAs) and medical groups, integrated delivery systems, hospitals and hospital systems, safety-net providers, associations or health plans. They are seeking competitive advantage, new opportunities to align with key providers to control costs and prepare for new payment approaches, and to improve the quality of care and service. As every provider knows, there can be a considerable distance between lofty goals and reality on the ground. That said, ACOs offer a real opportunity to address quality improvement issues because: ACOs require effective physician-hospital integration. They create a vehicle for providers, health plans and employers to collaborate to improve the quality of care and service for a given population while controlling costs. The Blue Shield, Hill Physicians, Catholic Healthcare West ACO-like program serving CalPERS members is a good example of effective collaboration that affected both quality and cost. CalPERS has reported that in the first year, readmissions were reduced by 17 percent, hospitalizations in excess of 20 days were reduced, and there was a 14 percent overall reduction in patient days. 20 California Family Physician Fall 2011
ACOs require clear quality measures. An appropriate set of basic quality measures that take into account the care of individual patients and the health of a population is essential to ACO success. The draft ACO regulations grouped 65 indicators into the following five domains: patient/caregiver experience, care coordination, patient safety, preventive health and at-risk populations/ frail elderly health. There has been some pushback from provider organizations about the number of indicators, but there is no disagreement about the necessity of measuring and reporting on quality of care and service. ACO success requires developing effective, integrated information systems. The information technology is now available to document, measure, track, compare and communicate about clinical as well as financial information. Ideally, to be most effective, all providers in an ACO would use the same electronic health record and a common analytical tool. There is increasing movement toward this objective. ACOs align incentives. The proposed Medicare Shared Savings Program (MSSP) ties financial risk sharing to quality performance. MSSP, and other payment programs such as episodes of care that tie payment to performance, will encourage all clinicians and hospitals to collaborate, provide quality care and keep costs in check. This has been among the greatest challenges of the current delivery system; ACOs have the potential to do things differently. Patient/family involvement is an essential element of the ACO model. Shared decision making, more effective provider-patient communication and increased patient access to information will improve the probability of better clinical outcomes and enhanced patient and provider satisfaction. ACOs should stimulate robust competition. Competition has the potential to enhance the quality of care and service. Although some areas of California have high degrees of provider concentration and lack significant competition, most areas are highly competitive. As commercial ACOs develop, they will compete on both quality and price. As employers and individuals have more transparent information, it should enable them to consider both quality and cost in their decisions about which ACO to use. Collaboration, clear quality measures, effective information systems, financial risk-sharing tied to quality, patient/family involvement, and robust competition are all part of an effective ACO and are all part of quality improvement. ACOs can build on these elements and have the potential to be a major answer to the quality improvement challenge. David D. O’Neill, JD, MPH, is a senior program officer with the California HealthCare Foundation, a nonprofit health care philanthropy based in Oakland.
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How Are Private Organizations Preparing for ACOs? By Steven Green, MD
Accountable Care Organizations (ACOs) are an attempt to encourage efficiency by potentially allowing physicians and health care organizations to partner to better coordinate care for patients across care settings. They could align the incentives to achieve quality, better health outcomes and cost savings. Medicare, or the Centers for Medicare and Medicaid Services (CMS) ACOs could be formed to care for Medicare patients, while commercial ACOs would care for commercial insurance patients. The triple aim of these programs is better care for individuals, better health for populations and lower growth in expenditures. Medicare recently released its regulations on how CMS ACOs would work within the fee-for-service Medicare market. Several issues could determine whether or not Medicare ACOs will be successful. How and when patients are aligned with an ACO is crucial, as is how any efficiencies are shared with the organizations within the ACO. CMS recently announced the Pioneer ACO Model for organizations more experienced with care management and coordination of care for populations. Patients would be “aligned” with CMS ACOs based on where they are currently receiving care. This alignment could be done prospectively or retrospectively. Retrospective alignment involves CMS looking back at where the majority of visits occurred during the year. Prospective alignment will go backward over a defined period and see where the patient received the majority of care and then align that patient going forward, no matter where they get care that year. With a retrospective alignment, an ACO would not know which patients qualified until after the measurement year is complete. This is challenging from a business perspective, as an ACO would want to focus resources on the aligned population. The Pioneer ACO model allows the option of prospective alignment, which would seem to be the logical choice.
is that the incentive has not been for efficiency, but just the opposite. If an ACO can provide better care, preventing costly emergency room visits or hospitalizations, the cost of care would go down, even if office visits increased. The ACO would be accountable for the total costs for the defined population, so more efficient care should theoretically result in both higher quality and shared savings to the organization, as long as the accounting of costs is fair and accurate. At some point it is possible the ACO participants would receive a cost penalty if they are felt to be inefficient. Interestingly many of the health systems held out as being examples of what health care reform wanted to emulate are not participating in CMS ACOs. Many of these more experienced organizations are choosing to participate in the Pioneer ACO Model. Smaller groups and solo practices may need to work together with other physician groups and health organizations to participate in ACOs, and if they do join an ACO, the challenge will be to implement the quality and efficiency standards to achieve the shared savings and to make sure they receive their fair share of these savings. I want to thank my colleagues at Sharp Rees-Stealy Medical Group (Jerry Penso, MD, MBA, Medical Director of Continuum of Care, and Vicki DeBaca RN, DNS, CPHQ, Vice President of Health and Provider Services) for their contributions to this article. Steve Green, MD is a family physician at Sharp Rees-Stealy Medical Group in San Diego. He is CAFP’s President-elect.
CMS has made it clear that seniors will not be locked into a specific group as they would be in Medicare Advantage. Medicare Advantage already involves quality incentives and sharing of cost savings in treating a population of patients, and 20 percent of seniors have chosen this for their health care. While the freedom to move in and out of an ACO with which a patient is aligned may sound good, it could make it more difficult for an ACO to control costs and quality. Sharing in savings is another area which is difficult to grasp. Fee-for-service Medicare pays based on a “per click” basis, where the more done to a patient, the more Medicare pays. The concern in the traditional Medicare fee-for-service model
Steve Green, MD and his staff at Sharp Rees-Stealy Medical Group in San Diego. California Family Physician Fall 2011 21
AC C O U N TA B L E C A R E O R G A N I Z AT I O N S
How Are Communities Responding to All this ACO Talk? By Joseph E. Scherger, MD, MPH Vice President for Primary Care Eisenhower Medical Center, Rancho Mirage, CA
The essence of an Accountable Care Organization (ACO) is a health care delivery system that is accountable for the health of the population being served and is committed to delivering quality medical services at an affordable cost. Value in health care delivery is quality at the best price, so any ACO is a value-driven health system. Donald Berwick, MD, Administrator of the Center for Medicare and Medicaid Services (CMS), is leading the ACO initiative in Washington. During his leadership at the Institute for Healthcare Improvement (IHI), he developed the “Triple Aim” for any health care system, and this is the starting point for any ACO. The Triple Aim is: Improve the health of the population; Enhance the patient experience of care (including quality, access, and reliability); and Reduce, or at least control, the per capita cost of care. When the famed Princeton health economist, Uwe Reinhardt, was asked what an ACO is, he responded “Kaiser.” Since its inception, Kaiser Permanente has been a value-driven health care system. Kaiser cares for nearly seven million Californians, so we have the largest and most experienced health care system with ACO behavior. California’s experience with managed care and the formation of health systems also gives us ample ACO experience. Non-profit systems such as Sutter, Catholic Healthcare West, Sharp and Scripps have been delivering value-driven care for at least two decades and are well-positioned to benefit from the ACO initiatives. What about the rest of us? ACOs are not compatible with independent private practices. Physician practices need to become part of network systems that follow the Triple Aim as core to their mission. It’s all about delivering quality care at affordable costs. The stories that follow are perspectives based on what is happening in counties across California to prepare for ACOs. 22 California Family Physician Fall 2011
“The ACO activity in our region comes in three forms: 1) Health Plandriven (e.g., Blue Cross of California or Blue Shield of California) for commercial patients; 2) Independent Practice Association (IPA)-driven, focused on Medicare fee-for-service (FFS); and 3) Hospital-driven, via the medical foundation model for commercial and Medicare patients. Not surprisingly, these are entities that have a certain degree of “ACO-ready” infrastructure, health informatics and the capital required to develop integrated health care systems. These ACOs focus on fee-forservice patients, but they are wise to apply the managed care approach to
“Since the release of the Medicare ACO regulations, Los Angeles County has seen a shift toward the development of ’Virtual ACO Networks.’ There are now robust models for regional networks that propose to care for patients with commercial and public insurance, including patients who will soon be shopping for coverage in the emerging health insurance exchange. The greatest challenge for our emerging ACO care networks is raising capital to pay clinics and hospitals to stop providing volumedriven, encounter-based care, and instead provide elements of the medical home for which there is still very little payment. Hospitals will require payment for the cost
patient care regardless of payer type. Local ACOs are recruiting heavily for effective primary care. The ACO model is an excellent opportunity for Family Physicians who adopt the Patient Centered Medical Home standards, especially for those who have group practices or who plan to merge their practices with other physicians for greater efficiency and negotiating clout.” – Hector Flores, MD Chair, Family Practice, White Memorial Medical Center, Co-Director, White Memorial Medical Center Family Practice Residency Program. East Los Angeles
of unoccupied beds, as medical home-based care reduces the need for emergency room and hospital services. Investment in unprecedented health information exchange will be required to achieve these goals. If we build it, payers will begin to pay for it. Show us the money and it can be done.” – Brian Prestwich, MD Assistant Professor of Family Medicine, University of California (USC) Keck School of Medicine Chief Medical Officer, Department of Family Medicine Medical Director, USC-Eisner Family Medicine Center at California Hospital USC-California Hospital Family Medicine Residency Program
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Need More Information About ACOs? There Are Plenty of Resources to Help You “At the time of this writing, it is not yet clear whether the four large competing health systems in the Sacramento region (Kaiser, Sutter, CHW/Mercy and UC Davis) will throw their hats into the ACO ring. Many pundits have declared that Kaiser is already a viable ACO and is way ahead of the competition. Others speculate that Sutter, with what is close to an integrated system with Sutter Medical Group and Sutter Independent Physicians is also well-positioned to achieve ACO status. With the recent April 1, 2011 announcement that the shared Epic Medical Record will be available to independent physicians, one of the key required ACO tools, a fully functional integrated medical record, will give Sutter a strong edge. This past February, Catholic Healthcare West announced that they had partnered with Blue Shield and Hill Physicians IPA to create a commercial ACO for 41,000 Sacramento-based members of the California Public Employees Retirement System, saving $15.5 million in 2010. A Medicare ACO could be the logical extension of this experiment. UC Davis, with an integrated health system of over 700 physicians, an integrated Epic Medical Record, a large urban academic medical center and one of the premier Telehealth Networks in the country has not officially publicly weighed-in on the ACO concept.” – José Alberto Arévalo, MD, FAAFP Senior Medical Director Sutter Independent Physicians Sacramento
Accountable Care Organization (ACO) development is encouraged by health care reform and, in particular, by the establishment of the Medicare Shared Savings Program (MSSP) and the Center for Medicare and Medicaid Innovation. Under regulations proposed by the Centers for Medicare and Medicaid Services (CMS) for the MSSP, ACOs would manage the health care needs of thousands of Medicare beneficiaries. The goal of an ACO is to integrate the health care system, including primary care providers, specialists, hospitals and others and to have that integrated system work in a meaningful and coordinated way. Below is a list of resources to inform you about ACOs and how you can participate and get paid in an ACO. •
CAFP’s ACO Page: The ACO webpage is one part of CAFP’s Patient Centered Medical Home Resource Center. Browse this page for information on ACOs, latest updates and developments in California. The calendar of events section is updated regularly with meeting information, webinars and CME events related to ACO development. http://www.familydocs.org/pcmh/acos.php
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Better to Best: Value-Driving Elements of the Patient Centered Medical Home and Accountable Care Organizations: This report was prepared by the Patient Centered Primary Care Collaborative and discusses the shared aims of Patient Centered Medical Homes and ACOs. The two models are complementary and this guide describes how the development of an ACO can support the medical home in physician practices. http://www.pcpcc.net/guide/better_to_best
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FAQs about ACOs: Many of your questions about ACOs are answered in AAFP’s ACO FAQ sheet. Questions about payment, shared savings, practice risk and legal issues are available in a simple and easy-to-read format. http://www.aafp.org/online/en/home/practicemgt/specialtopics/designs/ practiceaffiliationoptions/faq.html
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Accountable Care Organizations and Family Medicine: AAFP’s main ACO page has sections dedicated to provider resources, state restrictions, options for affiliation and more. AAFP members have access to archived CME webinars on the topic. http://www.aafp.org/online/en/home/practicemgt/specialtopics/ designs/practiceaffiliationoptions.html
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TransforMED: A subsidiary of AAFP advocating for and educating about the patient centered medical home model, TransforMED has a pool of experts who can provide advice and hands-on medical home facilitation. The TransforMED website has a page dedicated to ACOs and how their team can assist health care systems and primary care practices transform to ACOs. A free webinar is available on the site. http://www.transformed.com/accountable_care_organizations.cfm
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The Center for Medicare and Medicaid Innovation: The Innovation Center is also dedicated to educating health care stakeholders about the ACO model and supporting ACO development. Explore the Innovation Center’s website to learn more about the MSSP, the Pioneer ACO model, the Advance Payment Initiative and the ACO Accelerated Development Learning Sessions. http://innovations.cms.gov/ California Family Physician Fall 2011 23
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FAMILY INDUSTRIAL FITNESS PREVENTION
Busy solo urban practice physician is seeking an associate. The practice is located on the ground floor of a four story medical office in the Baldwin Hills area of Los Angeles. This physician is seeking a fellow doctor willing to invest financially and with time and effort become a partner in this stable thirty year practice. Interested parties contact Elizabeth Covington, MD 323.290.2107
24 California Family Physician Fall 2011
CFP’s New Advertising Manager Kaiser Permanente Southern California: We take your administrative concerns and offer you a balanced call and work schedule. We give you the support, resources, and autonomy you need to give your patients the exceptional care they deserve.
Full-Time Family Medicine Opportunities: Antelope Valley • Bakersfield • Moreno Valley Redlands • San Bernardino • Victorville Oxnard (Spanish Bilingual Preferred) Physician-lead practice that equally emphasizes professional autonomy and cross-specialty collaboration Comprehensive support network An excellent salary, comprehensive benefits Stability during times of change in healtcare nationwide Send E-Mail with your CV to: Bettina Virtusio — bettina.x.virtusio@Kp.org / Phone: 800/541-7946 We are an AAP / EEP employer
CFP will have a new publication coordinator beginning with the upcoming winter issue: Publishing Concepts Inc. 14109 Taylor Loop Road Little Rock, Arkansas 72223 800.561.4686 ADVERTISING: David Brown dbrown@pcipublishing.com www.pcipublishing.com Our best wishes and thanks for the past nine years go to Liana King and Tim King at Franciscan Commnications, email LianaKing@gmail.com 510.525.3990.
Susan Hogeland, CAE
EXECUTIVE VICE PRESIDENT’S FORUM
Is a Checklist Necessary for Patient Care? The theme of this issue of California Family Physician is Accountable Care Organizations (ACOs), but I’m not going to be addressing them in this article – sorry. I’m leaving that to more expert authors, but want to assure CAFP members we are closely monitoring ACO development, providing website resources for your use and advocating for primary care physicians’ close involvement, if not control, of these entities. We are also strongly advocating that transformation to the Patient Centered Medical Home (PCMH) model is a crucial element to the success of ACOs. What follows is commentary about some things I’ve read or heard recently that resonated for me about family medicine and CAFP. I had planned to make one my exclusive subject – but I was beaten to the punch by folks who’ve collaborated on writing a better article for a monthly CME newsletter, so I’ll only touch lightly on it. You should watch for “The Checklist Manifesto: Using Checklists to Improve Your CME Operations” by our own Shelly B. Rodrigues, CAE, CCMEP, Mary W. Ales, BA, Interstate Postgraduate Medical Association, Cheri L. Olson, MD, Mayo Health Systems AND CAFP President Carol Havens, MD, The Permanente Medical Group, Kaiser Permanente. Their article should be appearing in the Alliance for CME Almanac soon; it refers to a book by one of my favorite medical writers, Atul Gawande, MD: The Checklist Manifesto How to Get Things Right. London: Profile Books, 2010. I downloaded it on my Kindle and read it in about three hours. It set me to pondering whether family and other primary care physicians shouldn’t be taking a checklist approach to patient care in more instances. Dr. Gawande is a surgeon, but his statement that “the complexity of what we know has exceeded our individual ability
to deliver its benefits correctly, safely or reliably. Knowledge has both saved us and burdened us,” seems to me to be applicable to ALL society, much less ALL physicians. Back in the dark ages, when I worked at the San Francisco Medical Society, one of our neurosurgeon members used to rail against “cookbook medicine” – he found it highly offensive that anyone would tell him how to do anything related to his art/science. As Ms. Rodrigues and Dr. Havens and their co-authors make clear in their article about Dr. Gawande’s book, checklists aren’t step-by-step, howto guides for the mindless – they cull out the essential things that must be done to guarantee the safety of patients and, through a team process, ensure those things are completed before a procedure is carried out on the patient. CAFP helped family physicians in its New Directions in Diabetes Care collaboratories take a similar approach, using teams to their maximum level of training and licensure. Key points of care identified by a registry were assured: patients had to have their feet checked at every visit; their blood work needed to be completed before the visit; someone on staff confirmed the patient kept his or her appointment with an ophthalmologist. These functions were crucial to the wellbeing, and, potentially, the lives of these patients, but they weren’t prescriptive. They didn’t tell the staff member exactly how to accomplish the tasks, only that the tasks had to be done. How might you incorporate such key checklists in your practice and how would you involve every member of your team in identifying and carrying out such crucial functions? From July 21-23, Ms. Rodrigues and I attended our professional association’s annual meeting in Boston. CAFP staff is always wary when we come back from meetings like this as we’re chock full of
new ideas and lots of notes – in my case, 22 typewritten pages’ worth, plus all the handouts! Thomas H. Lee, MD, Network President, Partners HealthCare System, was a keynote speaker whom we found especially engaging. He said “progress generates costs and chaos” in medicine (see Dr. Gawande’s statement above). The flood of progress and knowledge imposed on our fragmented system leads individual clinicians to feel less knowledgeable and can result in ‘super-specialization,’ which leads to more people involved in patients’ care.” He added: “There are “too many people, too much to do, and no one with all the responsibility or all the information.” Amen, brother. He cited three physicians whose manifestos should be the basis for medicine’s path forward: Michael Porter for strategy, Dr. Gawande for tactics and Richard Bohmer for operations and said the goal should be simple: delivery of terrific care that’s affordable to the patient. Dr. Porter proposes the improvement of value as defined by outcomes that matter to patients and costs over meaningful episodes of care, with improvement and collaboration as key features. Dr. Lee noted that in discussions with physicians, when outcomes and costs are on the same page, the conversation is different. He emphasized that patients have to be part of the conversation to determine what “success” looks like to them. Dr. Lee cited Dr. Gawande’s Checklist Manifesto as a tactic for improving value by increasing reliability and said if we’re really reliable, we can reduce waste, harm and chaos. Richard Bohmer was identified as the operations guy who proposes shifting the role and mission of delivery organizations from being rewarded for performing services to being rewarded for outcomes, which will mean qualitatively different functions for service organizaExecutive Director's Message, continued on page 26
California Family Physician Fall 2011 25
Resident News, from page 11
that are important to the resident and student majority, but that do not infringe upon the rights of the membership minority, showed that our congress was truly a collaborative effort. For a complete list of resident resolutions passed at the congress, log on to www.aafp.org/online/ en/home/cme/aafpcourses/conferences/ nc/2009resolutions.html At the California Reception, Dr. Lee introduced his superhero concept and recognized students who received CAFP Foundation scholarships: Lily Adelzadeh, Oluyemi Ajirotutu, Margot Brown, Carolyn Candido, Kristina Carpenter, Angela Echiverri, Erandhi Hall and David Piccinati. AAFP also awarded Target School Scholarships to two students from Stanford: Alexis Hansen and Dinah Arumainayagam. The audience applauded as Dr. Lee praised each student’s unique superhero story.
Executive Director's Message, from page 25
opportunity for students from California (and students interested in coming to California) to mingle with the residents and physicians. As the conference came to an end, I found myself feeling rejuvenated and excited to continue to fight for family medicine and our nation’s patients. We superheroes are the ones who work tirelessly to make our voices heard. We are the foundation for the future of medicine. I am proud to be a part of such a special group that strives to deliver comprehensive, compassionate and affordable high-quality health care. See you all next year! Alisha Dyer, DO is a third year resident at Sutter Health Family Medicine Residency in Sacramento.
RESOURCES 1. Pensa, Mellisa MD, “Message from the Resident Chair”, http://www.aafp.org/online/en/home/ cme/aafpcourses/conferences/nc/aboutnc/chairsmessage.html
The reception was not only a great place to network for those in residency or practicing in California, but also a special SCI_CA Family Phys Ad_12.18.10.qxd:Layout
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26 California Family Physician Fall 2011
tions. The locus of knowledge becomes the organization, not the individual clinician, and the primary measures move from procedures to outcomes. • Among the implications of this proposed change for physician leaders he cited: • Importance of team care • Extension of teams beyond hospitals to the continuum of care • Relentless efforts to minimize waste, redesign care and adoption of time‐based, activity‐driven cost accounting • Focus on outcomes that matter to patients • Opportunity to show leadership to other physicians who must lead the changes that lie ahead And, bless Dr. Lee’s heart, he reported that his organization is trying to get 60 percent of its practices (at HARVARD) to be PCMHs by 2013. That’s what we’re talking about.
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