Jun 30, 2017 — primary care physicians and specialists, or between multiple specialists /Accountable%20Care%20News%20-%20December%202010(1).pdf.
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page 3©2019 Smith, Anderson, Blount, Dorsett, Mitchell & Jernigan, L.L.P.This strategic guide involved input through participation by many thought leaders of the following sponsoring organizations who have come together to form the Toward Accountable Care Consortium and Initiative (TAC). This paper would not have been possible without the generous support of all TAC Consortium member organizations, including signi˜cant support from the North Carolina Medical Society, as well as a substantial grant from The Physicians Foundation. Special thanks to the North Carolina Academy of Family Physicians and North Carolina Society of Anesthesiologists, whose seminal ACO white papers are the underpinning of this Toolkit. We are grateful to Julian D. (fiBofl) Bobbitt, Jr. of the Smith Anderson law ˜rm, for compiling the information in this non-technical fiblueprintfl format, and all the physicians and other contributors who made this compilation possible. ACKNOWLEDGMENT County / Regional Medical Societies Cleveland County Medical Society Craven-Pamlico-Jones County Medical Society Durham-Orange County Medical Society Mecklenburg County Medical Society Forsyth-Stokes-Davie County Medical Society New Hanover-Pender County Medical Society Pitt County Medical Society Rutherford County Medical Society Western Carolina Medical Society Wake County Medical Society Specialty Societies Carolinas Chapter, American Association of Clinical Endocrinology North Carolina Academy of Family Physicians North Carolina Chapter of American College of Cardiology North Carolina Chapter of the American College of Physicians continued next page
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page 4©2019 Smith, Anderson, Blount, Dorsett, Mitchell & Jernigan, L.L.P.North Carolina College of Emergency Physicians North Carolina Council on Child and Adolescent Psychiatry North Carolina Dermatology Association North Carolina Neurological Society North Carolina Obstetrical and Gynecological Society North Carolina Orthopaedic Association North Carolina Pediatric Society North Carolina Psychiatric Association North Carolina Radiologic Society North Carolina Society of Anesthesiologists North Carolina Society of Asthma, Allergy & Clinical Immunology North Carolina Society of Eye Physicians and Surgeons North Carolina Society of Gastroenterology North Carolina Society of Otolaryngology Œ Head and Neck Surgery North Carolina Oncology Association North Carolina Society of Pathologists North Carolina Society of Plastic Surgeons North Carolina Spine Society North Carolina Urological Association State Societies / Organizations Community Care of North Carolina Carolinas Center for Hospice and End of Life Care North Carolina Academy of Physician Assistants North Carolina Association of Local Health Directors North Carolina Community Health Center Association North Carolina Foundation for Advanced Health Programs North Carolina Medical Group Managers North Carolina Medical Society
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page 5©2019 Smith, Anderson, Blount, Dorsett, Mitchell & Jernigan, L.L.P.TABLE OF CONTENTS The Physician™s Accountable Care Toolkit How to Identify and Build the Essential Elements of Any Successful ACO I. Introduction .–––––––––––––––––––––––7 II. SPECIALTIES A. Anesthesiologists .––––––––––––––––––––15 B. Cardiologists .23C. Child Psychiatrists ..––––––––––––––––––––37 D. Dermatologists ––––––––––––––––––––––45 E. Emergency Physicians 49 F. Gynecologists –––––––––––––––––––57 G. Hospitalists ..––––––––––––––––––––––.65 H. Nephrologists .––––––––––––––––––––––.81 I. Neurologists ––––––––––––––––––––––.87 J. Obstetricians ..––––––––––––––––––––––.97 K. Oncologists ––––––––––––––––––––––.109
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page 6©2019 Smith, Anderson, Blount, Dorsett, Mitchell & Jernigan, L.L.P.L. Ophthalmologists ––––––––––––––––––––––.123 M. Orthopaedists ..–––––––.131 N. Pediatricians ..––––––––––––––––––––––.139 O. Primary Care Œ Family Practice, General Internal Medicine And Other Disciplines Which Provide Primary Care ––––––––151 P. Psychiatrists ..––––––––––––––––––––––.169 Q. Pulmonologists .––––––––––––––––––––––.175 R. Radiologists ––––––––––––– .183 S. Rheumatologists .––––––––––––––––––––––.189 T. Urologists .–––––––––––––––––––.195 III. How to Develop a Multispecialty Merit-Based Shared Savings Model ..–.200 IV. ACO Specialist Af˜liation Options ––––––––––––––––200
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page 8©2019 Smith, Anderson, Blount, Dorsett, Mitchell & Jernigan, L.L.P.are now dependent on each other, across specialties, to manage the health status and total overall costs of its patient populations. No longer is doing well as an individual enough. The bottom line is that the in˚uence of MACRA removes all doubt that value-based care is inevitable and that thriving in such an environment, where providers are compensated based on the overall costs of their patients, requires interaction across specialties. The new health care is a team game. For purposes of this Manual, the teams are generally termed accountable care organizations (fiACOsfl) or clinically integrated networks (fiCINsfl), but clearly can embrace any grouping of providers working jointly under value-based payment models, including single tax ID multi-specialty entities, Independent Physician Associations, and virtual networks. B. MACRA Is Not Going Away Œ MACRA was passed by both chambers of Congress with strong bipartisan support. 3 Implementing regulations have now been promulgated by both the Obama and Trump administrations. 4 C. Change Is Hard Œ We are moving inexorably to a team-oriented value-based payment model for integrated population health. This will require a disruptive transformation of health care delivery. Such a fundamental change is extremely dif˜cult, and there is a natural tendency to resort back to fee-for- service business practices even once in an integrated or alternative arrangement. Additionally change is dif˜cult even when there is universal support, which this movement has never purported to have. While adaptation is occurring at different rates around the country, the state of things described by Harold Miller in 2009 still holds true in many areas: fi[O]ne of the problems with healthcare in the U.S. is that there is little or no coordination between primary care physicians and specialists, or between multiple specialists treating different conditions affecting the same patient. This can result in problems such as duplication of testing and con˚icts between medications ordered by different physicians that lead to higher costs and poorer outcomes. Moreover, a recent study suggests that many of the visits made to specialists after initial referral are for routine or preventive care that could be more cost-effectively delivered through the patient™s primary care practitioner. – fiThis is likely in part a result of the dysfunctional fee-for-service system in the U.S., which pays each specialist independently for whatever they choose to do, including ordering duplicative tests, but pays no one to provide coordination. In many cases, more coordinated care could be provided by having the specialist consult with the primary care physician about how the primary 3 The Medicare Access and CHIP Reauthorization Act of 2015 (fiMACRAfl) as passed in April 2015 with a 92-8 Senate vote, and 392-3 House of Representatives vote. 4 During the Obama Administration, the Final Rule implemented by the law was published on October 14, 2106. During the Trump Administration, a Proposed Rule to ease administrative burdens was published on June 30, 2017.
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page 9©2019 Smith, Anderson, Blount, Dorsett, Mitchell & Jernigan, L.L.P.care practice can comprehensively manage the patient™s care, rather than having the specialist separately manage a portion of the care. Here again, the fee-for-service system is a barrier, since the specialists are paid for face-to-face visits with patients, but are typically not paid when they provide advice directly to the primary care physician. fiClearly, one of the opportunities for improving the ef˜ciency and effectiveness of healthcare in the U.S. is rationalizing the roles of primary care physicians and specialists. – [A] primary care practice will need to have a good working relationship with specialists in order to avoid overlaps and gaps in care and to achieve the best outcomes for their patients. – fiThe important factor will be the ACO™s ability to successfully work with a comprehensive set of specialists to achieve the most coordinated, ef˜cient care of the patients for whom the ACO is accountable.fl 5 As of this writing, it may be said that CINs, ACOs, and other value-based care teams are starting to emerge from primary-care only prevention and wellness activitiesŠACO 1.0, as it wereŠto ACO 2.0, of strategically utilizing value-adding specialties to address the diagnoses and process ˚aws of their patient population. But, there is no question that, from a cultural standpoint, this is hard. D. NCQA Patient-Centered Specialty Practice Program Œ Building upon the principles enunciated by Mr. Miller in I.C. above, this program was designed to link specialties across the spectrum in coordinated care. The NCQA states that: fiPractices that become recognized will demonstrate patient-centered care and clinical quality through streamlined referral processes and care coordination with referring clinicians, timely patient and caregiver-focused case management, and continuous quality improvement.fl 6 E. This Manual Is a Compilation of Single-Specialty White Papers Œ In what some may look back on as remarkable prescience, beginning in 2011, different medical and health care facility professional associations and societies pooled resources to develop multiple white papers to provide practical insights for the members of each respective association to optimize their contributions to, and thus their rewards from, the then new value-based care. This group, called the fiToward Accountable Care Consortium,fl (fiTACfl) now includes over 40 members. The current membership can be found at www.tac-consortium. org/about/members/ . The white papers on each topic combined the fibest of the bestfl national research on what is working elsewhere with actual examples from practicing providers and leaders for each paper assembled into fiAccountable Care Workgroupsfl for their respective specialties. The practical insights of these Accountable Care Workgroups will be referenced regularly throughout this Manual. The white 5 Harold Miller, How to Create Accountable Care Organizations , CHQPR, p. 13. 6 NCQA, Patient-Centered Specialty Practice Recognition , www.ncqa.org/programs/recognition/practices/pateint-centered-specialty-practice-pcsp (downloaded December 2017).
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page 10©2019 Smith, Anderson, Blount, Dorsett, Mitchell & Jernigan, L.L.P.papers included general overviews of the essential elements for any successful CIN or ACO, in value- based care, an analysis of legal issues unique to this new delivery model, merit-based shared savings strategies, and special guidance for rural health care and the use of community health resources. But, the core activity of the TAC over the six-year period was the creation of specialty-speci˜c guides addressing the best ways for each to contribute signi˜cantly in value-based integrated care environment. The guides are as follows: Specialty-Speci˜c Toolkits Ł The Anesthesiologist™s ACO Toolkit Ł Accountable Care Guide for Cardiologists Ł Accountable Care Guide for Child Psychiatry Ł Accountable Care Guide for Dermatologists Ł Accountable Care Guide for Emergency Medicine Physicians Ł The Family Physician™s ACO Blueprint for Success Ł Accountable Care Guide for Gynecologists Ł Accountable Care Guide for Hospice and Palliative Care Ł Accountable Care Guide for Hospitalists Ł Accountable Care Guide for Internal Medicine Ł Accountable Care Guide for Nephrologists Ł Accountable Care Guide for Neurologists Ł Accountable Care Guide for Obstetricians Ł Accountable Care Guide for Oncologists
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page 11©2019 Smith, Anderson, Blount, Dorsett, Mitchell & Jernigan, L.L.P. Ł Accountable Care Guide for Ophthalmologists Ł Accountable Care Guide for Orthopaedists Ł Accountable Care Guide for Pediatric Care Ł Accountable Care Guide for Psychiatrists Ł A Guide for Optimizing the Role of Health Departments in Accountable Care Ł Accountable Care Guide for Pulmonologists Ł Accountable Care Guide for Radiologists Ł Accountable Care Guide for Rheumatologists Ł Accountable Care Guide for Urologists General Toolkits Ł The Physicians Accountable Care Toolkit Ł Rural Accountable Care Guide Ł Accountable Care Guide for Community Health Partners Ł Accountable Care Legal Guide Ł The Bundled Payment Guide for Physicians Ł Distribution Based on Contribution: A Merit-based Shared Savings Distribution Model Ł The Physician™s CIN and ACO Contracting Guide This undertaking required hundreds of hours of research and input by professionals. It was underwritten by in-kind contributions from numerous contributors and the generous ˜nancial support of The Physicians Foundation. The grant required that all work product be shared without charge. This Manual is a
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