Tag Archives: accountable care organizations

Financial incentives for physicians may not be working as expected

Joseph Burns

About Joseph Burns

Joseph Burns (@jburns18), a Massachusetts-based independent journalist, is AHCJ’s topic leader on health insurance. He welcomes questions and suggestions on insurance resources and tip sheets at joseph@healthjournalism.org.

Photo: Yuya Tamai via Flickr

Photo: Yuya Tamai via Flickr

One premise behind the formation of accountable care organizations is that physicians and other health care providers would have financial incentives to deliver high quality care at lower costs. But research is indicating that the financial incentive may not be sufficient to foster improvements in care.

A study published in the July/August 2015 issue of the Annals of Family Medicine, noted that physicians both inside and outside of accountable care organizations (ACOs) have similar payment arrangements. They are paid a mix of salary, bonuses for productivity and a bonus equivalent to about 5 percent of total salary for delivering quality care and other factors, the researchers said. Continue reading

Accountable care organizations likely here to stay; explain them to public

Joanne Kenen

About Joanne Kenen

Joanne Kenen, (@JoanneKenen) the health editor at Politico, is AHCJ’s topic leader on health reform and curates related material at healthjournalism.org. She welcomes questions and suggestions on health reform resources and tip sheets at joanne@healthjournalism.org. Follow her on Facebook.

While we ponder what the court will do about the Affordable Care Act, let’s take another look at one aspect of the law already in effect,  the accountable care organizations. We’ve spotlighted good coverage of this in the past, but it’s a concept that still has people confused. Plus, if the court strikes part of the law but leaves sections standing, most of the delivery system reforms – including ACOs – are likely to continue, meaning you may want to cover ACOs in your area.

Explaining, localizing Supreme Court’s ACA decision

Tip sheet: A quick guide to covering the Supreme Court ruling on health reform

Webcast: To assist reporters who will need to localize the decision and what it means for their states and communities, AHCJ will host a one-hour online roundtable on Friday, June 29, noon ET, to offer suggestions on stories you can pursue right away and in the weeks ahead.

Joanne KenenAHCJ is committed to helping you cover this milestone decision. For many valuable tips and resources, visit our health reform topic page, compiled by health reform topic leader Joanne Kenen.

Tony Leys of the Des Moines Register recently took a look, in a story that did a nice job of mixing local examples and national context, and of blending narrative “real people” stories with a larger explanation. He got lots of space to do so – a mainbar focusing on doctors and patients and a small sidebar, explaining the policy in plain English.  Even if you don’t get the space he got, the sidebar works really well as a place to translate the wonky “what is an ACO” that helps the reader but doesn’t slow down the story as much. Good approach for complicated stories.

The story came out in May and, unfortunately, we can’t link to the whole thing. (If we find a way to do so, we’ll update this.) Update: The Des Moines Register has restored the story so our readers can see it. We’ll describe the structure of the story and provide some key quotes that give the reader a sense of what an ACO is.

“Supporters of a new method of paying for health care hope to hear more stories like Dave Kalous’.

Kalous, 57, was diagnosed this spring with a potentially deadly heart ailment. Since then, his doctor and other medical professionals have spent hours explaining the disorder and discussing ways he can try to live with it. Whenever he has a question, someone from the hospital gets right back to him with an answer. Every week or two, a nurse comes to his home to take his blood pressure, ask about his pain and check for complications.

He believes that without such support, he would be struggling more. “I definitely would have returned to the hospital more often,” he said.”

Trinity Regional Medical Center last January founded an ACO, in which hospitals doctors and other providers are judged on “how well their patients fare” not just how many tests and procedures they order. This program is under Medicare but private insurers and large hospitals are forming similar organizations. (Check with the big health plans in your area, like UnitedHealthCare, the Blues, Wellpoint, etc., to see what they’re doing).

Leys also describes how and why some doctors are warming up to the concept.

“Kalous’ physician, Dr. Timothy Ihrig, said he’s glad to see the country move toward a system that rewards doctors for talking at length” with  patients about the pros and cons of complicated and expensive treatments.

“We’re in a system now that perpetuates things because they can be done. But should they be done? That’s what we should be asking,” said Ihrig, a palliative care specialist.”

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Leys also explains why ACOs are not equal to HMOs … and that quality measurement, the literal concept of “accountable” care is a big difference.  Patients also have more choices.  And he outlines which patients an ACO focuses on first.

“The Fort Dodge program is focusing first on patients who have chronic health problems, such as diabetes, cancer or heart failure, that are likely to cause multiple hospitalizations. Such people tend to be by far the most costly patients, so they represent the best opportunity to save money.”

He also talks to some national experts (you could get the same result from more local experts at your state universities’ health and public policy programs)  about the pros and cons. One of the big worries – as we’ve said before but it bears repeating – is that ACOs may encourage greater consolidation, either more hospital mergers, or more hospital clout over physician groups. It’s worth mentioning in an ACO story and your state hospital association is probably a good place to start.

Editor’s note: Bruce Japsen writes today about the emergence of ACOs for Forbes.com in “Life After The Supreme Court: Accountable Care Catches Wave.”

Resources for explaining Supreme Court’s ACA decision

Responses to the Supreme Court’s health reform decision

Webcast: To assist reporters who will need to localize the decision and what it means for their states and communities, AHCJ will host a one-hour online roundtable on Friday, June 29, noon ET, to offer suggestions on stories you can pursue right away and in the weeks ahead.

A quick guide to covering the Supreme Court ruling on health reform

The Supreme Court’s health reform decision: What you need to know

Still plenty to watch, report on as Supreme Court considers health reform law

Webinar: Implementing health reform in the states

Covering state responses to Supreme Court decision on Affordable Care Act

Get familiar with alternatives to ACA’s individual mandate

AHCJ is committed to helping you cover this milestone decision. For many valuable tips and resources, visit our health reform topic page, compiled by health reform topic leader Joanne Kenen.

Back-to-the-beat resources on health reform

Joanne Kenen

About Joanne Kenen

Joanne Kenen, (@JoanneKenen) the health editor at Politico, is AHCJ’s topic leader on health reform and curates related material at healthjournalism.org. She welcomes questions and suggestions on health reform resources and tip sheets at joanne@healthjournalism.org. Follow her on Facebook.

Since so many of us are in storm (or non-storm) what-are-we-going-to-do-with-all-these-batteries cleanup and back-to-school mode, I thought I’d bring some resources and interesting studies to your attention to help bring your focus back on the beat.

Confusion still reigns

You probably saw the Kaiser poll reminding us once again how confused people remain about the health reform law – including the very people who would be most helped by it, the uninsured. It got a lot of coverage but if you missed it, it’s a must read. It ties into the theme of massive national confusion – and the frustration I feel that the confusion persists despite a fair amount of good reporting – that I wrote about in the first post I did for Covering Health. I think a lot of the confusion stems from the mandate . People hear that they will “have” to buy insurance, and they panic or get angry because they can’t afford it. They don’t hear that they may well qualify for subsidies to make it affordable-and they don’t have to be dirt poor to get the subsidies; many middle class people will also benefit.

kff-graphic-aug2011

Click to enlarge this graph from the Kaiser Family Foundation Data Note found at http://www.kff.org/kaiserpolls/8217.cfm.

Most of the coverage of the KFF poll I heard or saw centered on the uninsured, but there is also a related data note looking at knowledge and expectations of people who have employer-sponsored health insurance. Asked what they would be willing to do to lower health care costs, the answer could be summed up as “not much.” They are OK with participating in a wellness program (although not necessarily actually getting “weller”) but didn’t like the idea of more generic drugs, more restrictive networks of doctors, or higher copays and deductibles.

Eating away at the doughnut hole

An AHCJ member found this report by EBRI, the Employee Benefit Research Institute, useful so I’m sharing. It’s about how the health reform law will slowly (over a decade) close the “donut hole” for Medicare drug coverage, and how repealing the health law would create a savings hole for older Americans who use a lot of prescription drugs. (The doughnut hole is the gap after you use up the basic drug benefit but haven’t hit the “catastrophic” level. Beneficiaries pay monthly premiums through the gap, but don’t get benefits until they burn through the gap. ) EBRI studies health care and retirement issues and does periodic issue briefs.

What questions do you have about health reform and how to cover it?

Joanne KenenJoanne Kenen is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.

Staff physicians on the rise

The Center for Health System Change has been tracking health care developments in 12 communities and found that hospitals are hiring more staff physicians. In policy circles, the talk has been that the staff-physician model is a tool in creating more clinical integration, care coordination, higher quality and lower cost – but this study found that the hospitals are in it primarily for market share. Physicians like it because it’s fewer hassles. It doesn’t necessarily bring down overall health care costs. Now, this is a snapshot in a fee-for-service world; new payment models being developed by private insurers, and Medicare and Medicaid may change the dynamic. But it’s an attention-worthy snapshot. The HSC Issue Brief, “Rising Hospital Employment of Physicians: Better Quality, Higher Costs?” is available online.

Who applied to be ACOs?

There was a lot of coverage a few months back about all the health systems that were not going to apply to become Medicare Accountable Care Organizations, at least not under the original shared savings model. We aren’t hearing as much about who is applying – worth checking in your community. Medicare also created an alternative, called the pioneer ACO, to attract more plans. We won’t know until around November how many applied to be pioneers, or who they are, but here’s the story of one plan that’s ready to go.

Behind the drug shortage

There was a lot of discussion on the AHCJ electronic discussion list recently about drug shortages, particularly chemotherapy shortages. I was out of town for a few days (helping care for a relative and learning, among other things, that Medicare pays for oxygen concentrators but not for the batteries) and I haven’t caught up with all of the messages, but this essay in the Sunday New York Times a few weeks ago by Ezekiel Emanuel taught me lots I didn’t know about generic chemo drugs, pricing and shortages, and proposed solutions.

Shifts in health care delivery raise questions

Joanne Kenen

About Joanne Kenen

Joanne Kenen, (@JoanneKenen) the health editor at Politico, is AHCJ’s topic leader on health reform and curates related material at healthjournalism.org. She welcomes questions and suggestions on health reform resources and tip sheets at joanne@healthjournalism.org. Follow her on Facebook.

Christopher Weaver at Kaiser Health News has done two stories recently on new care models driven by insurers eager to save money. Both stories lay out issues that AHCJ members can examine in their own communities, particularly regarding the influence insurers will have over health care delivery and how it differs – or does not differ – from the HMOs of the 1990s.

What questions do you have about health reform and how to cover it?

Joanne KenenJoanne Kenen is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.

The first story, in May,  (Health Insurers Opening Their Own Clinics To Trim Costs) was about insurers (specifically Medicare Advantage plans)  opening clinics to treat some of their patients that need a lot of health care, and tend to get it in costly (to the insurer) as well as unpleasant (to the patient) places like emergency departments.  Giving high-needs patients easy access to care in a clinic – which one could think of broadly as a type of “medical home” – can give them continuity of care, avoid health crises, and cost less money in a closed system where the insurer can shape the payment incentives and share in savings.

The second, more recent, story (Managed Care  Enters the Exam Room as Insurers Buy Doctor Groups) reported on a trend that isn’t getting too much attention. Big insurers are buying up physician medical groups, or launching physician management companies. Weaver wrote that it’s “part of a strategy to curb rising health costs that could cut into profits and to weather new challenges to their business arising from the federal health law.”

As Weaver and other reporters have noted, more doctors are giving up solo and small practices in favor of large groups, multi-specialty groups, or staff positions at hospitals. (This Washington Post piece looked at the related trend of hospitals hiring primary care physicians.) Many health policy experts believe the trend toward larger groups and more integrated practices will help reduce fragmentation and duplication, saving money and improving quality.

But what happens when the insurers control the purse strings?  Weaver wrote:

“The doctors, at the end of the day, control the patients and currently [in the regular fee for service system, not this insurer-owned model] they’re financially incentivized to do more tests, more procedures,” said Chris Rigg, a Wall Street analyst for Susquehanna Financial Group. “But, if they’re employed by a managed care company, they’re financially incentivized” to do less.

That thought unnerves consumer advocate Anthony Wright of Health Access in Sacramento, Calif., who worries profit pressure could affect care decisions. But Wright also said there may be upsides to more tightly managed care: “No patient wants to get more procedures than they actually need.”

So that’s the dilemma. Will these insurer-owned and operated systems be curbing costs by getting rid of the unnecessary, wasteful and sometimes harmful care, or will they skimp on care? If they formally become Accountable Care Organizations under Medicare, they will have to be accountable for not only the cost but the quality, in defined and measurable ways. But if they are just slapping an “accountability” label on themselves, it’s less clear who they are accountable to, and what they are accountable for.  It’s not a given that it will be a reprise of the HMOs.

The business environment – purchasers of insurance wanting quality and value – is different than the 1990s. State-based exchanges starting in 2014 may be able to inject more accountability into the system. Medicare and Medicaid as well as state governments are doing more on quality measurements, value-based purchasing etc.  But it’s not clear exactly how all that will play out in the insurer-driven model and whether consumers will resist in ways reminiscent of the managed care backlash 10 or 15 years ago.

“There’s a gigantic Murphy’s law emerging here,” Weaver quoted a health care consultant as saying.  “The very people who were the demons in all of this, that the public can’t stand” – managed-care firms – “are the big winners.”

Explain elements of health reform through the eyes, stories of doctors

Joanne Kenen

About Joanne Kenen

Joanne Kenen, (@JoanneKenen) the health editor at Politico, is AHCJ’s topic leader on health reform and curates related material at healthjournalism.org. She welcomes questions and suggestions on health reform resources and tip sheets at joanne@healthjournalism.org. Follow her on Facebook.

In these posts about covering health reform, I usually don’t point to the big national dailies because a lot of people have already read those stories  but a recent New York Times piece, “As Physicians’ Job Change, So Do Their Politics” is a story that may be able to help reporters think about a good local or regional  jumping off point  for telling aspects of the health reform story in a more narrative, accessible manner, through the eyes and experiences of doctors.

What questions do you have about health reform and how to cover it?

Joanne KenenJoanne Kenen is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.

The Times story, by Gardiner Harris, described a shift leftward (or at least less rightward) among physicians. He cited several reasons: younger doctors, more female doctors, and above all more doctors who are salaried employees of hospitals instead of basically being small businessmen (or women) running a practice.

Because so many doctors are no longer in business for themselves, many of the issues that were once priorities for doctors’ groups, like insurance reimbursement, have been displaced by public health and safety concerns, including mandatory seat belt use and chemicals in baby products.

Even the issue of liability, while still important to the A.M.A. and many of its state affiliates, is losing some of its unifying power because malpractice insurance is generally provided when doctors join hospital staffs.

He wrote mostly about Maine, but had a few observations about other states, including Texas. Last year Texas physicians opposed the national health reform law by a three to one margin. But doctors who did not have their own practices were twice as likely to support the law. The same goes for female doctors.

How does a story about physician politics translate into a narrative about health reform?

The shift to salaried positions has many causes (including work-balance for doctors who want more time with their families) but the move toward more clinical integration  and the formation of accountable care organizations or ACO-like entities will hasten this trend.   It is really, really, really hard to explain ACOS clearly and concisely (when an editor of mine recently asked me to give him a nice, tight two-graf description, I began it something like, “One of the challenges of ACO is that they defy simple explanation.”)

But doctors who are joining hospital staffs or whose practices are being bought up by hospitals or who are entering different contractual relationships and affiliations with hospitals have stories to tell.  You can also talk about quality measures and “never events” and how that affects physicians and the practice of medicine, particularly in states mandating more public reporting. Through their stories, you can illustrate what an ACO is or isn’t, or how a medical home works, or  what “clinical integration” means.

I interviewed a physician in South Carolina the other day, Dr. Angelo Sinopoli, who told me about  how the team approach and the use of electronic medical record with clinical decision support was giving him more real-time feedback on his own performance – and he welcomed it.

“You think you are doing something and you might not be, or think you might not be, but you are,” he said. “Seeing real data in as real time as possible made a difference in how we think.” That made me understand an aspect of the electronic medical record that I hadn’t understood before, and readers can grasp that too.

You can explore the changing attitudes and politics along with that – in some states that may be more significant than others, depending on what your state is doing with health exchanges, malpractice legislation, quality reporting etc.

Editor’s note:

Learn more about how electronic health records could mean new opportunities to improve clinical care and public health, according to David Blumenthal, M.D., the former national coordinator for health information technology. Blumenthal spoke at Health Journalism 2011 as he was leaving his federal position.