Burns noted that the PCMH program Blue Cross has today is different than the one rolled out in November 2009. “And that is good, because it does get to the continuous improvement.” According to Burns, the program has reached a new level in terms of quality measures and producing the metrics employers want to see.
“One of the things that I think is a positive about the PCMH movement is that we’re working in a more collaborative teamwork model with our patients,” said Eric Justin.
Bagley acknowledged that the ability to measure outcomes has improved, but, he added, “There isn’t a physician I know who thinks the current quality measurement system fairly evaluates their daily work.”
Accountable Care Organizations
Wilson asked a theoretical question of what a reimbursement system would look like, if given today’s technologies, the industry could start from scratch.
“We need to rethink what things are worth,” said Bagley. Many of the things that we pay for every day, whether it’s an X-ray or MRI, are priced in a way that’s not necessarily based around the value to the patients.”
Bagley raised the issue of an Accountable Care Organization, a group of doctors, hospitals, and other providers who collaborate to coordinate care for their patients. “Each component has to demonstrate its contribution to the overall effectiveness and efficiency for the enterprise,” said Bagley. “And if they’re not able to do that, they won’t be asked to join.”
The basic concept of the ACO, Rick Kahle explained, involves moving from a discounted fee-for-service to another form of payment methodology.
“We are very progressive in the ACO world,” said Kristie Arthur. “We’re trying to be innovative in our approach to patient care and transferring that to where the patient is.”
Kansas City Internal Medicine did an ACO for reasons other than monetary. “It wasn’t at all about reimbursement,” said Jean Hansen. “It was really because we’re passionate. We think that’s the way care should be delivered.” As Hansen explained, her organization’s ACO is a Medicare shared savings plan, created after the fact. “You’re getting this pot of money, and you have to decide among your team how it’s going to be divided.”
“The promise of ACO was care coordination, care quality,” confirmed Brian Burns. He noted that the strategy behind ACO reimbursement is to foster and encourage coordination of care.
“I do like the competitiveness of it,” said Burns. He said that there are multiple ACOs forming, which he sees as good both for the industry and his own company. “If you can improve quality of care, improve access, and bend the cost curve, you’ve hit the trifecta,” said Burns.
Joseph Galate was less sanguine about the ACO model. The one example with which he was familiar proved to be “horribly flawed” when it came to distributing revenue. The patients, he believed, suffered most. “They didn’t get good care,” said Galate. “They were run around the system and when all the stuff was done, they were sent back to wherever.”
The ACA and its Effects
Rick Kahle addressed the effect of the ACA on small businesses. As he explained, many of the small businesses bought a year’s delay with early renewals. By the end of the year, however, the effect of community rating should be more obvious.
Before Jan. 1, 2014, the difference in the individual price for coverage on a healthy 18-year-old, as compared to an unhealthy 64-year-old, may have been as much as 25– or 30–1. Under the ACA, the community rating structure mandates that that band get narrowed to 3–1.
