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ACO Wars – Pioneer vs Shared Savings Programs

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ACO

Well, it is not a war in the strictest sense of the term, but it does denote the recent developments in the ACO or Accountable Care Organization scene where many Pioneer ACOs have been opting out of the program due to difficulties in meeting the targets and the high risks involved.  About 25% of the Pioneer registered Accountable Care Organizations are in the process of exiting the program and joining the lower-risk option, the Shared Savings Program.   CMS had this to say about the fallout :

 “We’re encouraged that these organizations want to continue in programs that promote better care at lower costs, we fully anticipated that as these programs get up and running, some organizations would shift between models.” 

Health Reforms & ACOs

 For those of you, who have been too busy to register what an ACO exactly is, it is a category of CMS program, which is part of the government health reform, which includes others like Patient Centered Medical Home, Medical Neighborhood, Health Home, etc.  The reforms themselves consist of three main components, which is a superset of any practice models.  They are :

a. Care Delivery Reforms.

b. Payment Reforms.

c.  Health and Healthcare Community Reform.

 ACO is a model which is, to quote a popular definition, “an organization, virtual or real that agrees to take on the responsibility for providing care for a particular population while achieving specified quality objectives and constraining costs.”

 As the above definition clearly points out, an ACO platform is expected to stimulate more integrated care for the patients, which would ultimately result in quality improvements and healthcare cost reduction.  Also, in these programs the ACO gets a share in the costs ultimately saved.

Pioneer vs Shared Savings Programs

 SSP and Pioneer were two landmark ACO programs created by CMS.  The latter has a slightly complex format, which takes into consideration organizations that already have some experience in providing coordinated care.

 The Main Differences between the two are:

 1.  SSP has two payments tracks and it is upto to the ACO to choose either the non-risk sharing one (which has less cost savings share) and the risk-sharing track (which has higher cost savings share but at the same time there are possibilities of losses upto even 60%).

 2.  The Pioneer utilizes a trending methodology that, all other things being equal, produces a slightly higher benchmark than the SSP for high-cost areas.

 3.  The SSP will need to cater to at least 5,000 Medicare fee-for-service beneficiaries, whereas the Pioneer needs to service 15,000.

 4.  The Pioneer program importantly includes a clause that 50% of Pioneer ACOs revenues should come from participating in “risk” contracts with other non-CMS  (private) payers.

 The Significance of events such as the above

Republicans have been ardently opposing the health reforms (which is really an attempt for universal healthcare).  The recent refusal by the National Football League to team up with the government to promote ObamaCare has been touted as some sort of vindication for their stance.  Also, the refusal of some states to adopt the Medicaid expansion plan and the setting up of online HIE, to realize the goal of “healthcare for all” , is seen as further supporting evidence.   And the above developments in the Pioneer ACO scene is construed by some health reform detractors as the “straw that will break the ACO camel’s back”.

 MedicalBillingStar :  A Voice of Sanity

 With a decade of hands-on experience in servicing over 500 clients when it comes to the RCM Cycle, MedicalBillingStar always endeavors to float above the cacophony of healthcare gossips and half-truths, to provide their medical billing and coding clients with information that is relevant, besides of course catering to their entire RCM workflow.   We are aware of the impact that ACO’s will have on payment models, the changes from which ultimately have to be incorporated into the RCM process.  Thus, we keep abreast of the latest happenings in the payment model scene.  Meanwhile you may call MedicalBillingStar at 877-272-1572 or visit our website at www.medicalbillingstar.com if you any questions about any of the above or the Medical Billing/Coding processes in general.

Increased Reimbursement For Primary Care Physicians, A Closer Look !

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A welcome respite for primary care physicians !

Everybody knows that primary care physicians are struggling to stay in business. A mandate by the Affordable Care act has announced that Medicaid rates for certain primary care procedures will be paid on par with Medicare rates.

 To receive additional reimbursement physicians will have to fill out, a, state specific Medicaid self-attestation form.

Medicare

Who are covered ?

Family practices, pediatricians and general internal medicine physicians are eligible for increased reimbursement. So are several other sub-specialties and physicians who perform high levels of primary care services. The major criteria are that, physicians should be board certified and have a billing history that indicates that about 60% of their billing is for primary care codes.

The rate increase will be in effect till the end of 2014. Physicians, who’ve registered through MITS and are approved by the Office of Medical Assistance, can see more digits in their pay check from April 2013.

The code to more dollars !

Primary care physicians will be reimbursed in accordance to HCPCS codes related to primary care. Evaluation and management codes from 99201 through 99499 are eligible, as are certain vaccine administration codes.

The rough and tumble of practicing primary care…

Primary care physicians are working under heavy financial pressure. The sequestration cuts of 2013 have taken a heavy toll on medical practices. The sustainable growth rate formula has quickly turned in to a nightmare for physicians.

 Reimbursement cuts, operational pressures and complicated regulations scared the daylights out of physicians.

Quite arguably it was primary care practices that were the hardest hit. Primary care centers were soon shutting their doors as it became increasingly difficult to practice. Primary care practitioners were finding it almost unfeasible to take care of their elderly Medicare patients.

At a time when it was needed the most !

The increase in reimbursement has come at a time when physicians need it the most. The increased Medicaid reimbursement means physicians are offered a reprieve after all the financial pressures they’ve gone to.

Want a few tips to increase the revenue of primary care practices ?

Will Doctors Fade Into Oblivion? The Survival Guide For Newyork Physicians !

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Can I Meet A Physician ?

The answer would most probably be “no” in a few years time. It is going to get increasingly hard to find a physician in New York. The State University of New York center (SUNY) has predicted that there will be severe physician shortage in New York by 2030. The study further reveals that the average age of physicians in New York is alarmingly high.

Medical-Billing-Newyork

I Have An Insurance Number, But Not Medical Care…

The huge physician deficit can leave millions of newly insured patients, under Obama-care  have insurance numbers. But it is no guarantee they will get to meet a doctor. The physician workforce is slowly dwindling and finding a doctor can be the biggest challenge, in the years to come.

The problem is steadily getting worse and it is not just the healthcare law that is to be blamed. Proprietary and complicated EHRs and ambiguous reimbursement models are driving physicians out of the business.

84% Docs Feel The Profession Is In Decline !

And nearly 60% wouldn’t recommend medicine as a career choice. About 75% of physicians feel they are being overworked. These are just a few worrying markers of the disillusioning climate the healthcare industry is in.

Doctors Across New York ; The Much Needed Relief For Physicians !

The DANY program offers physicians based in New York the life support they need. It offers physician practice support, physician loan repayment and help for facilities that recruit new doctors. The application process has also been streamlined to help practices based in NY meet the financial pressures they’re under.

Large health plans are also working in tandem with local medical practices and community health centers to bring in more primary care doctors.

Joining Forces…

Nurse practitioners can fill in the void by offering primary care to patients. Physicians and NPs instead of being at loggerheads, can work together to provide better care for patients across the state. As the shortage worsens team based care will act as the most effective solution.

Outsourcing documentation and billing needs will also offer harried Newyork physicians a brief respite in an otherwise blistering healthcare climate !

Has the Doc-Fix formula saved Physicians but put Hospitals in a Quandry?

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[AnythingPopup id="15"] CFO-Hospitals

Happy New Year !

The year started on a high note for healthcare professionals. The SGR formula that meant 26.5% cuts in reimbursement has been averted. But nobody is popping the champagne just yet. It is a temporary reprieve and only means that physicians can continue seeing Medicare patients, without the fear of working for free. Till the end of this year.

Left to pick up the Tab !

As the healthcare industry, should by this time know, no reform comes without a heavy price to pay! Hospitals have been forced to face the brunt of the “Doc fix solution”. Heavy operational costs and compliance pressures are giving hospitals, sleepless nights. An additional pain of decreased payment is certainly not what they need, at this juncture.

Bedridden Hospitals…

Many feel that the recently released deal to avoid the fiscal cliff is only going to help in pushing pressing problems, down the stream. The 10 million dollars reduced Medicare payment to hospitals, coupled with the ACO cuts, can lead to bedridden hospitals.

Both Peter and Paul are unimpressed !

The latest move by the government has come in for scathing criticism.

With Chif Kahn the president of the Federation of American Hospitals, to famously quoting that it was like “robbing Peter to pay the fiscal cliff of Paul”.

Though physicians are happy about escaping from the deathly blow of almost 30% cuts in reimbursement. The growing need and frustrating lack of a permanent, workable solution has left neither physicians nor hospitals particularly thrilled with the new arrangement.

Can hospitals manage to stick their neck above water ?

In the present climate it is important for hospitals to take a stock of the situation and act quickly. Hospitals will have to create an annual budget that excludes unnecessary costs. Utilize every resource available whether it is manpower or healthcare IT, to the maximum.

Operational costs need to be reduced to at-least break even for most hospitals. Outsourcing is an option that can cut back on expenses. It requires smart out of the box thinking. Identifying and eliminating money drainers. And start the year with a new and revamped revenue cycle, lots of positivity and a smart annual budget.

Its Time To Resuscitate Healthcare !

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[AnythingPopup id="13"] Time to Resuscitate Healthcare

The odds are stacked against physicians. Rising operational costs, hours lost due to data entry and compliance thresholds have made practicing medicine a nightmare for physicians. An increasing number of them are contemplating early retirement. With so much to deal with and a lot more to come, it is a testing time for the healthcare industry.

Buckling Under Pressure…

Slashes in reimbursement and compulsion to gravitate towards EHRs are the major reasons why medical practices are ailing. With divided opinions about ACOs and everybody blaming everybody else, the healthcare field resembles a war-zone. A recent study conducted by Bloomberg points that there is an estimated shortage of 13,000 doctors.

It is time the policy makers take remedial measures to help resuscitate physicians.

Over taxed slaves ?

Disincentives and pressures have made doctors feel like over worked slaves. After a long and expensive education, it is a bleak and challenging future that lies ahead. It doesn’t work for the doctor who is gasping for change and for patients who feel a strain in the physician-patient relationship.

Increasing Costs For Doctor Owned Practices !

The operating costs of a physician working in a full time in a physician owned multi-specialty climbed to 1.3% from last year. The commercial fee for service amounted to 51% of total charges.

A Few Bitter Truths…

  • Operational costs for running  a practice have increased over the last year.
  • Labor costs are the major money drainer for medical practices.
  • EHRs increase the amount of time spent on data entry tasks.

Solutions That Might Just Work…

  • Outsource to cut down on labor costs and operational expenses.
  • Train staff or vendors on using EHRs to reduce data entry pressures.
  • Select an EHR that automates workflow to a major extent, to save on time and resources.

Will Accountable Care Organizations Pave the Way for Change?

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 ACO’S- And the Debate continues…

Are accountable care organizations the future of the healthcare industry ? Or will they force independent practices to shut their doors ?

According to a recent report 49 percent of primary care physicians and 53 percent of endocrinologists are expected to switch to the ACO model in the coming year.

Financial Security and Better Care.

Physicians who’ve partnered with ACOs are provided incentives for prescribing more generic medication. They are also encouraged to lower hospitalization costs. This accent on the quality of care and containing costs can offer clinical benefits and savings, for healthcare providers.

 The much needed Compass…

One of the major reasons attributed to the popularity of ACOs is that they provide a sense of direction. And help physicians to focus on quality metrics, to receive reimbursement and incentives.

It is Not all Gravy…

There are strong oppositions to practices adopting the ACOs model of working. Some section of the healthcare sector, feel it can pressurize independent practices, to join larger organizations. The clinical benefits it offers are also viewed with a sense of skepticism.

The sustainability of independent hospitals is one major concern. And the fact that it focuses more on hospitals rather than physicians is another key factor that works against acos.

Will it join the IDNs of the 90’s ?

Integrated delivery networks were followed by several healthcare providers in the 90’s. Hospitals followed and pursued two strategies, of vertical and horizontal integration. There were different models such as strategic alliances and acquisitions. There was one common factor that bound all the models together, they just didn’t work.

Whether acos join the ill fated idns of the 90’s, or become the, future of the healthcare industry, remains to be seen.