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URMC moves to form group

Rochester Business Journal
February 8, 2013

The University of Rochester Medical Center filed papers with the state Health Department this week to establish a new physician organization.
 
Accountable Health Partners IPA LLC starts with a 1,000-doctor core membership consisting of URMC's employed-physician Medical Faculty Group.
 
It is organized to help URMC and area physicians adjust to changing demands on health care providers as the evolving reforms of the Patient Protection and Affordable Care Act and Centers for Medicare and Medicaid Services remake the U.S. health care system.
 
The medical center hopes it can quickly recruit some 500 area private practice doctors and extend the new group's reach to doctors in outlying communities. Talks with practice groups are under way, URMC officials said.
 
In recruiting private doctors, the university would not look to take over or absorb private practices and would not seek to bind Accountable Health Partners doctors exclusively to UR's sprawling medical complex, officials said.
 
The Monroe County Medical Society is cautiously optimistic but not yet recommending that its members in private practices participate, Executive Director Nancy Adams said. The society was host for a presentation by a URMC official involved in forming Accountable Health Partners and is conferring with other URMC officials on the organization.
 
"We haven't yet seen what its structure is going to be," Adams said. "It's imperative that an organization like this be truly physician-led. There is, to some extent, a basic level of distrust between some of our private practice members and health systems. But I would have to say that URMC so far is saying the right things."
 
In organizing Accountable Health Partners, "We're not looking to take over any practices," URMC CEO Bradford Berk said. "We think this will help private doctors stay independent."
 
URMC also has kept Unity Health System and Rochester General Health System abreast of its Accountable Health Partners plans, Berk added. Members of the URMC-affiliated doctors group would be free to join other, similar physician groups, he said. One such group already exists-the RGHS-affiliated Greater Rochester Independent Practice Association, more than a decade old-and more would be likely to form, he added.

Powerful group
Once established, the new URMC-affiliated organization-likely to be the largest and most powerful of its kind locally-would seek to sign contracts with private payers, including insurance companies and self-funded employers, serving as an intermediary between its members and the payers, said Robert McCann M.D., Accountable Health Partners' interim director and Highland Hospital chief of medicine.
 
Termed an affordable care network, Accountable Health Partners is meant to be an analog of accountable care organizations, Berk said. Those organizations, called for under Centers for Medicare and Medicaid Services reform initiatives, are intermediaries between providers and the government-run Medicare insurance program.
 
Both types of physician groups seek to move doctors and hospitals away from the fee-for-service model of provider reimbursement, which long has dominated U.S. medicine, to an evolving payment scheme being pushed by the Affordable Care Act, CMS and some private insurers, Berk said.
 
In the fee-for-service model, providers are paid set fees for services such as office visits or surgical procedures. It is a system doctors say drives up costs by incentivizing them to do more procedures and schedule more visits while providing scant reward for quality.
 
The new models guiding accountable care networks and accountable care organizations seek to impose a new standard known as the Berwick triple aim, Berk said.
 
Named for its author, former CMS director Donald Berwick M.D., a Harvard Medical School physician and reform advocate, the triple aim seeks to create a provider-reimbursement scheme that equally encourages high-quality care, patient safety and cost containment.
 
Toward that end, the new URMC doctors group and GRIPA seek to follow a clinical integration model, fostering tight coordination of care among primary care physicians, specialists and hospitals, Berk said.
 
GRIPA is a 900-member physician organization formed in the late 1990s. Half-owned by RGHS and half-owned by its members, it is one of a few physician groups nationally to have won Federal Trade Commission certification as a clinically integrated organization.
 
GRIPA and RGHS are in talks with Excellus BlueCross BlueShield over a contract similar to the pacts URMC's Accountable Health Partners hopes to sign with health insurers. GRIPA entered an agreement several years ago to provide care for workers of the self-funded LiDestri Foods Inc.
 
That GRIPA needed FTC permission to negotiate contracts with private payers speaks to the fundamental health care changes being attempted under federal law and regulations. In 2007, when GRIPA won the clinical integration designation, doctors were barred from negotiating contracts with payers as a group. Defined by the Justice Department as sellers of a service, doctors would violate price-fixing rules of the Sherman Antitrust Act if they cooperated with each other to set fees, the FTC held.
 
The FTC exempted from the price-fixing ban a tiny handful of doctor groups that it regarded as sufficiently clinically integrated. The agency reasoned that clinically integrated physician networks could slow the rate of increase in health care costs by improving quality and thus reducing utilization.
 
GRIPA remains one of three organizations nationally to have earned the FTC's clinical integration seal of approval. The RGHS group won the FTC certification only after investing substantial sums in information technology to support communication among its members.
 
A provision imposed by the FTC in granting the clinical integration certification as protection against possible market domination demanded that GRIPA not increase its membership. Such restrictions are being relaxed and re-examined under the Affordable Care Act, said URMC vice president Raymond Mayewski M.D., one of several medical center officials who has been working to form Accountable Health Partners.
 
There is little solid guidance on how or whether the FTC would weigh in on accountable care networks or accountable care organizations, Mayewski said. But there is little sense that the antitrust concerns previously limiting physician groups would apply now.

Big investment
URMC, which has spent tens of millions of dollars on information technology to improve the electronic medical records systems of its owned practice groups and hospitals, is investing more in IT systems to make Accountable Health Partners work, Mayewski said.
 
To offset those costs, doctors joining the URMC organization would be asked to buy in, Berk said.
 
Adams said the one-time entry fee-which, based on the briefings URMC has given to the Medical Society, she expects to be in the range of $2,000 to $2,500-would not be a problem for most area practices. Such a fee is understandable, given the steep price of installing IT to make clinical integration work, she added.
 
An underlying question remaining is how well the realignment of payment incentives will rein in health care costs.
 
Berk is optimistic on that score. URMC quietly instituted a payment model similar to the models being developed under the Affordable Care Act and CMS reforms more than a year ago, he said. And URMC physicians subject to that model last year saw an average $20,000 payback for meeting quality standards and holding down costs.
 
The evolving new models continue to pay fees per procedure or office visit but are making an escalating portion of those fees subject to quality, outcome and patient satisfaction measures.
 
"Right now, 99 percent of payments are still fee-for-service. That percentage is going to keep going down," Mayewski said.
 
As third-party payers, health insurance carriers account for a large share of doctors' and hospitals' revenues. How ready are insurance companies to switch from a model that generally has given them an upper hand in dealing with providers to one that gives doctors and hospitals more ability to negotiate terms, potentially putting providers in the driver's seat?
 
"We definitely see the future delivery of value in these innovative payment arrangements involving physicians," said Paul Eisenstat, Excellus BlueCross BlueShield senior vice president for health care and network management.
 
One key to making Accountable Health Partners work would be access to private insurers' claims data, Berk said. Combined with patient data made readily available by electronic medical records, claims data can be analyzed to help doctors understand trends affecting their patient populations and to more closely track individual patients.
 
Insurance companies traditionally have seen claims data as proprietary and held the information close to the vest, refusing, for example, to share employee groups' claims experience with companies paying all or part of their workers' premiums.
 
In a reversal of such policies, Excellus, the dominant health insurer in the Rochester area with more than half of the region's commercial health coverage, has begun sharing limited claims data with URMC's employed physicians, Eisenstat said.
 
Seeing a promise of cost control in the new payment models, it would be ready to expand the sharing to private physicians as members of clinically integrated organizations such as Accountable Health Partners, he said.
 
Despite such apparent good fellowship, Adams sees some possibility of trouble ahead.
 
To stay viable, she believes, accountable care networks will need to keep their physicians' patients' business in their own networks. And one way they might seek to ensure that result is by offering their own insurance plans, a move that would put the provider organizations in direct competition with private third-party payers.
 
Asked whether such a possibility is part of Excellus' calculations, Eisenstat said, "There's a lot of interest in new types of insurance. It's too early to consider where that might lead."

2/8/13 (c) 2013 Rochester Business Journal. To obtain permission to reprint this article, call 585-546-8303 or email service@rbj.net.


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