You wouldn’t give a 4-year-old a drink, so why would you give one to an unborn child? As a physician, it’s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy. Share 049: Zero Alcohol For Nine Months.
www.mofas.org
Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
March/April Index to Advertisers TCMS Officers
President Thomas D. Siefferman, M.D. President-elect Peter J. Dehnel, M.D. Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Gregory A. Plotnikoff, M.D. Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Katie R. Snow
Secretary Edwin N. Bogonko, M.D. Treasurer Melody A. Mendiola, M.D. Past President Ronnell A. Hansen, M.D. TCMS Executive Staff
TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.
Sue A. Schettle, Chief Executive Officer (612) 362-3799 sschettle@metrodoctors.com Jennifer J. Anderson, Project Director (612) 362-3752 janderson@metrodoctors.com Nancy K. Bauer, Assistant Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Katie R. Snow, Administrative Coordinator (612) 362-3704 ksnow@metrodoctors.com For a complete list of TCMS Board of Directors go to www.metrodoctors.com.
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March/April 2011
MetroDoctors
The Journal of the Twin Cities Medical Society
CONTENTS VOLUME 13, NO. 2
2
Index to Advertisers
4
PRESIDENT’S MESSAGE
MARCH/APRIL 2011
How Many Times Do We Need to Hit Our Head? By Thomas Siefferman, M.D.
5
TCMS IN ACTION By Sue Schettle, CEO
7
Frank B. Cerra, M.D., Receives Shotwell Award
8
2nd Annual TCMS Board of Directors Dinner Held First a Physician Award: Amos S. Deinard, M.D., MPH
Page 9
9
COLLEAGUE INTERVIEW
Bobbi Daniels, M.D. ACCOUNTABLE CARE ORGANIZATIONS
12
s Paul Ellwood, M.D., Father of HMOs, Critiques ACOs By Paul Ellwood, M.D. with Gregory Plotnikoff, M.D.
14
s TCMS Physicians to Create “Model” ACO White Paper
15
s Independent Private Practices and ACOs: Is Compatability Possible? By Peter Dehnel, M.D.
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s The ABCs of ACOs
Page 8
By Nathaniel Mussell, J.D.
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s A Virtual ACO By Liz Quam
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s Fairview is Changing Models to Manage the Health of a Population By Dave Moen, M.D.
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s Minnesota and the Emerging ACO By George J. Isham, M.D., M.S.
26
YOUR VOICE
The Physician’s World—Turned Upside Down and Inside Out By Terril H. Hart, M.D. Page 32
27
New Pilot Sites for Honoring Choices Minnesota EMMS Foundation Awards Grants
28
In Memoriam Career Opportunities
Page 8
MetroDoctors
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New Members
32
LUMINARY OF TWIN CITIES MEDICINE
Elizabeth K. Jerome, M.D. The Journal of the Twin Cities Medical Society
On the cover: TCMS past president Edward Ehlinger, M.D. presented the Shotwell Award to Frank B. Cerra, M.D. Article begins on page 7.
March/April 2011
3
President’s Message
How Many Times Do We Need to Hit Our Head? THOMAS SIEFFERMAN, M.D.
O
ne of my favorite times of the day is coming home to a full house of kids, all still curious about “interesting stories” from another overly long day at work. Usually, these include some life lessons for my children derived from some poor child’s misfortune or poor decision. As I frequently remind my children, there seems to be three predominant ways of learning. The most painful being the “school of hard knocks.” Such a school where some children who don’t believe that things like gravity apply to them, learn that gravity affects us all. The next, less painful school is that of observation; learning from watching someone else learn from the “school of hard knocks.” The least painful school, but the school that many people seem to forget their lessons so readily, is the school of the written word. Reading about an unknown person’s misfortunes does not seem to stay with many people, or, worse, they seem to take away the “wrong lesson.” Such seems to be the case throughout all aspects of life. The teenager who suffered a concussion from a bicycle fall without a helmet, only to suffer a concussion from a fall snowboarding without a helmet. In each case, the lesson of speed and gravity and head coming to a stop before the brain, failed to trigger the forethought of wearing a helmet. The same lesson applies to the practice of medicine. If the reimbursement for services does not meet my costs, and there is no way to make up for such losses, I can go out of business or I can quit the practice of medicine. Medicare with their almost yearly threats to lower reimbursements, only to be deferred another year, is continuing to result in more doctors dropping new Medicare enrollments — I prefer to call them patients. This would lead to a shortage of doctors providing care and longer waits to see those that accept Medicare, further lowering the incomes of those physicians, till they too leave. Those of us who care for the young enjoy our own yoke of Medicaid; receiving payment of 40¢ on the dollar does not lend itself to an all Medicaid practice. Why this seems to be beyond certain people’s understanding again has its roots in learning the “wrong lesson.” Now we have before us the Accountable Care Organizations (ACOs). At its base, an ACO is just another version of capitation. For those younger than me, or for those who forgot, capitation was where the 4
March/April 2011
HMOs gave the doctors money to care for a certain number of souls, whether those souls came in your office or not. It sounds wonderful, encourage doctors to be thrifty with their ordering of tests and use of medications and you get to “keep more of your money.” The reality was harsher, one really sick individual could and did lead to extreme financial hardship and use of “stop gap” insurance which further cut into a physician’s payment. Also the idea of teaching doctors to deny treatments and tests so they get more money goes against the grain much less the oath we all ascribe to in medical school. The hope was through “well-care” and anticipatory guidance we could reduce medical expenditures as all our patients listen to us, eat healthy, exercise daily, never smoke or drink, and they always wear their helmets. The only winners were the insurance companies that formed these HMOs as they kept the full premiums and paid themselves handsome salaries and fees to do the hard work of administering these plans. ACOs will basically move this up a notch and have larger doctor groups or hospitals assume all the risk for the population of patients they are given. If hospitals “control physicians,” why, of course, they will be better able to control that urge to order “unnecessary tests and prescribe excessively expensive medications” — once more leading to health and nirvana. Again, the winners are the insurance industry. The losers will not only include the patients and doctors as before, but also the hospitals or large groups as well. Unfortunately, again life’s lessons will intervene and after some hospital nearly goes into bankruptcy as they will not be able to obtain stop-loss policies, common sense will kick in and only one of two decisions will happen. Either we will return to a market-driven environment where there is competition for charges and costs of medications and tests, and these will control medical costs; or we will wander into the darkness of nationalized health care under the misguided notion that governments will be an efficient guardian of health care and provider of adequate reimbursements like Medicare and Medicaid currently is, or was that “isn’t.” The hope of the Twin Cities Medical Society will be to guide policy makers and creators of ACOs to attempt to prevent this last outcome. Maybe an alternative method will be found that keeps a doctor from becoming a double agent — one that supposedly cares for the patient and at the same time limits care for the patient. Hopefully, physicians will be allowed to guide the care of patients in a cost-efficient manner and, yet, account for the losses incurred by that teenager not wearing his helmet while rollerblading. MetroDoctors
The Journal of the Twin Cities Medical Society
TCMS IN ACTION SUE A. SCHETTLE, CEO
Congratulations to TCMS immediate past president, Edward Ehlinger, M.D. on his appointment by Governor Dayton as Minnesota’s Commissioner of Health. Dr. Ehlinger replaces Dr. Sanne Magnan who served as Commissioner of Health under the Pawlenty administration. The 2nd Annual Meeting of the Twin Cities Medical Society Board of Directors was held on January 18, 2011. (See article on page 8.) Amos Deinard, M.D. was selected as the recipient of the First A Physician Award. He was honored at the annual Board meeting of the Twin Cities Medical Society. (See article on page 8.)
A recent survey was mailed to hospital physician leaders to determine the value and continued interest in the Metropolitan Hospital Physician Leadership Committee, currently chaired by Robert Moravec, M.D. The response was overwhelmingly supportive of continuing to meet with 100 percent of respondents noting the MHPL structure as a valuable opportunity for communication and networking with their peers on common topics. Dr. Ed Ehlinger presented the Shotwell Award to Frank B. Cerra, M.D. at the January meeting of the Abbott Northwestern Medical Staff meeting. (See article on page 7.) The Senior Physician Associations
The Public Policy Committee has designated Accountable Care Organizations as one of its primary focus areas for the year. Terri Hyduke has been hired as a facilitator to assist in the creation of a white paper for distribution to the membership early summer. The white paper will serve as a tool to empower physicians to better understand the requirements and ramiďŹ cations of participating in an ACO. (See article on page 14.) “In the Red Again: What’s Old, What’s New, What’s Next?â€? was the topic of the TCMS Forum held on January 19. The panel of speakers included Rep. Steve Gottwalt, Rep. Erin Murphy, Peter Dehnel, M.D., Mr. Peter Nelson (Center for the American Experiment). Robert Geist, M.D. served as the moderator. Dr. Peter Dehnel will serve as the chair of the TCMS Forum starting in March 2011. Honoring Choices Minnesota continues
to gain momentum as additional pilot sites were launched in January. Funding has been secured from community and health care foundations to support a multi-year community engagement initiative with TCMS, TPT/Channel 2 and the Citizens League. TCMS will be contracting with a Community Engagement Director who will serve as the key staff person for the initiative moving forward. MetroDoctors
The Journal of the Twin Cities Medical Society
of the East Metro and West Metro agreed to merge effective January 2011. Richard Pfohl, M.D. will serve as its president. The Senior Physician Association meets four-ďŹ ve times a year. Speakers are arranged on topics that are generally lighthearted and fun. If you are retired and would like to stay connected with your colleagues, consider attending an SPA event. Meeting notices are sent via e-mail.
Become Involved! Write a resolution, serve as a delegate, attend the MMA Annual Meeting Medicine is rapidly changing. Many powerful inuences are impacting our practices. Change will come. It is vital for you to have a say in the future direction and shape of our health care system and our practices. Our patients depend on us to protect them from the worst of these changes and to assure that they have ready access to the best that medicine can offer. If we say nothing, others will decide. This is your opportunity to have your say! All members of the Twin Cities Medical Society are invited and encouraged to become engaged in setting the priorities and next year’s agenda for organized medicine. This is the time to indicate your interest to serve as a Delegate. Being a Delegate keeps you informed and it assures that your voice is heard. The process works like this: s #ALL FOR 2ESOLUTIONS $UE BY -ONDAY !PRIL E MAIL TO NBAUER METRODOCTORS COM Start thinking about issues that you would like to address through the MMA. What issues are important to you, your practice and your patients? Sample resolutions on TCMS website: www.metrodoctors.com. Click on In Action tab, then Caucus. s
!TTEND THE 4#-3 #AUCUS ON -ONDAY -AY 6:00 – 8:00 p.m. Broadway Ridge Building – Conference Room D 3001 Broadway St. NE, Minneapolis, MN 55413
s
!TTEND --! !NNUAL -EETING $ULUTH -. September 14-16, 2011 (Wed. evening-Fri. mid-afternoon)
For more information, contact Nancy Bauer at nbauer@metrodoctors.com or (612) 623-2893.
March/April 2011
5
Frank B. Cerra, M.D., Receives Shotwell Award
T
he annual meeting of the Abbott Northwestern Medical Staff on January 12, 2011 served as the venue for the presentation of the 2010 Shotwell Award, presented by Edward Ehlinger, M.D., immediate past president of the Twin Cities Medical Society. The Shotwell Award was established by Metropolitan Medical Center in 1971 in recognition of the philanthropic support and dedication of Mr. and Mrs. James D. Shotwell. The wording on a plaque in the Abbott Northwestern lobby reads: The Shotwell Award, established in honor of Mr. and Mrs. James D. Shotwell for their contributions to the hospital, is presented yearly for a noteworthy effort in the ďŹ eld of health care. The Shotwell Award is presented annually to a person within the state of Minnesota for a noteworthy effort in any or all of the following areas of health care: 1. Dedicated service to mankind; 2. SigniďŹ cant breakthrough in some form of research or, signiďŹ cant contribution to the ďŹ eld of medicine; and 3. Innovations and/or improvements in health care delivery. The award is not limited to physicians. The original award was a bronze copy of the sculpture entitled Sprites created by Paul Granlund located in the courtyard of the former Metropolitan-Mount Sinai Medical Center hospital — currently part of the HCMC campus. The current award is represented by a new work titled Asclepius and Hygieia created by local sculptor Nicholas Legeros. Asclepius represents the healing aspect of the medical arts, while his daughter, Hygieia, is associated with the prevention of sickness and the continuation of good health. The Hennepin Medical Society (now Twin Cities Medical Society) assumed responsibility for selecting the recipient of the Shotwell MetroDoctors
Award since the closing of Metropolitan-Mount Sinai Medical Center in 1991. The award is funded through the generosity of Abbott Northwestern Hospital and its medical staff. A permanent plaque recognizing all the award recipients resides on the Abbott Northwestern campus. Frank B. Cerra, M.D. is the 2010 recipient of the Shotwell Award. In making this presentation, Dr. Ehlinger cited the following accomplishments: s $R #ERRA RECEIVED HIS MEDICAL degree from Northwestern University School of Medicine in 1969. s 0RIOR TO HIS SURGICAL INTERNSHIP AND RESIdency at Buffalo General Hospital, State University of New York at Buffalo he served as a research assistant in pharmacology, Upstate Medical Center, and in transplantation at Northwestern University. s (E WAS A CARDIOVASCULAR FELLOW WITH $R DeBakey at Texas Medical Center and a research associate in Immunology and Cardiovascular Research Laboratories at Buffalo General Hospital. s (E THEN SERVED AS A CHIEF RESIDENT IN SURgery followed by a fellowship in critical care at Buffalo General Hospital, State University of New York at Buffalo. s (E BEGAN HIS CAREER AT THE 5NIVERSITY OF Minnesota arriving in 1981 as tenured faculty in the Department of Surgery. Respected as one of the original surgical “intensivists,â€? he started one of the ďŹ rst critical care residencies in the country in 1986-87. s $R #ERRA WAS APPOINTED CHAIR OF THE $Epartment of Surgery in October 1994, dean of the Medical School in May 1995, and provost of the Academic Health Center in 1996, a title and position he held along with medical school dean until his retirement on December 31, 2010.
The Journal of the Twin Cities Medical Society
Frank B. Cerra, M.D. (left) accepts the Shotwell Award from Edward Ehlinger, M.D., past chair, TCMS.
s
s
s
$URING HIS TENURE AS SENIOR VICE PRESIdent, Dr. Cerra led the effort to stabilize the clinical components of the Academic Health Center by partnering with Fairview. He also led an effort to change medical education to be more interdisciplinary. (E DEVELOPED THE "IOMEDICAL $ISCOVER District and the adjoining Minnesota Science Park and was instrumental in creating The Minnesota Partnership for Biotechnology and Medical Genomics, a joint venture between the University and Mayo Clinic. (E IS CO DEVELOPER OF THE BIOARTIlCIAL liver, a device similar to a kidney dialysis machine.
Dr. Cerra is a highly regarded researcher, surgeon and administrator and is the ďŹ rst to hold the dual position of senior vice president for Health Sciences and dean of the University of Minnesota Medical School. Dr. Frank Cerra is well-deserving of the Shotwell Award. He has an incredibly broad range of knowledge and experiences; he’s an effective leader; he has a great sense of humor; and a commitment to the University that has beneďŹ tted everyone in the state of Minnesota.
March/April 2011
7
2nd Annual TCMS Board of Directors Dinner Held
T
he Town & Country Club was the venue for the 2nd Annual Twin Cities Medical Society Board of Directors Dinner held on January 18, 2011. Thomas D. Siefferman, M.D., a pediatrician at Pediatric & Young Adult Medicine, PA, was installed as president along with Executive Committee members: president-elect: Peter J. Dehnel, M.D.; secretary: Anthony C. Orecchia, M.D.; treasurer: Melody A. Mendiola, M.D.; and past-president: Ronnell A. Hansen, M.D. (replacing Edward P. Edward Ehlinger, M.D. accepts outgoing President's Award from Thomas Siefferman, M.D. Ehlinger, M.D.) and members-at-large: Edwin N. Bogonko, M.D., and Kenneth N. Kephart, M.D. New members joining the Board of Directors include: Cole D. Greves, M.D., Young Physician Section representative; Matthew A. Hunt, M.D.; Lisa Mattson, M.D.; Carolyn A. McClain, M.D.; medical students Laura Gorsuch and Jessica van Lengerich; and Eric Crockett, vice-president, Minnesota Medical Group Management Association. Edward P. Ehlinger, M.D. was acknowledged as outgoing president of TCMS and congratulations were extended on his appointment by Governor Mark Dayton as Minnesota’s Commissioner of Health. Recognition of additional outgoing members of the Board of Directors included: Peter Boosalis, M.D., Clint Hawthorne, M.D., Candace Simerson, Wade Swenson, Jessica Voight, Marie Witte, M.D. and James Young, M.D. TCMS CEO, Sue Schettle, provided the attendees with a summary of Thomas Siefferman, M.D., 2011 TCMS president and family. 2010 activities highlighting efforts that are underway to implement the TCMS three-year strategic plan. She also provided insight into the public and comFirst a Physician Award munity health efforts that are being led by TCMS. Concluding the evening, guest speaker, Robert L. Veninga, Ph.D., professor Amos S. Deinard, M.D., MPH emeritus, University of Minnesota School of Public Health, shared his humor he 2010 First A Physician Award was and encouragement to survive the cold days of winter and life’s challenges presented at the annual meeting of incorporating the following strategies for resilience: the Twin Cities Medical Society to Amos Expand…learn…grow! Deinard, M.D., MPH, a respected pediaBefriend energized people! trician, teacher, notable researcher and Have a hearty laugh – on yourself! outstanding community contributor, by Define one big dream! Dr. Thomas Siefferman, TCMS president.
T
New TCMS Board Members from left: Carolyn McClain, M.D.; Matthew Hunt, M.D.; Eric Crockett, MMGMA vice-president; Laura Gorsuch and Jessica van Lengerich, medical students. Not pictured: Lisa Mattson, M.D, and Cole Greves, M.D.
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March/April 2011
The First a Physician Award, established in 2007, recognizes a member of the medical society who has made a positive impact on organized medicine by selflessly giving of his/her time and energy to improve the public health, enhance the medical community’s ability to practice quality medicine, and/or improve the lives of others in our community. In presenting the award, Dr. Siefferman noted that Dr. Deinard exemplifies the criteria of the award through the decades of work he has done through the Minneapolis Health Department, the Community University Health Care Center, the University of Minnesota Department of Pediatrics, and many other organizations to serve high risk and needy populations by tirelessly reaching out to underserved populations to provide medical, dental, and public health services.
MetroDoctors
The Journal of the Twin Cities Medical Society
COLLEAGUE INTERVIEW
A Conversation With
Bobbi Daniels, M.D.
B
arbara (Bobbi) Daniels, M.D. received her medical degree from the University of Washington School of Medicine. She completed an internal medicine residency at the University of Minnesota, serving as chief medical resident at the VA Medical Center and continuing as a clinical fellow and research fellow in nephrology at the University of Minnesota. In 1996 Dr. Daniels was appointed vice-chair of Clinical Affairs, department of Medicine; professor of Medicine in 2000 and in 2009 became vice dean, Clinical Affairs, University of Minnesota Medical School. She was also named chief executive officer of UMPhysicians in 2009. Questions were provided by: Drs. Macaran Baird, Lee Beecher, Aaron Friedman, and Kenneth Kephart.
You have the role of CEO of University of Minnesota Physicians and vice dean for Clinical Affairs at the University of Minnesota Medical School. How do the two roles interdigitate? The two roles are very much intertwined and are most easily understood by considering the essential role of clinical excellence in meeting the academic mission of the medical school. The medical school’s aspirations for academic prominence in education and research are highly dependent on outstanding clinical care, both to role model and educate trainees as well as to inspire and deliver on the innovation that is at the core of academic medicine. As a vice dean, my major responsibility is to ensure that the faculty have the clinical resources to accomplish the academic mission. University of Minnesota Physicians is the entity through which the full-time faculty of the medical school practice medicine and serves as the clinical care delivery arm of the University. UMP generates approximately $175 million for faculty salaries and an additional $38 million in academic support for the medical school. The strategic planning, operational management, and infrastructure support for the clinical activity of the 700 faculty, 100 community physicians, and 130 NPs and PAs occurs within UMP, a 501(c)(3) not-for-profit corporation and is governed by a Board of Directors, including the Dean of the Medical School, nine faculty, nine department chairs, and five external directors. As CEO, my role is to ensure that UMP is strategic in growth, clinical investments and program development and is an exceptionally well-managed business.
What are the challenges/opportunities in working with physician groups and health systems in our state and region? Listening to the needs of patients, physician groups and health systems and mutually developing solutions for patients and the region is a significant opportunity. Electronic technology can make services once only available in major referral centers more accessible in rural communities, for example. In addition, more broadly our state and region could become a national model for physicians, health systems, payers and employers to work together to best use resources to accomplish what our patients most need for good health and outstanding clinical outcomes. The challenge in that aspiration is to “stop the arms race” where mal-aligned incentives drive decisions that are not in the best interests of the whole.
How can practicing clinicians contribute best to the continuing need to train new physicians if we are not part of a formal academic practice? There are many opportunities for clinicians to be engaged in the training of new physicians. The preceptorships that begin very early in medical school provide a very meaningful opportunity to role model clinical care and profoundly impact the views of young medical students. Throughout medical school, clerkships occur in community practices and many residents also utilize sites that are not traditional academic sites to provide breadth of experience to their trainees. The chairs of each of the medical school departments can help provide a link to the (Continued on page 10)
MetroDoctors
The Journal of the Twin Cities Medical Society
March/April 2011
9
Colleague Interview (Continued from page 9)
appropriate educational leader to determine what opportunities might be available in any given specialty.
How do you plan to balance UMP’s need to partner with Fairview in its developing ACO [becoming closer aligned with Fairview] and its role in being seen as an “independent” tertiary care referral source for many health systems?
Proceeds from MPS help to support the operations of TCMS. Please consider our business partners listed below as you look to reduce your operational costs.
Currently, much of the focus across the country on the development of ACOs to care for populations has emphasized primary and secondary care. For tertiary or more complex care, providing care for specific illness/ disease episodes in collaboration with multiple ACOs is a likely strategy. Beyond what occurs if ACOs become more prominent, approximately 85 percent of the patients served by UMPhysicians at UMMC Fairview are referred from physicians without a connection to Fairview. In addition, we have a variety of relationships with other health systems, such as providing orthopaedic trauma services and leadership at Regions, gynecologic oncology at North Memorial, Park Nicollet, and HealthEast and providing primary care in clinics associated with HealthEast and North Memorial. So, UMP works with many health systems and practices throughout the state and that needs to continue to have a vibrant medical school. In addition, the catchment area required to support our Bone Marrow Transplant and Solid Organ Transplant programs extend beyond the the state’s borders and could not be provided by a single health system. So, UMP desires to work with health systems and physicians across the state and the region. If every ACO seeks to replicate tertiary and quarternary care in a “self contained” manner, there will be significant duplication of expensive resources and that will negate any potential cost savings.
Please comment on the unique challenges facing academic health centers nationally being true to their quaternary versus teaching mission.
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Academic health centers, and particularly one as large as the University of Minnesota’s academic health center, have a broad range of responsibilities, from providing innovative treatments developed in the research labs of faculty (as occurs in our Bone Marrow Transplant program) to teaching the next generation of health professionals in primary care clinics that serve underserved populations (as occurs at our Broadway clinic, in collaboration with North Memorial). The clinical excellence necessary to meet our teaching and research mission requires a broad range of capabilities that are complimentary.
Regarding the University faculty, what is your thinking on squaring up clinical production (third party revenue) vs. activity and doing clinical (and basic) research? How do you operationally steer this ship?
To Learn More, Call (612) 362-3704
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March/April 2011
With only 6 percent of the medical school’s budget deriving from state funding, faculty and each department are expected to generate revenue to pay for salaries and research activities, and to a certain extent educational activities. So, accountability at the level of individual faculty and each department is critical for the organization’s success. MetroDoctors
The Journal of the Twin Cities Medical Society
Steering the ship is easiest when the strategic direction is clear. UMP is focused on being the best in clinical care and outcomes and that means that all decisions will be tested by their ability to deliver on that goal. With 800 physicians (including 100 non-faculty physicians), 130 NPs and PAs, and multiple different potential priorities (clinical, research, education), the focus on patients and clinical outcomes provides clear direction, and there is no doubt that clinical excellence is also central to the success of the medial school’s research and education mission.
With the growth in the aging population, please address why the University no longer has a division/department of geriatrics or palliative care. Historically, geriatrics and palliative care were considered essential parts of the work of many of the departments rather than requiring a separate division or department. That means there are programs within family medicine, internal medicine and other departments to ensure all physicians have core understanding of the unique issues associated with aging. That is probably even more true today, as few patients and few diseases are conďŹ ned to a single academic department or division. Our focus needs to be on the function — are we delivering the expertise? — rather than the academic structure. Looking to the future, we know from patients that few are interested in leaving their primary care provider upon reaching a certain age to seek a specialist with limited availability that can be hard to access. The preference is to provide ongoing education to today’s students and physicians to ensure geriatrics and palliative care are integrated into the curriculum and are core to the education of all physicians. Finally, as the medical school adjusts to ongoing reductions in core public support for its program, the development of any new divisions or departments is simply economically unsustainable today.
League “Honoring Choices� program help develop a community-wide discussion about ethical, and human, issues that impact the decisions we make. Between these two bookends is a need to align incentives to provide the best treatments (home vs. in-center dialysis; transplantation vs. dialysis) and to be sure that all available evidence is brought to bear in how we advise, engage and treat patients. The U.S. currently spends over 18 percent of our GNP on health care, by far the highest in the world, with outcomes that are not commensurate. As with the ESRD program, the broader problem cannot be addressed without both societal discussions, personal (patient) engagement and responsibility, and wise medical decision making.
What is your view on physician pay-for-performance as research? Steps to integrate medical and societal ethics into these endeavors at the University (i.e., David Satin, M.D. in family medicine)? Initiatives like “pay-for-performance� need to be every bit as much evidence-based as treatments for diabetes or heart failure. So, research is essential to inform how incentives should be aligned to achieve the outcomes that patients and society desire. Increasingly, we need to expand our research efforts to include issues dealing with how health care is delivered, how innovation is more rapidly implemented (rather than the 17 years demonstrated in some studies), and how patients can become more engaged in their own health care outcomes. NIH is increasingly supporting such areas of research and our faculty are becoming increasingly engaged in such efforts.
Your Opinion Please!
As we study and compare various state and national health care funding cost-control approaches, Medicare end stage renal disease is an interesting case of an expensive and costly government entitlement. Given also that the ďŹ nal “quality outcomeâ€? is death for all of us, what are the management and ethical challenges here? The gradual, but enormous, expansion over the past 30 years in the indications for initiating and continuing ESRD treatment, the expansion of societal expectations, and a near epidemic in the incidence of ESRD has created many challenges and as a still practicing nephrologist I deal with the challenges regularly. Applying the clinical evidence to prevent and slow the progression of renal disease is very important, but will likely take years to impact the prevalence of end stage renal disease. There must also be a focus on how we make choices regarding the initiation and continuation of dialysis, and programs like the TCMS/TPT/Citizens MetroDoctors
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Is it important that your referrals go to only Board Certified Specialists? Email your choice(s) to survey@uptowndermatology.com: a) Yes, and I have verified their BC status at www.ABMS.org b) Yes, but I don’t check their BC status, I just assume they are BC c) Yes, and I am comfortable with BC MD supervised mid-levels also d) No, I am comfortable with NON-BC specialists and their mid-levels
We appreciate your feedback and look forward to serving you and your patients. Referrals seen in 2-3 weeks! Education , Experience, Excellence...with a smile!
Jaime Davis, MD Mayo Clinic Educated Board Certified Dermatologist
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March/April 2011
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Accountable Care Organizations
Paul Ellwood, M.D., Father of HMOs, Critiques ACOs
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ne of Minnesota’s most important leaders in national health care reform is former U of MN clinical professor of pediatrics, neurology and PM&R, Paul Ellwood, M.D. His best known impacts on national health policy are HMOs and the Agency for Healthcare Research and Quality (AHRQ). He came to Minnesota from Stanford to intern in pediatrics with a special interest in poliomyelitis. While still an intern, he was named chief of Inpatient Care at the Sister Kenny (polio) Institute. He subsequently led the notfor-profit American Rehabilitation Foundation, InterStudy and the Jackson Hole Group. He has provided solicited and unsolicited advice to every presidential administration from Johnson to Clinton. He has not participated in the Obama Administration’s “Affordable Care Act” deliberations. His passion is to devise health care systems whose structure, incentives and accountability promote better health while containing medical inflation. To stimulate thought, Dr. Ellwood asked Twin Cities Medical Society members to recall an incident from the early HMO reform efforts. The Hennepin County Medical Society was one of the pioneers in establishing an independent-practice HMO where individual private physicians shared risk and responsibility for achieving cost and quality objectives for a population. In 1976, our IPA and others were concerned with their member physicians’ uneven willingness to assume responsibility for cost containment. Coincidentally, the Federal Trade Commission was raising IPA medical monopoly issues. Dr. Ellwood, as head of InterStudy, believed that one associate, Rich Burke, had the capacity to help the medical society’s fledgling By Paul Ellwood, M.D. with Gregory Plotnikoff, M.D.
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March/April 2011
health plan. After Burke was hired, Ellwood was struck by Burke’s take over management style. This event later turned out to have profound significance. First, from this inauspicious foundation grew “Burke’s” United Health Care where insurers instead of physicians MANAGED CARE. Second, this act forecast the decline of the type of HMO where independent physicians could collaborate to promote health care at competitive costs. Ellwood noted that it was only a matter of time before managed care killed the HMO ideal for non-multispecialty
...the most promising new feature [in ACOs] is the promotion of outcome accountability. group physicians and their patients. By 1996, 81 million people were enrolled in managed care organizations with the ensuing HMO backlash. What went wrong? What lessons might there be for today? Ellwood noted a series of erroneous assumptions about human and corporate behavior. First, many assumed that the medical community would come together and share the risks and rewards for the good of the patients and of medicine. Ellwood notes that Accountable Care Organizations (ACOs) are also based upon this assumption. This means that physicians will need a common set of goals
and ground rules in order to share in the success of the enterprise. Second, policy makers assumed that profits would accelerate growth of organizations but that consumer forces would inhibit profiteering. Instead, shifts in public policy fostered profit-oriented managed care plans focused on risk selection. Although the current ACO legislation proposes to limit insurer “medical loss ratios,” the criteria are too loose. Third, Ellwood assumed that outcomes accountability, so necessary for informed patient and physician decisions, would be central to the HMO legislation. He was surprised that medical organizations lobbied against this and accountability was rejected from the HMO legislation. He believes that failure to get outcomes accountability was a huge factor in the failure of the HMO movement. The result was that no one could tell the good guys from the bad guys. Now, more than 35 years later, ACOs are to spring into action in January, 2012. The law considers them a permanent institutional reform as opposed to an experiment. The goal is greater accountability for costs and the health of populations. Ellwood notes that ACOs are envisioned as a joint venture of MDs and other providers, especially primary care, with hospitals who agree to provide total care for at least 5,000 Medicare recipients designated by Medicare to become members. According to the legislation, if a payer has evidence that the ACO saved money in serving this defined population, then a bonus will go to the ACO organization that will then decide how this will be distributed. There is no guarantee physicians will benefit. Also, if the ACO generates excessive charges, the ACO will still be paid. The result is no downside risk for continued health care inflation. Ellwood also noted that the opportunities for Medicare savings are much less in Minnesota than in Miami
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or other high Medicare cost regions. This means that the big financial rewards will go to Miami rather than Minnesota. The bottom line for Minnesota: Ellwood does not believe that the ACO concept is a winning proposition. He warns that no one should get serious about ACOs until regulations are posted and reviewed. Everything rides on them. These regulations are expected to be released early 2011. Ellwood noted, however, that three organizations have already weighed in on the ACO issue and he advises physicians to consider their critiques. First, MEDPAC, the now more-powerful CMS advisory board, has asserted that the proposal to reward good financial outcomes is too one-sided. They asked, “Why not punish those doing the wrong thing?” MEDPAC also asserted that beneficiaries ought to know whether they are assigned to an ACO. They should be told that they are as much collaborators in the ACO as the providers. Furthermore, MEDPAC asserted that the quality measures should be kept simple: ER utilization, preventable admissions, in-hospital morbidity and re-admission rates. Ellwood notes that these are a good place to start but won’t address over-utilization issues or resolve ambiguities in evidence-based guidelines. Ellwood noted that the American Hospital Association’s critique of the ACO legislation is very revealing as they strongly suggest eliminating regulatory barriers including the Stark laws, civil monetary penalties, anti-kickback laws, anti-trust laws and IRS restrictions on payments to providers. Therefore, by such reasoning, conflicts of interest and monopolies can be allowed even if they historically raise costs. Finally, the numerous articles on ACOs in the New England Journal of Medicine represent a great resource for constructive thought and articulation of the many issues. Ellwood especially recommends “Physicians versus Hospitals as Leaders of Accountable Care Organizations” by Robert Kocher, M.D., that appears in the December 30, 2010 issue. Ellwood has three take home messages for the Twin Cities Medical Society. 1) Do not do anything until reviewing the regulations. These will be complex so the society should set up a study group to review these carefully and anticipate how participating physicians, hospitals and patients will behave. 2) Although the motives of those who put the ACO concept together are unassailable, their idealistic MetroDoctors
proposal’s prognosis is poor. ACOs are likely too complex, do not lock-in assignees, and their criteria for patient assignment are too uncertain but absolutely critical for overall success. And, finally, 3) Wall Street firms are already trying to get in on the action (i.e., purchase hospitals and hospital systems). Ellwood emphasized that there should be no place for leveraged buy-out profiteering. He challenges the Twin Cities Medical Society and all physicians to put aside politics and to build on our traditional joint sense of responsibility. Are there any good features in ACOs worth noting? Yes, the most promising new feature [in ACOs] is the promotion of outcome accountability. Ellwood notes that if this massive data base could be refined, interpreted and made available to patients and providers in real time, this would positively transform medicine. Paul concluded “Minnesota medicine can continue to devise more promising reforms than those coming from the prevailing intemperate and divisive political atmosphere. For starters, let’s catch up to the information age such as internet-based care with malpractice reform and removal of the HIPAA barriers to open sharing of experience and responsibility.”
The Journal of the Twin Cities Medical Society
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March/April 2011
13
Accountable Care Organizations
TCMS Physicians to Create “Model” ACO White Paper
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ast summer and fall, the newly constituted Public Policy Committee of the Twin Cities Medical Society debated the contribution it could make to the Society and its members. Prior to consolidation of the East Metro and West Metro Medical Societies, the Public Policy Committee primarily provided a metropolitan physician reaction to proposed bills in the Minnesota Legislature. While this was considered a laudable activity, we wished to explore other potential initiatives that may be able to more proactively contribute to the health of patients in the metropolitan area and to the physicians providing care — particularly in the climate of health reform. Discussion at the first three committee meetings led to putting aside the priority of reacting to legislation. Rather, a redirecting of committee efforts to the development of a white paper describing a model physician created Accountable Care Organization (ACO) might have the most potential value to Twin Cities’ physicians. Simultaneously, the TCMS Executive Committee and Board would monitor and react to legislative issues as appropriate. The TCMS Board of Directors agreed. While a physician-created model itself was considered important, of equal importance was a post-creation assessment of the impact that a physician-based model would have on various types of practitioners, e.g., independently practicing physicians, physicians working in groups, and specialist physicians. Thus, included with the deliverable of a model ACO white paper would be a post hoc assessment of the way that the ACO would affect selected types of practice. This would allow TCMS physicians to foster development, to fight development, or to plan ahead for the changes they will need
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to make to be a part of the next generation of health care. Public Policy Committee members attended the presentation last fall co-sponsored by MMA and TCMS by a well recognized expert on ACOs, Harold Miller, who provided a national perspective. The committee also listened to presentations from local leaders on local ACO initiatives which included presentations by Dr. George Isham from HealthPartners, Dr. David Moen from Fairview, and Dr. John English and Ms. Victoria Champeau from Midwest Independent Physician Association. These presentations have helped the members come up to speed on core features of ACOs and to consider the direction to take in the development of our white paper. The goal of this work is to submit a white paper to members of the TCMS and the MMA. The Executive Committee of TCMS has approved contracting with a facilitator to assist us in this process. Terri Hyduke, CEO for the Children’s Physician Network, accepted responsibility for this important activity and began her work at the January 2011 Public Policy Committee meeting. The intent is to have a formulated draft by June 2011, which can be disseminated to members for review. It is hoped that an edited version will then be presented for discussion at the annual meeting of the Minnesota Medical Association in September in Duluth, MN (September 14-16). It should be noted that decisions related to the TCMS Public Policy Committee target of creating a physician conceptualized ACO white paper have not been without controversy. Some of the committee members were hesitant to give up the focus on TCMS’ ability to respond to potentially harmful legislation. Others wished
to pursue focused issues of concern and importance in other areas of medicine. Still others did not want to pursue the creation of a white paper since it might give the indirect message to outsiders that physicians in the TCMS at least tacitly support ACOs as a solution to the health system’s ails. The committee agreed, however, that whatever we were about to do we should have at the forefront the goal to empower physicians by providing them with tools that they can use to evaluate the pitfalls and benefits of ACOs. The Public Policy Committee is now on a journey. We will attempt to connect the practical application of care processes that will place at the center the doctor-patient relationship, provide quality care, minimize additional physician non-clinical work, and reduce the total cost of health care. We are excited about this opportunity to empower our physician members by lending the voice of physicians as potential problem solvers and leaders to this discussion about ACOs. TCMS Public Policy Committee Members: Roger Kathol, M.D. (co-chair) Ronnell Hansen, M.D. (co-chair) Lindsay Byrnes, M.D. Stuart Cox, M.D. Peter Dehnel, M.D. George Edmonson, M.D. Paul Kettler, M.D. Lisa Mattson, M.D. Rick Morris, M.D. Carol Stark, M.D. Lynne Steiner, M.D. Michael Tedford, M.D. Ann Wendling, M.D. Benjamin Whitten, M.D.
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Independent Private Practices and ACOs: Is Compatability Possible?
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o a number of physicians in private practice, both primary care and specialty care, the current developments in health care policy seem to be based on magical thinking, similar to the words of this song by John Lennon: “Picture yourself in a boat on a river, With tangerine trees and marmalade skies. Somebody calls to you, you answer quite slowly, A girl with kaleidoscope eyes. Cellophane flowers of yellow and green, Towering over your head. Look for the girl with the sun in her eyes, And she’s gone. (CHORUS) Lucy in the sky with diamonds….” (“Lucy in the Sky with Diamonds” – Sgt. Pepper’s Lonely Hearts Club Band, the Beatles Released: June, 1967)
ACOs are a major component of current policy development. They will enter the health care scene with a thunder over the next three to five years. Starting as Medicare demonstration projects in 2012, they are likely to extend to a number of other health insurance products soon after they are established for Medicare. To physicians who work in independent practices (i.e., not affiliated with larger health systems like Allina, Fairview, Park Nicollet and so on), ACOs represent a serious concern and an uncertain future. Questions like: “Will the expansion of ACOs destroy my ability to maintain a viable, independently functioning clinic? Will my ability to care for patients in the best way I can be hamstrung by the rules of participating within an ACO? Will patients By Peter Dehnel, M.D.
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I currently see have to transition to an ACO if I choose to remain outside of that ACO? Will my current referral relationships with specialists/primary care clinicians change because of participation or incorporation within an ACO — either theirs or mine? What about my patients’ access to inpatient and/or hospital outpatient services — will I have to choose one hospital system or another? Finally, what if I am forced to adopt an ACO’s patient care guideline that seems primarily based on the cost, and not quality, of care?” On the other hand, from a government policy standpoint, ACOs are seen as a critical part of the cure to what is currently being promoted as wrong with American health care: fragmented, expensive care that is not delivering the outcomes for patients that our current investment of resources should be producing. Furthermore, the rate of increase in health care costs is not sustainable and will eventually bankrupt our nation. Finally, the number of uninsured/underinsured is intolerably high and there is too great of disparity in the availability
The Journal of the Twin Cities Medical Society
of care for minority groups and other populations at risk. The traditional fee-for-service (FFS) private practice model is typically seen as a major component of our current “broken” health care system, and therefore needs to be replaced — or at least significantly altered. Conversely, to independent private practice advocates, ACOs as proposed look like “capitation revisited” or “capitation on steroids.” Patient care decisions within ACOs appear to be strongly influenced by the cost of delivering that care. Higher risk populations, or patients not willing to comply with care guidelines, will likely be systematically eliminated from an ACO. The patient outcomes that are measured and reported will likely take priority in terms of staff and office resources — to the exclusion of other patient needs. ACOs will also be trying to manage insurance risk — a task usually performed by insurers — with little or no background to do this well. The likely governance of ACOs can also send chills up the spines of many private practice clinicians. By design, an ACO is supposed to provide for services across the continuum of care for the population of patients for which it contracts. Individual physician groups are unlikely to have sufficient capital to create the infrastructure to operate an ACO. Since hospital care is included in that continuum and physician groups are lacking in capital, hospitals suddenly become a very influential partner, if not the leading partner, in ACO development. This will feel very “unnatural” for physicians who are much more accustomed to just managing their own group, even if their group is larger and has multiple sites of service. What lies ahead, then, for physicians who wish to maintain an independent primary care or specialty practice? Is there a compromise (Continued on page 16)
March/April 2011
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Accountable Care Organizations Independent Private Practices (Continued from page 15)
position between independent, private practices and ACOs? From the outset, I believe that most physicians, regardless of the model through which they deliver care, want to see the goals of the Triple Aim achieved: (1) improving the health of the population; (2) enhancing patients’ personal experience of care; and (3) reducing, or at least controlling, the per capita cost of care. Both models can do much to enhance the patient-physician relationship and lead to great patient outcomes. Conversely, both FFS private practice and ACOs can erode the patient-physician relationship and act primarily in the best ďŹ nancial interests of the clinic or organization, leaving the patients’ interests as a distant or only secondary concern. What are options for an independent practice today, which sees this “freight train of changeâ€? speeding down the tracks toward them? Is there a blending of the models of care that is possible? I would suggest that there are four general choices that clinics can consider as they chart out their future:
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Be purchased or assimilated by a health system that is developing an ACO. This would be the “Borg Option,â€? based on the Star Trek series. The ďŹ nancial risks and infrastructure expenses would be borne by the larger system. Physicians act in accordance with the decisions of the ACO, however that is structured. The biggest risk to the clinician is whether the chosen ACO is successful in the long run. Align with a developing ACO, but structure it in such a way so as to retain a certain degree of autonomy for the clinic. This is still likely to impact the way clinicians in that practice can practice, but there would still be some individual identity retained. A compatible electronic health record (EHR) is likely to be required, so that quality reporting and population health measures for the ACO as a whole can be calculated. Future administrative and IT costs to the clinic can be considerable, and currently not required for clinics to operate effectively and efďŹ ciently. Form an independent ACO with other independent clinics. In addition to the need for external legal and regulatory issues
to be resolved — antitrust, Stark laws, fee-splitting, etc. — clinics would have to supply considerable working capital to build and support the needed infrastructure. Negotiating for a broad range of services to provide the continuum of care needed for the population served by this ACO is another task the ACO will have to complete. Understanding ďŹ nancial and insurance risk is also needed by the clinical and administrative leadership of this future “independent ACO.â€? Needless to say, there is signiďŹ cant overall risk in this type of business venture being successful. 4. Remain as independent of clinic entity as possible. It is predicted that there will be a shortage of physicians within the next several years, and predictably there will be a certain percentage of patients who are willing to pay extra and go outside of the system to get care at “free standingâ€? independent clinics. Those clinics will likely have to think “outside of the boxâ€? to meet the needs of their patients in ways that the system-based clinics are unwilling or unable to do. This will likely involve the incorporation of a variety of non faceto-face options — e.g., e-mail, Internet, telemedicine and “smart phone apps.â€? An emphasis on customer service and personalized care will likely be components of a successful “stand aloneâ€? clinic. Overall, from a public policy standpoint, it seems important for there to be a variety of options through which patients can receive care — everything from independent practices to large accountable care organizations with a number of variations in between. Physicians will need to take an active role to advocate on behalf of their patients and families to retain a number of options. Showing real value and good outcomes of care in each and every setting will be important. An intentional effort to study and compare what works best is essential for care to really improve. The Twin Cities Medical Society provides a means through which physicians can work on these issues in a collaborative way. Your input is, as always, welcome and much needed to sort through these complicated and challenging issues. Peter Dehnel, M.D., medical director, Children’s Physician Network; pediatrician, All About Children Pediatrics.
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The ABCs of ACOs
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s it became more apparent in recent years that the rising cost of health care in this country is not sustainable, there has been increased pressure to come up with solutions that help control costs while still maintaining the high quality standards and accessibility to which patients have become accustomed. Tucked away in the annals of the 2,000 page Accountable Care Act was an idea that had been generating considerable buzz in the health care community as a way to attempt to help bend the cost curve — Accountable Care Organizations (ACOs). Many believe the ACO concept can effectively bring down the cost of, for example, treating patients with chronic conditions through a system of care coordination. Additionally, the ACO model is designed to help bring down costs by reducing hospital readmissions. However, what many view as a novel reform idea, others view as the return of a once failed experiment. There is considerable skepticism by many in the medical community that the ACO model is a recreation of managed care models of the late 1990s. Despite the concerns, many hospitals, provider groups and medical clinics, in Minnesota and throughout the rest of the country, remain committed to the need to bend the cost curve and see the onset of ACOs as one tool to help achieve these long-term goals. What is an Accountable Care Organization? The fundamental question that hospitals and providers are attempting to answer is what exactly is an ACO? At its very basic, an ACO is a group of health care providers that becomes accountable for the cost and quality of the health care delivered to a defined set of patients. The ACO could receive certain financial incentives should the providers within a given ACO meet By Nathaniel Mussell, J.D.
MetroDoctors
specific cost and quality performance benchmarks. Beyond this basic concept, ACOs begin to take on many different forms and structures. From a structural standpoint, ACOs are likely to encompass a variety of ownership and/ or contractual arrangements. These include integrated health systems, physician-hospital organizations (PHO), independent practice associations (IPA), partnerships between PHOs and IPAs, hospitals, large multi-specialty group practices, and joint ventures owned by physicians, hospitals or other health care providers. In addition to the formal structural arrangements, ACO development will require the necessary administrative and clinical systems, including a strong health information technology infrastructure to allow the ACO to effectively manage and coordinate the care of its patient population and report on the applicable quality measures. Most important to the success of an ACO will be a shared goal and commitment among the physicians and providers to create a culture of accountability, integration and coordination. At the outset, integrated delivery systems are likely better positioned to move forward with ACO development earlier than other organizations. This attention toward larger integrated systems has left many smaller group practices and independent physicians wary of potential consequences. Given the time and investment
The Journal of the Twin Cities Medical Society
required to forge the infrastructure and financial and contractual arrangements to bring together groups of independent providers and small group practices, some fear the prospect of further consolidation as the ACO model moves forward. With much of the attention focused on provider networks and the role of physicians in the ACO model, there has been little focus on what role patients play in ACOs. To this point, it appears patient beneficiaries under Medicare and Medicaid could be assigned to a particular ACO, potentially without knowledge of the assignment. However, for the ACO concept to prove successful, patients will need to play an active role through loyalty to their designated ACO. In the long term, this could prove difficult given the historical unwillingness of some patients to participate in a closed physician network. Additional questions and concerns have been raised by hospitals and physicians regarding how ACOs will be paid. Again, the fluid nature of the ACO concept seems to allow varying forms of payment depending on the formal structure of the organization. Commentators have suggested that ACOs could see everything from fully capitated payments in which the entity largely bears the risk, to partially capitated payments, all the way down to a standard fee-for-service (FFS) payment with financial incentives. Many physicians and hospitals have expressed concerns that a fully capitated model results in providers assuming a form of insurance risk, raising questions of solvency, cherry picking of healthier patients, and potential withholding of care. On the other hand, there is some feeling that continuing with a FFS system with incentives may not be enough to constrain providers to move away from a volume-based model to a value-based model and invest in the tools and (Continued on page 18)
March/April 2011
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Accountable Care Organizations The ABCs of ACOs (Continued from page 17)
infrastructure necessary for ACO development. With all these questions unanswered, many providers interested in exploring development of an ACO model are looking toward the Medicare Shared Savings Model proposed in the Accountable Care Act for potential guidance. What did the Accountable Care Act Say About ACOs? The Accountable Care Act laid out a basic framework of and listed multiple requirements for ACO development and participation in a Medicare Shared Savings Program.1 These requirements include: 1. Commitment to provide patient centered care. 2. Participation for at least three years. 3. Formal legal structure allowing the ACO to receive and distribute shared savings to participants. 4. Provide primary and other health care services to at least 5,000 Medicare beneficiaries. 5. Leadership structure that can define and implement evidence-based practices. 6. Ability to report on quality and cost measurements. 7. Ability to provide coordinated care management. The lack of any further clarity from CMS beyond these basic requirements has left providers around the country frustrated as they begin to implement ACO models without any assurance of participation in the Medicare pilot program. CMS is expected to release proposed guidelines for the Medicare Shared Savings Program in early 2011. The regulations are expected to include the reporting requirements and quality measures for ACOs. It is expected that CMS will draw from some of the existing measures that physicians are currently reporting. At that point, hospitals and physician groups will have the chance to comment on the guidelines, with final guidelines expected by the end of 2011. One of the challenges CMS has faced in the drafting process is attempting to coordinate Medicare Part A and Medicare Part B, two programs that currently operate under different payment structures. The idea behind the shared savings concept is relatively straightforward. As previously alluded to, the FFS payment structure would remain 18
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in place and CMS would set a total expenditure benchmark for those patients attributed to that particular ACO. If an organization of providers is able to keep the total cost of care to those patients under the respective benchmark, the ACO would receive an incentive payment in return. How is Minnesota Prepared to Implement ACOs Minnesota currently has in place many of the basic structures required for ACO development. Many believe Minnesota was at the forefront of delivery system reform back in 2008 with the passage of landmark health care reform legislation. As part of the 2008 legislation, Minnesota set the framework for Patient Centered Medical Homes (PCMHs), quality and cost measure reporting, bundled and total cost of care payments. Over the past year, Minnesota has moved forward with implementation of the medical home model in numerous clinics throughout the state — a jump start on other states around the country given the key role that PCMHs will play in the ACO model. Additionally, during the 2010 legislative session lawmakers included language in the HHS Budget Agreement that called on the Minnesota Department of Human Services to “develop and authorize a demonstration project to test alternative and innovative health care delivery systems, including Accountable Care Organizations that provide services to a specified patient population for an agreed upon total cost of care or risk-gain sharing payment arrangement.”2 This project is expected to begin in July, 2011 and would apply to patients enrolled in the state’s Medical Assistance and MinnesotaCare programs. Potential Legal Barriers to ACOs There are potential conflicts between the goals of Accountable Care Organizations and current anti-fraud and antitrust laws. The primary legal concern many have expressed with ACO development is whether the sharing of a single payment or sharing of incentive payments will run afoul of the several fraud and abuse laws, including the Civil Monetary Penalties law (CMP), Stark law, and Anti-Kickback law. Each of these anti-fraud laws has the potential to be implicated through the relationships and financial arrangements that are necessary for ACO formation. The prohibitions under the CMP law could be implicated in the ACO model through offers of financial incentives to
comport with utilization controls. Similarly the Stark law prohibitions might be implicated through gain sharing arrangements while the Anti-Kickback law might be implicated through shared savings payments between a hospital and a referring physician. While the Accountable Care Act did give CMS and other regulatory agencies the ability to waive these laws for hospitals and physicians participating in an ACO, the question of how these waivers will be applied remains a mystery. The irony of these potential legal barriers is that the original intent behind the Stark, Anti-Kickback and CMP laws was to help curb health care costs — the same desired goal of ACO implementation. Another legal concern for ACO development are the antitrust laws. The very nature of the ACO model would require groups of individual physicians or multi-specialty practices to coordinate and collaborate in joint price negotiations. These arrangements have the potential to implicate current antitrust laws prohibiting price fixing. Those interested in exploring the ACO model have limited guidance dating back to 1996, leaving many hesitant to move forward without bright-line guidance from the FTC. In early October, at a joint ACO conference which included officials from CMS, the Office of Inspector General (OIG), and Federal Trade Commission (FTC), Jon Leibowitz, Chairman of the FTC, said the FTC was working to develop potential “safe harbors” for ACOs under the antitrust laws.3 He went on to say that questions brought before the FTC would be given an expedited review to determine whether any of the “safe harbors” applied to the ACO arrangement in question. Despite the potential for concessions from both CMS and the FTC regarding application of the anti-fraud and antitrust laws, it remains difficult to anticipate the potential outcomes of their efforts in this area, leaving many hospitals and physician practices without answers as they move forward in their ACO development.
Nathaniel Mussell is an attorney and lobbyist with the Lockridge Grindal Nauen’s (LGN) government relations with a focus primarily on health care clients. (Endnotes) 1. Social Security Act, § 1899(b)(1). 2. MN Session Laws 2010, 1st Special Session, Article 16, Sect. 19, Minn. Stat. § 256B.0755. 3. Transcript, “Workshop Regarding Accountable Care Organizations and Implications Regarding Antitrust, Physician Self-Referral, Anti-Kickback and Civil Monetary Penalty Laws,” Oct. 5, 2010.
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A Virtual ACO
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merica is at a crossroads with its health care delivery system. It’s not just “who” pays the bill, but also “who” provides the care that must be re-evaluated and possibly re-allocated. There is potential for innovation, yet there is also inertia endangering our collective success as convoluted additions-inthe-name-of-reform are loaded into an already cumbersome system. In addition, many of the current ideas are repackaged from earlier with no assurance of improvement this time. A group of Minnesota providers is hoping to discard much of the “bricks and mortar” of the current provider systems, offering instead a more flexible, wrap-around model that attaches to whatever and wherever the patient calls [medical] home. As is obvious from the daily media coverage, the country is not like-minded regarding the payment methodology for health care. Individual and/or employer mandates, single payer or commercial competition and levels of coverage and cost-sharing are all part of a discussion that will go on at least through the 2012 election. Knowing that the electorate will eventually decide the question of “who” pays, physicians have a unique opportunity to focus on “who” provides. The state regulatory reforms put in place in 2008 and the many regulatory programs contained in last year’s federal health reform legislation (which are already funded and being implemented), have set a future course for physicians that most likely will be maintained. This charted course, according to legislative promise, sets out a vision for wellcoordinated, high quality care and an activated patient. However, the manner that cost-savings will be achieved in has not yet been directly By Liz Quam
MetroDoctors
identified. There has been a presumption by many that the cost-savings will come if the provider-based care delivery system is reformed to include a primary care medical home and if the patient is activated. Physicians are appropriately dubious about the ability to achieve the necessary infrastructure changes to support this model with primary care providers, as well as some specialists who are already in short supply. The thought of adding millions of patients with new insurance coverage does not seem to fit with the goal of reducing costs unless a collaborative rather than duplicative model is created. The lack of specificity of “where” the savings will come from or how to successfully activate the majority of patients has caused angst in even many who are not prone to skepticism. Providers are wary of looming reimbursement cuts and some elected officials and employers are expressing great concern about how they will manage increasing costs, if the legislative theories regarding achieving savings are not realized. Last year’s election indicates serious reservations from consumers as well. Voters from all sides of the political spectrum are voicing worries about what may be coming next. For example, a federal task force issued guidelines last year which limited screening mammograms for most women in their 40s. The subsequent furor indicates Americans fear that if cost savings are not achieved in other ways, they may be barred from adequate services. In Minnesota, the health department and the state’s commercial insurers have worked with providers to define and identify health care homes and the initial steps needed to institute Accountable Care Organizations (ACOs) which will “attribute” patients to certain providers and measure total cost of care. Many specifics, such as risk adjustment methodologies and if there is patient choice in the payment attribution, are still to be worked out. Yet, good
The Journal of the Twin Cities Medical Society
work is occurring; methods are being analyzed and refined and there is promise of innovation and improvement, especially toward the goal of better coordination of care. Achieving cost savings and patient engagement, however, remain elusive. Large provider and payer entities have had the resources to advocate in both the state and national capitols regarding their ideas on how to achieve better care coordination; so much of the attention has gone to hospital-centric models of delivery. The Medicare agency, CMS, has been especially supportive of reform ideas coming from these large and integrated provider settings. However, as with the entrepreneur who invents the next best thing in his garage, there are fresh and creative concepts in development which offer more diversity in access to primary care and are more customized to the patient. It is as if the large health systems are expanding by building on to their mainframe computers (Continued on page 20)
March/April 2011
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Accountable Care Organizations A Virtual ACO (Continued from page 19)
whereas the latest models are mobile, based on portable electronic devices. While hospital-centric coordinated delivery models have much to offer many types of patients, by their very nature (i.e., big/integrated/process-oriented), they lack the capability and motivation to nimbly customize to meet the needs of a single, activated patient. Nor does a large, vertically integrated system have the capability of efficiently pulling apart various components of the total cost of care to eliminate, refine or expand an individual component. This means that in our pursuit of coordinated care from a health system, we may very well lose an earlier goal of transparency of both costs and quality within that system. For example, under the total cost of care model, will an activated patient be able to seek her pulmonary care from a noted specialist in another health system if her medical home is part of an integrated hospital system which offers its own pulmonologists? Likely not! Many now worry about the lack of competition if megasystems own all the physicians and can dictate
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price. Monopolies never produce efficiencies and cost-competitiveness. The Minnesota Medical Group Management Association states that the collective goal should be to: Create a collaborative care system, not winners and losers. Primary care and many other specialties are already experiencing physician shortages and this trend will certainly continue. As a result, care systems should be inclusive, not exclusive, as we will need all health care providers working together to solve the current system’s dilemmas. [This means we should] develop electronic tools for universal patient registries, care coordination and care management systems which can be accessed by all of a patient’s care team members to promote wellness and improve outcomes. To create a patient-customized, well-coordinated delivery vehicle that is nimble, high quality and cost-efficient, the “system” must also be accountable to each patient to assure transparency of costs — both in total and when broken into components. The care delivery vehicle must also offer choice and transparency of quality measures by individual providers, in addition to the total cost of care level. The activated patient should be able to “act” when he or she prefers a different access point for primary care or, for whatever reason, a different specialist that better fits the patient’s condition, culture or temperament. This also means the patient’s health care records must be as mobile as an iPad and fully accessible to the patient, no matter which doctor’s office the patient is visiting, nor in which town, state, or even country that office is. By offering this flexibility as an impetus to patients, a virtual physician network can better achieve success at activating, motivating and engaging more patients. And, as indicated by much of the literature, true cost savings cannot be achieved without this engagement. With the goal of developing a care coordination vehicle that provides customization and nimbleness for the activated patient, a group of health care providers across the state have been working on an innovative concept which allows the care to be wrapped around the patient, with coordination done electronically by linked providers who are not necessarily tied to the same hospital or health system. The goal is to allow the patient to choose his or her point of access or medical home, whether it be the specialist
treating a patient with Crohn’s disease, a federally qualified health center, a Minute Clinic, a family physician clinic (whether or not it is legally integrated to a hospital system). Other services then become those which wrap around the patient, from physical therapy to medical sub-specialists who electronically “click” onto the patient-chosen, patient-centric medical home. This wrap-around of coordinated care options allows the patient an à la carte menu of sorts: the medical home is the entrée with various choices of wrap-around providers, allowing the patient to customize to his or her needs, interests and health condition. At every stop, from preventive services to a disease episode, the physicians “click-on” to the patient and his or her chosen home, coordinating care through electronic communications, with expectations that the patient will do likewise. Only then, will we meet the earlier goal of patient portability and accountability as contained in the 1996 HIPAA law. There are many details yet to be addressed in this innovative effort to build an electronic, wrap-around care coordination product. Yet, in the few months it has been underway, it has already sparked interest from policy makers and providers around the state. There is a growing apprehension regarding the deterrent that electronic fences have had. These electronic fences have developed as health systems have focused on their internal electronic connectivity without also pursuing interoperability with other providers. Also of concern is the opaqueness that comes with the total cost of care model. Especially for government-sponsored health care, taxpayers and elected officials alike must be able to see specifically how health care dollars are used. The wrap-around concept is also of interest to community leaders who are concerned that their constituencies may be ostracized because they are at high risk or because they may avoid seeking care if the medical home is not one that is culturally comfortable to them. Great opportunities lie ahead for physicians and patients if we can allow at least some of the mainframes to be recycled and allow new vehicles of care delivery that are based on the newest electronic tools, accompanied by a commitment to transparency of cost and quality data and a passion for encouraging an activated patient. Liz Quam is the executive director of the CDI Quality Institute at the Center for Diagnostic Imaging, headquartered in St. Louis Park, MN.
MetroDoctors
The Journal of the Twin Cities Medical Society
Innovation from Within Fairview is Changing Care and Business Models to Manage the Health of a Population
I
t’s not working. Providers across this country, state and at Fairview Health Services will tell you the current health care system — both care delivery and the payment structure — is not working. So Fairview has set out to do something about that. “I believe we not only can do this work, we must do it, for our patients and communities, and for ourselves,â€? says Mark Eustis, Fairview president and CEO. “This is our chance to be in on the ground oor of creating a system that does work.â€? In 2008, Fairview embarked on a major transformation. Changing that which it can control, Fairview is working to fundamentally improve care delivery and patient experience. Fairview also is seeking new payment contracts that reward value. The goals for the innovation work are simple but ambitious: s Change care to focus on the health of a population and deliver improved outcomes at a reduced cost. s Change payment to models that are aligned to enable new care models and reward providers for the value they produce (move from fee-for-service that rewards volume to payment systems that reward value). s Change the experience of the individuals accessing the health care system and ensure the engagement of the patient/consumer to drive dramatically improved outcomes. ACO or Another Name Fairview is building capabilities to serve as an Accountable Care Organization (ACO) — assuming performance risk (total cost of care and quality) and accountability for the health of a population. In the commercial sector, where the term ACO is not as prevalent, insurers are starting to incent and reward providers that deliver value. In the public sector, the Patient Protection
By Dave Moen, M.D.
MetroDoctors
and Affordable Care Act (ACA) has created the opportunity for Medicare to offer an ACO option by 2012. Regardless of the name applied, the concept of managing the health of a population is becoming the common theme in all sectors. Changing the Focus to the Triple Aim Fairview launched a fast-paced process to fundamentally change care delivery with an initial focus on primary care. Ideas are generated and tested. “Some work, some don’t — it’s a discovery process,â€? says Terry Carroll, Fairview senior vice president of transformation and chief information ofďŹ cer. As innovations are proven to work, they’re integrated into day-to-day operations across Fairview. All the work is focused on the Triple Aim — improve care, improve experience, reduce cost. Each is of equal importance; one will not be sacriďŹ ced to achieve success in another area. Work started in late 2009 and early 2010 with four clinics within the Fairview Medical Group. Those sites served as beta sites for innovation, making changes that included: s ORGANIZING STAFF INTO TEAMS %ACH TEAM includes a physician, nurse practitioner, nurses, medical assistants and schedulers. s ENGAGING PATIENTS IN THEIR CARE 3OME CLINics sent their patients a survey last summer aimed at better understanding their level of “activationâ€? — their interest in managing their health. Results help shape patients’ care plans. s OFFERING MORE EFlCIENT WAYS TO GET CARE Options include nurse-only visits; virtual care visits via e-mail and phone; and group appointments. s IMPLEMENTING hCARE PACKAGES v 4EAMS FROM across Fairview and University of Minnesota Physicians deďŹ ned 12 care package standards and designed new care approaches, particularly for higher-cost conditions such
The Journal of the Twin Cities Medical Society
as low back pain, diabetes, hypertension, migraine, kidney transplant and prenatal care. When this combination of steps proved effective at improving quality and managing the total cost of care, these standards spread to all 40 Fairview Clinics in the greater metro area. Technology and data are key infrastructure components. Ultimately, technology should help drive up quality and the patient experience while reducing costs. Fairview is moving to a single, uniďŹ ed electronic health record system for our entire continuum of services to more effectively manage care delivery and patient transitions. Fairview also is an investor and a principal player in Minnesota Health Information — a statewide secure electronic network to share data among providers and between providers and payers. The next phase of work to manage the health of a population involves growing a network of aligned providers and rolling out care management processes across Fairview and the aligned provider network. In late 2010, Fairview started developing the Fairview Health (Continued on page 22)
March/April 2011
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Accountable Care Organizations Innovation from Within (Continued from page 21)
Network — a group of independent and employed physicians working together to deliver a high-quality, consistent product — clinical quality and patient experience — while reducing total cost of care. Network providers beneďŹ t from common processes and care protocols as well as the opportunity to achieve shared savings through commercial insurance contracts. Improving Quality and Controlling Costs The cultural, process and clinical changes are working. Preliminary results show the four beta clinics, as compared to the rest of Fairview clinics, reduced the cost of care while they improved quality and patient experience. To understand the cost effectiveness of the model, Fairview used data from one representative payer group to look at cost trends of patients attributed to the four Fairview clinics as compared to the rest of the Fairview clinic group. Data show the per-member, per-month (PMPM) costs in various segments of care are being held at or reduced when compared to other clinics.
The cost model attributes patients retrospectively to Fairview based on their utilization of primary care services throughout a calendar year. Fairview has chosen to measure cost as the total cost of care — all the care and services consumed whether or not they happen at Fairview. How has Fairview controlled costs? It happens through a variety of actions including consistent use of care packages, team-based care that’s focused on the right care at the right time and care management services to efďŹ ciently manage transitions throughout the care continuum. Payment Changes Recognize Value While changes in care delivery are vital to reform, the payment structure also must change to reward and sustain the work. In 2008, Fairview began building new partnerships with innovation-minded payers. Fairview and Medica set out to change the adversarial dynamics typical between health systems and health insurers with a mutual goal to fundamentally change the way care is delivered and paid for. In July 2008, Fairview and Medica agreed to a contract that included an investment to fund key innovation work, including the care delivery redesign at
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Fairview Eagan and Fairview Rosemount clinics. In July 2009, Fairview and Medica entered into a two-year contract. The contract placed a material percentage of revenue at risk based on Fairview’s achievement of deďŹ ned outcomes for quality and total cost of care. Meaning, Fairview is compensated based on the value it creates for patients. The Medica contract was the ďŹ rst step on the continuum of new payment models. Major payers in Minnesota have shown interest in setting up contracts that better align the ďŹ nancial incentives of the provider and the payer. In late 2010, Fairview and Blue Cross announced a new three-year shared savings contract. Built on a fee-for-service structure, the contract also rewards quality and management of total cost of care. Contracts evaluate Fairview’s total cost of care as it is compared to market performance. Quality is assessed using a panel of ambulatory and inpatient measures. For 2011, Fairview anticipates that their contracts representing over 50 percent of overall revenue and over 70 percent of non-governmental payers will include total cost of care incentives. What’s Ahead? Fairview is looking to actively partner with Medicare to explore new ways to pay for care delivery. Current payment models, including Medicare, aren’t exible enough to recognize new lower-cost, high-quality methods of care. Medicare pays for 32 percent of all care delivered at Fairview. Fairview needs Medicare to adopt new payment models to achieve critical mass to substantively change the marketplace. The Medicare ACO has the potential to be a change that will recognize value. The regulatory details for the Medicare ACO have not yet been announced; there is much anticipation — and concern — about how Medicare will deďŹ ne, structure and pay for care delivery in the ACO model. Regardless of the Medicare details, Fairview will continue to pursue the goal of managing the health of a population — utilizing the full continuum of providers and services within Fairview to meet the needs of our patients, to improve quality and experience, and reduce the total cost of care.
Dave Moen, M.D., is Fairview’s executive medical director for Care Model Innovation and Network Development. MetroDoctors
The Journal of the Twin Cities Medical Society
Minnesota and the Emerging ACO
W
hen you think about subjects for Internet videos that go viral, Accountable Care Organizations probably won’t top your list. But one such video produced by Centura Health of Colorado did just that in 2010 — at least within health care circles. In the video1, an animated health care executive stands before a consultant. He’s heard that starting an Accountable Care Organization would be a great way for his system to succeed under health care reform. He and his board of directors are anxious to get started. “O.K.,” says the consultant. “What do you know about Accountable Care Organizations?” The executive stammers. It’s clear he has no idea. And after the consultant asks a few difficult questions, the executive admits, “This sounds way harder than I expected.” The video is meant to be funny, and it is, but there’s some truth underlying the humor. Many administrators and clinicians have felt some discomfort and confusion around what ACOs are, about what they ought to be, and even about how we should have a discussion about them on national and local levels. As we enter 2011, though, the ACO picture is at last beginning to clarify. While we might chuckle a bit at the confused cartoon executive of today, we’re also seeing the ACO move from concept to applied reality. It no longer takes a leap of faith to imagine ACOs transforming health care delivery in a serious way. And as has so often been the case with health care innovation, one can trace much of this progress back to work being done here in Minnesota.
By George J. Isham, M.D., M.S.
MetroDoctors
Minnesota as a Home for Model ACOs
We’ve seen many different approaches to health care reform in recent years, but at some level they all seek to address some common, interrelated challenges. We know, for example, that the health of American populations could be better — and in many cases, much better. We know that quality of care is improving, but it’s not improving as quickly as it could or should. We know that consumers want a better and more satisfying experience of care. And above all, we know we can’t sustain our giant increases in health care costs. At the same time, health care leaders are focusing on finding ways to achieve “Triple Aim” outcomes — the simultaneous improvement of the health of a defined population, the experience of each individual within it, and the affordability of care. Enter the ACO. Formulated in large part by Dr. Elliott
The Journal of the Twin Cities Medical Society
Fisher, professor at Dartmouth Medical School, and informed by a seminal 2001 Institute of Medicine report called Crossing the Quality Chasm, the concept of the ACO is designed to address a key problem: The fragmented, disconnected nature of fee-for-service health care delivery in most parts of the U.S. — and the ways in which it rewards volume instead of results. As ACO models have matured, they’ve been increasingly connected with the Triple Aim, recognizing that associating goals, measurements and transparency with each of those aims is important to transforming the system overall. Approaches vary, but in practice, an ACO should allow hospitals, clinics, administrators and clinicians to work together — usually across systems — to address challenges in planned, measurable ways. It should be able to manage a continuum of care as an integrated system — either an actual integrated system or a virtual one. It should be large enough to support meaningful and comprehensive performance measures. And lastly, it should be able to distribute payments of shared savings (as well as allow the sharing of risk) internally among participants. Furtherance of the ACO concept was greatly strengthened in 2010 through legislation. The Affordable Care Act, for example, set aside $10 billion for the creation of a Medicare Center for Innovation to evaluate new approaches to health care, such as ACO reforms and payment models, through 2019. It also called for Medicare to be able to pay for care provided in ACOs and to collaborate with private and state-based systems in doing so. The federal government is expected to issue guidelines early this year about ACO regulation, and the National Committee for Quality (Continued on page 24)
March/April 2011
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Accountable Care Organizations Minnesota and the Emerging ACO (Continued from page 23)
Assurance (NCQA) is developing ACO accreditation standards expected to be finalized this spring. As these factors align in support of ACO development, the Minnesota medical community is especially well-suited to create them. HealthPartners, as an integrated organization with a health plan, medical group and hospitals, for example, already operates in many ways as a self-contained ACO, as do several other systems around the country. These organizations have a comprehensive view of populations, data from multiple sources and perspectives, and experience with evaluating and managing risk and provider networks — many of the capabilities needed to begin an ACO. Many other Minnesota health systems share aspects of these same capabilities, including Allina Hospitals & Clinics, Fairview Health Services, Park Nicollet Health Services, the Mayo Clinic and St. Mary’s/Duluth Clinic Health System. A Minnesota ACO Example: The Northwest Metro Alliance
Within the HealthPartners organization, we’ve
been focused on achieving Triple Aim results for the past decade, and made formal commitments to structure our system around pursuit of them in recent years. By developing reliable care processes that deliver consistent care, customizing care that is adapted to the values and needs of our patients, improving access to care, information and knowledge for patients, and coordinating care across sites, specialties, conditions and time, we’ve seen our cost of care decline to 90 percent of the market average while seeing improvements in quality of care and the experience of care we provide our patients (see Fig. 1). This work was a valuable precursor to our recent, seven-year collaboration with Allina Hospitals and Clinics called the Northwest Metro Alliance. We view the Alliance as an ACO “learning lab” that’s consistent with other pilot approaches being explored locally and nationally. It seeks to improve the health of the more than 300,000 people receiving care from our organizations in the northwestern Twin Cities suburbs by targeting cost and care improvements, optimizing available network and specialty services, and by preventing duplication of capital or other outlays for patient care services.
Figure 1
TRIPLE AIM: Health Experience Affordability HealthPartners Clinics 42.5%
1.000 97.1%
97.6%
TOTAL COST INDEX
0.980
0.960
0.940
45%
35%
95% 25%
0.920 15% 9.0%
0.900
0.8952
4Q
04 1Q 05 2Q 05 3Q 05 4Q 05 1Q 06 2Q 06 3Q 06 4Q 06 1Q 07 2Q 07 3Q 07 4Q 07 1Q 08 2Q 08 3Q 08 4Q 08 1Q 09 2Q 09 3Q 09 4Q 09 1Q 10 2Q 10 3Q 10
0.880
Total Cost Index (compared to statewide average) < 1 is a better than network average
% Patients w/optimal Diabetes Control* * controlled blood sugar, BP and cholesterol (per ICSI guideline A1c changed from <7 to <8 in 1Q09 and BP control changed from <130/80 to <140/90 in 3Q10), AND daily aspirin use, AND non-tobacco user
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March/April 2011
% Patients “Would Recommend” HealthPartners Clinics
90% 5%
The Alliance has three key components: Coordinated care management: The Alliance strengthens connections between primary care clinics, hospitals, and associated payer services to deliver coordinated care for patients with chronic conditions and to reduce admissions and readmissions. This includes identifying the high-risk and high-cost patients in the community, working to engage them in case management and other care services, and ultimately improving their self-management ability to avoid future readmissions. Payer-based data models: The Alliance uses HealthPartners’ multiple population-health data models to understand the patient population, to identify variation in treatment patterns and clinical practice, and reveal the total cost of care and health care treatment patterns in the community and market. Electronic health information sharing: The Alliance involves use of electronic health information to coordinate care, improve efficiency and safety and improve the patient experience, allowing shared access to each organization’s electronic health record. The Alliance also involves creation of shared tool kits and clinical best practice protocols and contracting models, development of standard performance metrics to manage, identify and track opportunities for improvement, and open and transparent communication of progress and results. It’s governed by an agreement outlining the overall terms of the partnership and providing a structure and process for planning and joint venture developments. Chief medical officers and medical leadership meet monthly to review data and evaluate progress against goals. Success is measured by performance against the three goals of the Triple Aim, and a model of withholds and incentives has been established to return shared savings to all participants based on results. The results to date have been encouraging. At the end of the first year, preliminary data suggested movement in the right direction on total cost of care trends. We saw good sharing and collaboration among all the key players within our organizations, and we’re seeing signs of cultural change supporting this new model of care delivery.
MetroDoctors
The Journal of the Twin Cities Medical Society
But while early results are positive, it remains an experiment. The complexity and learning curve associated with an initiative like the Alliance reinforces the reality that there isn’t a “silver bullet” for accomplishing Triple Aim results. Joint planning requires effort, and those involved face hurdles. It takes time and a willingness to build new operating structures in stages — not in one fell swoop. Above all, it takes engaged, committed leadership and a clear intent of all organizations involved to create change for the better. Future Implications for the Minnesota Medical Community
Here in Minnesota as well as nationally, administrators and clinicians have viewed the emergence of ACOs with a mixture of excitement and apprehension. There are concerns that ACOs could reduce autonomy, create downward pricing pressure, or stipulate new transparency about performance and results — none of which might be immediately welcomed. At the same, many see ACOs as opportunities to demonstrate their ability to provide superior care in line with Triple Aim goals. In any case, and regardless of the exact form ACOs take in coming years, Minnesota will likely continue to be an early ACO proving ground and provide a pathway for others nationally to model. In that light, the development of ACOs will begin to gradually change the practice of medicine in Minnesota, and clinicians will likely see changes in several areas. For example, clinics and doctors who aren’t part of larger systems will see expectations, and even requirements, for working in conjunction with others outside of their own system, with reimbursement increasingly tied to cooperative efforts. Joint management of care will increase clinician reliance on EHR systems and other technologies for performing their work. And a focus on results measurement, tracking and reporting will continue to gain more prominence at every level of care. Above all, it makes sense for all of us within the Minnesota medical community to keep a creative and open mind about the possibilities of ACOs to help transform the care delivery system in our state. Instead of a system that’s increasingly consolidated and resistant to Triple Aim outcomes, we can work together to lay the foundation for a system
MetroDoctors
that’s increasingly collaborative and that supports better health, better experiences and affordability. It’s my hope that — based on good work done to date — we can continue to reach across traditional boundaries and constraints to do just that. George J. Isham, M.D., M.S., is chief health officer and plan medical director at HealthPartners, Inc., Minneapolis, where he is responsible for health promotion and disease prevention, research, and health professionals’ education. Active in health policy issues at state and national levels, he is past co-chair and current member of the National Committee for Quality Assurance’s Committee on Performance Measurement, as well as a founding board member of the Institute for Clinical Systems Improvement, a collaborative of Twin Cities medical groups and health plans that is implementing clinical practice guidelines in Minnesota. Footnote: 1) “In Search of an Accountable Care Organization,” Centura Health. http://www.youtube.com/ watch?v=lF8bK7AJyL0. Accessed Jan.11, 2010.
The Journal of the Twin Cities Medical Society
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March/April 2011
25
YOUR VOICE
The Physician’s World— Turned Upside Down and Inside Out WHAT, AMID ALL THE CURRENT CACOPHONY OF CHANGE
in health care, is the most fundamental theme of how a physician’s world will change? The seed of that answer was planted for me during my formal introduction to management. Several years ago I was attending a seminar meant to teach physicians some of the rudiments of modern management, finance and economics. One of the presenters, facing a room full of us, asked for a show of hands. “How many of you still practice clinical medicine?” Most of us raised our hands. “Economically, you’re all piece workers in a garment factory.” Except for a few nervous chuckles, silence reigned as the mass of arms slowly dropped. Seems truth had a quieting effect. Such is the flow of revenue to this day. As physicians we perform a procedure or service and get paid for it. Our revenue depends on the payment rate times and the number of procedures or services we provide. The system is so established and ingrained, we scarcely think about it. The fundamental theme of the future will be the disappearance of this system. The transition seeds already appear in laws passed under the name of “health care reform.” Instead of piecework generating revenue, insurance companies are going to pay physicians according to the results we obtain. We also have to accept that the exact mechanisms remain somewhat vague at present. The rule makers are hard at work but haven’t produced all the details. This orientation to results is embedded in the State of Minnesota’s health care reform initiatives such as Health Care Homes, Provider Peer Grouping, Baskets of Care, Health Care Quality Measurement and other aspects now passed into law. Nationally, discussion abounds on what will be the features of Accountable Care Organizations. The term “pay-for-performance” is inaccurate. Performance of services and procedures occurs now. “Pay-for-patient results” is coming. In response, physicians will change the environments in which they work, change the roles within their organization, change their knowledge base of organizational and management practices, and obtain their economic and professional rewards in less direct and more diffuse ways. Detailing each of these changes isn’t possible in the space available here, but let’s enlarge each briefly. The work environments will become larger and more complex. That trend has been active for some time, but will accelerate. The demands for capital to fund information technology, as well as the need for management skills to install and make useful IT capabilities, are powerful drivers. Regulatory demands don’t significantly lessen 26
March/April 2011
for smaller-sized entities and can be better managed in larger organizations. Within these larger businesses, physicians will become team members and managers rather than the center of all activity. That will increase the need for cooperation and coordination among multiple resources to obtain desired results in the care of patients. Demands for continuity of care push physicians, hospitals and major ambulatory facilities into closer integration. Physicians who broaden their views and accept this new world will have a greater likelihood for success than those who hunker into the “just want to practice my profession” fox hole. The health care winners in the Baldrige National Quality Program may provide insight as valuable to physicians as readings of the New England Journal of Medicine. The best doctors will also be skilled management persons. In their new and larger environments, with team member roles and enhanced understanding of management, rewards will come in a different manner. The team’s revenue will be shared. The team’s recognition will be shared, and both may take longer to arrive after work is performed. Finally, a subtle shift in focus will occur. We will begin to think about those under our care outside the walls of our workplace. In our large organizations and work teams, we will focus more on prevention, both for those currently healthy and for those who, in increasing numbers, bear the burden of chronic conditions. We will think in terms of populations we serve and look for improving trends in health and well-being. These are just a sampling of the changes physicians must accept to thrive in the new results-oriented world. Just as the introduction of DRG payments altered the behaviors of hospitals, this new pay for results will lead to new ways of thinking and caring for our patients. Terril H. Hart, M.D., Experienced Resources, LLC Health Care Executive. MetroDoctors
The Journal of the Twin Cities Medical Society
New Pilot Sites for Honoring Choices Minnesota
H
onoring Choices Minnesota is working with five new sites to pilot an advance care planning program with a controlled patient population. The sites are: • Lakeview Hospital • North Memorial Medical Center • Queen of Peace Hospital • Redeemer Health and Rehab Center (Elim Care) • Ridgeview Medical Center After six months, the teams from each location will come together to report their findings at Sharing the Experience: Honoring Choices Minnesota Conference, which is set for July 20, 2011, in Minneapolis. With the addition of these new pilots, every major hospital in the Twin Cities is now involved in Honoring Choices Minnesota. The Advisory Committee continues to serve as the
governing body and committee members recently approved a revised health care directive form to be shared by all systems. The directive is available at www.metrodoctors.com for free. For additional information on Honoring Choices Minnesota, please contact Katie Snow at (612) 362-3704 or KSnow@metrodoctors. com.
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Call for Resolutions Resolutions are due in TCMS office by Monday, April 25. E-mail to: nbauer@metrodoctors.com Fax: (612) 623-2888
Attend the TCMS Caucus Monday, May 2, 2011 6:00-8:00 p.m. Broadway Ridge Building, Conference Room D • 3001 Broadway St. NE, Minneapolis, MN 55413 • • •
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Serve as a Delegate at MMA Annual Meeting September 14-16, 2011 Duluth, MN
Crutchfield Dermatology EMMS Foundation Awards Grants
“Remarkable patient satisfaction from quality, service, convenience and excellent results” “Exceptional care for all skin problems”
T
he EMMS Foundation Board recently awarded three gifts under a newly-restructured granting process. The first was presented to Honoring Choices Minnesota in the amount of $25,000, to be used in the development of advance care planning patient education materials. $5,000 was given to the Minnesota Medical Association Foundation for their Urban Physician Loan Forgiveness Program, which is aimed at increasing the number of physicians practicing in underserved areas. A grant was also approved in the amount of $2,500 for the Minnesota Academy of Family Physicians to conduct Self Management Workshops for patients with chronic and complex diseases. Grant requests are received throughout the year and the EMMS Foundation Board reviews them each fall. MetroDoctors
The Journal of the Twin Cities Medical Society
Charles E. Crutchfield III, M.D. Board Certified Dermatologist
Psoriasis &
Acne Specialist
Your Patients will Look Good & Feel Great with Beautiful Skin www.CrutchfieldDermatology.com
1185 Town Centre Drive Suite 101 Eagan, MN 55123
Appointments 651-209-3600 At your request, we have same day appointments available for your patients with acute skin care needs.
March/April 2011
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In Memoriam JOSEPH BERTIL FRIBERG, M.D., passed away Sunday, January 16, at the age of 95. He was born in the city of Loyang, in central China, where his parents had established a mission hospital in 1907. He came to America in 1927 and eventually went on to attend the University of Minnesota Medical School and graduated in 1940. Intending to return to China, he and his wife were asked by the mission board to go instead to East Africa. They served at the Kiomboi mission hospital in central Tanganyika until Eileen developed chronic malaria in the fall of 1949 and eventually was advised to leave the tropics. After returning to the U.S., he practiced medicine in Minneapolis for 48 years until his retirement from Fairview Hospitals and Clinics in February 2000, at the age of 84. Dr. Friberg joined TCMS in 1952. CHARLES W. FRYE, M.D. passed away on November 20, 2010 at the age of 82. Dr. Frye
CAREER OPPORTUNITIES
received his medical school training at the University of Illinois College of Medicine, Chicago, IL and practiced in the ďŹ eld of radiology. He served as chief of staff for Midway Hospital, president of the Ramsey County Medical Society, and a clinical assistant professor at the University of Minnesota. He was made a Fellow of the American College of Radiology in 1984. Dr. Frye joined TCMS in 1963. JOHN A. HIATT, M.D., 78, a family physician in south Minneapolis, died on January 7 of pneumonia. Dr. Hiatt attended the University of Minnesota Medical School. He was an avid outdoorsman and nature photographer. He joined TCMS in 1961. BENI KATZ, M.D., age 81, of Golden Valley, passed away January 12, 2011. Born in Havana, Cuba, he graduated from the University of Havana Medical School in 1954 and married the
See Additional Career Opportunities on page 29.
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What are you looking for?
Enjoy life in Winona, Minnesota, a beautiful community bordered by spectacular bluffs and the mighty Mississippi River. At Winona Health, nearly 100 healthcare providers offer a full continuum of care in several specialty areas.
Join our progressive healthcare team, full-time physician opportunities available in these areas: t &NFSHFODZ .FEJDJOF t 0SUIPQFEJDT
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Winona, a sophisticated community with art exhibits, museums, theater and several festivals, also offers excellent schools, two universities, international businesses, and endless recreational opportunities from boating and fishing to golf and indoor tennis. Winona is located within 45 minutes of two airports.
Contact Cathy Fangman t cfangman@winonahealth.org
love of his life, Dalia. They ďŹ&#x201A;ed Castroâ&#x20AC;&#x2122;s Cuba in 1960 to Minnesota. Becoming a United States citizen was one of his proudest moments. He was a meticulous physician and surgeon with a particular passion for infertility issues. He was a clinical professor at the University of Minnesota Medical School and he continued teaching into his retirement. In recent years Dr. Katz courageously lived with vascular dementia and maintained his dignity through his ďŹ nal days. THOMAS O. NICHOLS M.D., age 77, died on November 19, 2010 after a three year battle with ALS. Dr. Nichols served the Eastside Community for 50 years as a family physician and held many prestigious positions including, St. Johnâ&#x20AC;&#x2122;s chief of staff and president of the Ramsey County Medical Society. Dr. Nichols received his medical degree from the University of Minnesota and he joined TCMS in 1963. TAKASHI OKAGAKI, M.D. age 77, of Edina, passed away on Dec. 18, 2010 after a long struggle with cancer. Born in Tokyo, he came to the United States as a young doctor on a Fulbright scholarship. Dr. Okagaki graduated from the University of Tokyo Medical College, and completed residencies and research and teaching fellowships in both obstetrics/ gynecology and clinical pathology at the medical schools of Tokyo University, University of Washington, Harvard University and Columbia University. He was on the faculty of all those medical schools. For the past 40 years, he has been a gynecological pathologist as Stone Professor of Cancer Research at the University of Minnesota. Besides his M.D. and Ph.D. degrees, he earned a Masters in Public Health. Dr. Okagaki joined TCMS in 1946. JOSEPH W. TEYNOR M.D., a Commander U.S.N. Flight Surgeon (Ret.), 20 years active and reserve, died November 17, 2010 in Salt Lake City. He was born in New Ulm, Minnesota on June 29, 1927. Dr. Teynor received his medical degree from the University of Minnesota Medical School and was trained in the specialty of otolaryngology. He joined TCMS in 1959.
.BOLBUP "WF t Winona, MN 55987 t 800.944.3960, ext. 4301 t winonahealth.org
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March/April 2011
MetroDoctors
The Journal of the Twin Cities Medical Society
New Members
Search for Twin Cities Medical Society on Facebook
Robert C. Anderson, M.D. Dermatology Consultants, P.A. Dermatology Kathryn L. Eggleston, M.D. Planned Parenthood of Minnesota Family Medicine Julie E. Esasiuk, M.D. SouthLake Pediatrics Pediatrics Gregory R. Hanson, M.D. Metro Urology, P.A. Urology Richard E. Karulf, M.D. Colon & Rectal Surgery Associates, Ltd. Colon and Rectal Surgery Anders F. Mellgren, M.D. Colon & Rectal Surgery Associates, Ltd. Colon and Rectal Surgery
CAREER OPPORTUNITIES
3/$17
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The world-renowned Hazelden Foundation invites candidates for a full-time Staff Physician position.
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As a physician at Hazelden you would be part of a team of full-time physicians trained in a multifaceted approach to the treatment of addictions and function as part of a multidisciplinary team to provide up-to-date, Twelve Step and evidence-based care for patients with addictions.
Melissa A. Oâ&#x20AC;&#x2122;Halloran, M.D. Southdale OB/GYN Consultants Obstetrics and Gynecology
Position includes: Â&#x2021;PDQDJHPHQW RI FRPSOH[ ZLWKGUDZDO Â&#x2021;SKDUPDFRWKHUDS\ RI DGGLFWLRQ Â&#x2021; FDUH RI DFXWH DQG FKURQLF medical problems-patient and staff education
Heather L. Rossi, M.D. Colon & Rectal Surgery Associates, Ltd. Colon and Rectal Surgery Gilbert J. Shin, M.D. Metropolitan Anesthesia Network, LLP Anesthesiology
Qualifications required: Â&#x2021;0 ' ZLWK OLFHQVH HOLJLELOLW\ WR SUDFWLFH PHGLFLQH LQ WKH 6WDWH RI 0LQQHVRWD Â&#x2021; %RDUG FHUWLILFDWLRQ LQ ,QWHUQDO 0HGLFLQH )DPLO\ 3UDFWLFH (PHUJHQF\ 0HGLFLQH $1' SUHYLRXV H[SHULHQFH LQ PDQDJLQJ SDWLHQWV ZLWK DGGLFWLRQV Â&#x2021;'($ DQG %XSUHQRUSKLQH FHUWLILFDWLRQ UHTXLUHG $6$0 FHUWLILFDWLRQ RU HOLJLELOLW\ LV GHVLUHG
Michael P. Spencer, M.D. Colon & Rectal Surgery Associates, Ltd. Colon and Rectal Surgery Kristine K. Spiewok, M.D. Sister Kenny Rehabilitation Associates Physical Medicine and Rehab Jeremy S. Springer, M.D. Park Nicollet Clinic Creekside Family Medicine Judith L. Trudel, M.D. Colon & Rectal Surgery Associates, Ltd. Colon and Rectal Surgery James B. Williams, M.D. Colon & Rectal Surgery Associates, Ltd. Colon and Rectal Surgery
MetroDoctors
The Journal of the Twin Cities Medical Society
See Additional Career Opportunities on page 30.
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,I \RX ZRXOG OLNH WR OHDUQ PRUH DERXW WKLV IDQWDVWLF opportunity, please contact Hazeldenâ&#x20AC;&#x2122;s Physician 5HFUXLWHU %HWV\ 1RUGE\ DW EQRUGE\#KD]HOGHQ RUJ or 651-213-4267
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March/April 2011
29
Career Opportunities
CAREER OPPORTUNITIES
Please also visit www.metrodoctors.com for Career Opportunities.
Introducing the “Career Opportunities” section of MetroDoctors!
A great avenue for professionals to learn about job opportunities AND a perfect place for recruiters to promote openings! Recruiters, call for our special recruitment rate. Betsy Pierre, ad sales 763-295-5420
THE STRENGTH TO HEAL and get
back to what I love about family medicine. Do you remember why you became a family physician? When you practice in the Army or Army Reserve, you can focus on caring for our Soldiers and their Families. You’ll practice in an environment without concerns about your patients’ ability to pay or overhead expenses. Moreover, you’ll see your efforts making a difference. To learn more about the U.S. Army Health Care Team, call SFC Daniel Ebbers at 952-854-8489, email daniel.ebbers@usarec.army.mil, or visit healthcare.goarmy.com/info/e928.
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Visit TCMS at www.metrodoctors.com
Fairview Health Services Opportunities to fit your life Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Shape your practice to fit your life as a part of our nationally recognized, patient-centered, evidence-based care team. Whether your focus is work-life balance or participating in clinical quality initiatives, we have an opportunity that is right for you:
With just one click you will find information on the latest TCMS news, events and legislative issues; Board and committee actions; past issues of MetroDoctors;
Dermatology Emergency Medicine Family Medicine General Surgery Geriatric Medicine Hematology/Oncology Hospitalist Internal Medicine
Med/Peds Nocturnist Ob/Gyn Palliative Pediatrics Psychiatry Pulmonology/Critical Care Urgent Care
Visit fairview.org/physicians to explore our current opportunities, then apply online, call 800-842-6469 or e-mail recruit1@fairview.org. Sorry, no J1 opportunities.
and new career opportunities! fairview.org/physicians TTY 612-672-7300 EEO/AA Employer
MetroDoctors
The Journal of the Twin Cities Medical Society
March/April 2011
31
LUMINARY of Twin Cities Medicine By Marvin S. Segal, M.D.
ELIZABETH K. JEROME, M.D. This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com. “UNIQUE” DOESN’T TOTALLY CAPTURE the es-
sence of Elizabeth Jerome, M.D. “One of a kind” is more like it! That vibrant and enthusiastic pediatrician inspired a legacy in Twin Cities medicine that won’t easily be forgotten. Betty Jerome was among the founders of the Teen Age Medical Service (TAMS) in 1968, and became its first Medical Director in 1970, a position she held for 20 years. The Center facility has occupied a renovated duplex site on Chicago Avenue, conveniently located close to the Minneapolis facility of Children’s Hospital & Clinics, its sponsoring organization. TAMS was among the first clinics in the nation specializing in the distinctive care of adolescents. Dr. Jerome was in the forefront of tending to the exceptional needs of that “in between population” … not still children, but not quite adults. Her influence is felt today as TAMS continues to serve the young people of our community. Dr. Jerome was born and raised in West Virginia. Her school teacher mother and engineer father, after some attempts to curb her unorthodoxy, eventually supported her tomboy ways. Her love of the wilderness was spawned in that hill country, and remains a part of her today. She conquered dyslexia with the help of an understanding school librarian, and as a five-year-old aimed to follow in the footsteps of her admired family doctor. After graduation from the University of Illinois Medical School and completing her pediatric residency at Minneapolis St. Barnabas Hospital and the University of Nebraska, she began private practice in 1950 in Minneapolis. Her 28 year marriage to Dr. Bourne Jerome produced four children — all of whom achieved professional and occupational success. 32
March/April 2011
As an adolescent specialist, Dr. Jerome tackled the difficult issues: pregnancy, substance abuse, sexually transmitted disease, emotional and mental problems. Her forthright and direct approach to these conditions won the admiration of her colleagues and patients alike. She said, “There are a lot of things that need fixing” … and fix them she did. She served on the governing boards of the Family and Children’s Service, Children’s Hospital, the Walk-In Counseling Center, the YWCA and International Health Volunteers. She found time to serve the University of Minnesota Medical School and the underserved in Thailand and Uganda, and even developed a modified version of Japanese brush stroke art. Dr. Jerome’s numerous awards include an Honorary Doctor of Science from Carleton College, a Distinguished Service Award from the Minnesota Academy of Pediatrics and the Woman of the Year Award from the Minnesota Medical Association. Dr. David Aughey, the current Medical Director of TAMS, who worked closely with Dr. Jerome, called her “a visionary who was adored by her many patients.” Others have described her as an outspoken pioneering advocate for women’s and adolescent health, and a consummate teacher with superb clinical and people skills. Betty Jerome suggested that we “plan to do something to leave the world in better shape than it is now.” She has most certainly followed her own plan by wisely using her head, her heart and her gut. MetroDoctors
The Journal of the Twin Cities Medical Society
“suppose I wasn’t to live. The doctors said
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