Changes in 2017: PODS

Getting past the fact that Congress has vowed to make significant changes to Obamacare, transitions in healthcare in 2017 are already having an impact on long-term strategic decisions.

We need to accept that Medicare Access & CHIP Reauthorization Act (MACRA) is going to happen in ways that redefine the parameters of the Medicare Quality Payment Program, i.e., the long-planned move to value-based performance. MACRA reporting requirements began on January 1st, so the program is operational and the option to do nothing has passed.

The end result of this development is the reality of medical delivery accepting the advent of “risk reward”. It is now time to understand both the upside payment gains and downside penalty impacts. The Management Service Organization (MSO) serving Physician Direct Access (PDA/IPA) anticipates this change, not in a pro or con manner, but as a reality-based opportunity.

Our management has worked in this environment of performance “wins” for years; the option to pursue otherwise is unacceptable. The opportunity at-hand will thrive with hard deployment of modern population management and technology while providing high-quality patient care at an efficient cost.

This is a major shift from the somewhat unpredictable changes of managed care and the limitations of a messenger-model IPA. This blog has addressed a future of “risk-reward” contracting for several years. We have both recollections and first-hand knowledge of how physician organized delivery systems (PODS) can work. We have gloried in the PODS’ ability to save the patient hassle and cost while paying the practitioner based on results. Now the market and government changes are supportive to “risk-reward” initiatives.

The plan is to select practitioners (Specialists & PCPs, mid-level providers, allied health practitioners, Chiropractic Physicians, etc.) who are candidates for engaging in a physician organized delivery system. That is the goal. The MSO is at work to build IPA capability and inter-disciplinary collaboration with every possible avenue of IPA member participation.

Much more to follow…

After The Blocked Aetna-Humana Merger…

This is a message for clinical colleagues, office managers, and PDA’s working teammates. Insurers can only scale so much to drive efficiency and profits.  Saying it again…“Going forward, both industry consolidation and the changes relating to the Affordable Healthcare Act, will not be a panacea for growing insurer profit margins.” Eight years of a dramatic federal redo of the healthcare insurance model is perhaps in the rearview mirror. And, the view of the road before us is somewhat unclear. Still, leading insurance executives must continue to look for other ways to increase returns.  Achieving return on investment is inescapable.

This message underscores that IPAs must perform the credentialing, verification, and contracting support functions with a higher level of efficiency. Also, communication with the carriers and providers must be constantly improved and reviewed for quality control. PDA and our peer group need to improve our performance ASAP. This means the IPA has to be engaged with the membership while continuing to serve as an administrative resource. We must aggressively assert the rights for the independent providers. And, we have to determine new avenues of provider income enhancement.

We are going to grow closer in synergy with the carriers and partial self-funded plans. Our physician members will be called on to assist in enhancing the carrier and business-owner relationships. Our primary care group has an important role in interacting with businesses, law firms, engineering firms, etc. Throughout this year, we will work to effectively communicate to professionals and patients the added value of independent providers who care about performance and value. This has exciting, practical potential.

This retooling of the essentials means an increased emphasis on vertical integration with the preferred carriers and business community—that is, supporting more involvement by payers at the provider and patient level to more effectively manage risk. We are headed into the risk-reward area of providing service. We are actively evaluating third-party ACO systems to jump start risk-reward contracting.

The size of a provider group is not the key in value-added service. It is how good are we in managing performance metrics, intergroup financial equity, and patient satisfaction.

More to come….

House Republicans have unveiled a plan to repeal and replace the Affordable Care Act

The plan—detailed in a document called “A Better Way”—says that “Obamacare must be fully repealed so we can start over and take a new approach.” To replace the president’s signature healthcare law, the plan weaves together a variety of healthcare policy ideas in its outline of what should replace the ACA. A copy of the plan may be requested from your PDA office, or downloaded here.

Here’s a breakdown of some of the plan’s key provision:

A new approach to exchanges. The Republicans’ plan would offer everyone who doesn’t qualify for employer coverage, Medicare or Medicaid to access a refundable tax credit to use in the individual market—instead of the ACA’s current policy of offering tax credits to just those of certain incomes. The credit is also age-adjusted, the report says.

Association health plans,” in which small business and groups such as alumni organizations and trade associations band together to offer healthcare coverage at better rates via improved bargaining power with insurers. This would “free employers from costly state-mandated benefit packages and lower their overhead costs,” the document says.

Robust high-risk insurance pools. The plan would set aside at least $25 billion to fund programs that Republicans say would give financial support for those with high medical costs who find themselves priced out of coverage. Premiums for those participating in the high-risk pool would be capped, and wait lists would be prohibited, according to the document.

A one-time open enrollment period for the uninsured, regardless of health status. If consumers who lack coverage don’t enroll in a plan during that open enrollment period, they forfeit continuous coverage protections and could face higher insurance costs in the future.

The sale of insurance across state lines. This often-cited GOP policy proposal, according to the document, will make the insurance market more competitive and give consumers the ability to access the most affordable policies.

The preservation of certain ACA protections. The plan would prevent those with pre-existing conditions from being denied coverage, as well as allow individuals to stay on their parents’ insurance plan until age 26.

Medicaid reforms that would allow states to choose between either a per capita allotment for their programs or a block grant. States would be allowed the flexibility “to charge reasonable enforceable premiums” or offer a limited benefit package. The proposal also takes several steps to “modernize” the Medicaid demonstration waiver process, requiring them to be budget neutral while grandfathering in some successful waiver provisions.

The document, however, lacks details about how the plan would be financed. That’s because it is mainly a “framework” upon which congressional committees will build next year.

Sources: Kaiser Health News, Fierce Healthcare IT

Preparing your healthcare organization for value-based care

Baker Tilly presents a value-based care readiness series to help your healthcare organization be better prepared for the paradigm shift to value-based care.


“Pay for Performance”

An outstanding nurse practitioner and physician assistant cadre is growing, adding to PDA’s capability to perform successfully in the new environment

The escalating shortage of primary care physicians has led IPA management to consider the emerging roles of nurse practitioners (NPs) to improve access to primary healthcare services. Since 1996, there has been a steady increase in the number of NPs. That trend, along with the enactment of state laws to expand the scope of practice, prescriptive authority, third-party reimbursement and national efforts to improve healthcare access, has resulted in dramatically expanded roles for NPs in providing primary care services.

PDA has respectfully and conservatively evolved policy and IPA procedures over its lifetime. Today, PDA offers Nurse Practitioners an opportunity characterized by equality, with hospital-owned practices and other employment roles. PDA welcomes the energy and vision of all licensed healthcare providers who are seeking an IPA that provides credentialing and verification by contracted managed care companies.

The changing state of care delivery systems, value-based provider delivery models (PODs) and consumer demand have led PDA to credential and represent medical professionals such as physician assistants, nurse practitioners, nurse anesthetists, psychiatric and psychological clinicians and therapists, physical therapists, and speech therapists. As PDA supports integrated delivery in coordination with managed care, these medical and clinical services represent a growing number of current and future dues-paying members of the organization. Their decision is sound, allowing PDA to represent their services in contrast to the unstructured, contract-by-contract selection process and spot market compensation by managed care. They will be treated with equality regarding dues, contract opt-in, policy, procedure and opportunity to serve on the Board and/or Committees.

PDA has proven to be resilient and creative in representing members as the managed care market has evolved. These changes have been subtle and effective because they exactly track with the managed care market for funding healthcare, the inpatient and outpatient segments, and a diverse provider universe.







6 things doctors need to know about the MACRA final rule

By Todd Shryock, Medical Economics
October 14, 2016

The Centers for Medicare & Medicaid Services (CMS) released its final rule for the Medicare Access and CHIP Reauthorization Act (MACRA) on October 14. Here’s what physicians need to know…

6. Who has to participate in MACRA? If you bill Medicare more than $30,000 annually or provide care for more than 100 Medicare patients each year, you are affected by MACRA. If you do not meet those benchmarks, you are exempt from its requirements.

5. When does MACRA take effect? The program begins Jan. 1, 2017, but if you are not ready by then, you can choose to start collecting performance data as late as Oct. 2, 2017. Whenever you start, performance data is due by March 31, 2018.

4. Why are there different starting dates? To make it easier for practices to comply with MACRA, CMS created four options, each with its own requirements.

  • Option 1: Test the quality payment program. As long as you submit some data—for example, one quality measure or one improvement activity—you can avoid a downward payment adjustment. You need to start collecting data no later than Oct. 2, 2017.
  • Option 2: Participate for part of the year. If you submit 90 days of 2017 data to Medicare, you may earn a neutral or small payment adjustment. You must start no later than Oct. 2, 2017.
  • Option 3: Participate for the full year. If you submit a full year of 2017 data to Medicare, you may earn a moderate positive payment adjustment. You must start collecting data Jan. 1, 2017.
  • Option 4: Participate in an Advanced Alternative Payment Models in 2017. Instead of reporting quality data and other information, the law allows physicians to join an Advanced Alternative Payment Model, such as a Medical Home Model. This can result in a 5% incentive payment in 2019.

Regardless of which option you choose, to earn the possible positive payment adjustment that starts Jan. 1, 2019, all 2017 data must be submitted by March 31, 2018.

3. What happens if I ignore MACRA? If you don’t send in any data, you will receive a negative 4% payment adjustment in 2019. This penalty increases each year thereafter: 5% in 2020, 7% in 2021 and 9% in 2022.

2. Is this the last of the changes to MACRA? No. CMS indicated it will continue to listen to feedback and adjust rules as necessary and is already working on additional APM options to get more physicians involved.

1.  Is there any help available to help me with implementation? The Transforming Clinical Practices Initiative (TCPI) program offers assistance to transform your practice. Clink on the following link to find organizations in your area that can help:

Message From The PDA Benefits Desk

Some small companies driven by a tightening labor market and rising costs and fewer choices for individual coverage are reversing the practice of providing no health insurance. Workers are looking for healthcare. Job candidates are seeking employment that offers health benefits. That fact is also driven by major carriers ceasing to offer individual coverage. Individual policies seemed like a good option when the Affordable Care Act took effect. But, group plans have more value now.

Unlike large employers, small businesses –those with the equivalent of fewer than 50 full-time employees– aren’t required to offer health benefits under the ACA. Many do so anyway to remain competitive in the job market or because they think it’s the right thing to do.

The world for small businesses is quite dynamic. Companies in the current small group market are also accepting that benefit plan financial contribution is a creative variable. For example, 50 percent of premium cost can be a positive position for a less-than-50 full-time employee group. Also, the small group self-insured market, when joined with wellness and population health services, is an attractive cost-benefit option.

Questions about the merits of individual-versus-group coverage are intensifying as changes continue to roil the insurance market.  There are two sides to this issue. Agencies that work with small businesses across the country say most small businesses making changes continue to shift to individual coverage because their workers are eligible for significant government subsidies. But the trajectory of that is slowing, as there is a reverse migration back from individual to group.

Timely Statistics and Facts

Conflicting forces are buffeting small companies. Transitional rules that allowed certain companies to continue offering existing plans that don’t meet certain ACA requirements expire at the end of 2017. In North Carolina, some companies could face cost increases of as much as 40 percent for ACA-compliant plans.

At the same time, prices for individual coverage are climbing and insurance companies are dropping out of the state and federal marketplaces that sell individual coverage. Last week, Aetna Inc. said it would withdraw from 11 of the 15 state exchanges on which it currently offers coverage, making it the latest major insurer to pull back from that business. Estimates of how many small businesses offer group coverage vary. 54 percent of companies with three to 49 workers offered health benefits last year, about the same as in 2014 but down from 66 percent in 2000, according to a 2015 Kaiser Family Foundation survey.

Companies with three to 50 employees paid an average of $15,602 annually for each worker who elects family coverage, according to Kaiser, up from an average of $12,809 in 2010. Government subsidies can make individual coverage attractive to small firms employing workers earning as much as four times the poverty rate. For 2016, the ceiling generally was $97,200 for a family of four. Employers, however, generally can deduct the cost of group healthcare premiums.

Before the ACA, insurers often denied coverage to individuals with existing conditions; one reason costs were often higher for small groups. But the price gap has narrowed significantly. Individual coverage, meanwhile, has grown less attractive as insurers narrow options for physicians, hospitals and prescription drugs in an effort to cut costs.  There are also a lot of bad surprises, like showing up at a hospital with a doctor and being out of network. Finding affordable coverage is hard. The Broker/Agent is an invaluable asset, if educated with facts and aggressive in working with the market.

Sources: Wall Street Journal, CNBC and other wire reports.