2014 October Affiliate Practice by NJPhysician Magazine

OCTOBER 2014 Visit us now online at www.NJPhysician.org

Cyber Liability, the Booming Threat for Doctors and the Health Care Industry The Importance of Checking the OIGâ&#x20AC;&#x2122;s Exclusion List ACOs Struggle with Advanced IT, Interoperability, Survey Shows Pioneer ACOs Get High Marks from Patients, Mixed Grades on Quality

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Published by Montdor Medical Media, LLC Co-Publisher and Managing Editors Iris and Michael Goldberg Contributing Writers Beth Christian Virgil Dickson Melanie Evans Beth Fitzgerald Bob Herman Andis Robeznieks Lisa Schencker Darius Tahir Layout and Design - B&L Printing, Co. Inc. New Jersey Physician is published monthly by Montdor Medical Media, LLC., PO Box 257 Livingston NJ 07039 Tel: 973.994.0068 Fax: 973.994.2063 For Information on Advertising in New Jersey Physician, please contact Iris Goldberg at 973.994.0068 or at igoldberg@NJPhysician.org Send Press Releases and all other information related to this publication to igoldberg@NJPhysician.org Although every precaution is taken to ensure accuracy of published materials, New Jersey Physician cannot be held responsible for opinions expressed or facts supplied by its authors. All rights reserved, Reproduction in whole or in part without written permission is prohibited. No part of this publication may be reproduced or transmitted in any form or by any means without the written permission from Montdor Medical Media. Copyright 2010. Subscription rates: $48.00 per year $6.95 per issue Advertising rates on request New Jersey Physician magazine is an independent publication for the medical community of our state and is not a publication of NJ Physicians Association

C O N T E N T S

Cyber Liability The Looming Threat for Doctors and the Health Care Industry

CONTENTS

The Importance of Checking the OIG’s Exclusion List

ACO’s Struggle with Advanced IT, Interoperability, Survey Shows

Pioneer ACOs Get High Marks From Patients, Mixed Grades on Quality

Medicare’s Pioneer Program down to 19 ACOs After Three More Exit

At Home With the Specialist: Oncologist and Other Specialists Launching Patient-Centered Medical Homes

HHS Extends Stark, Anti-Kickback Waiver for ACOs

CMS Launches $840 Million Initiative To Accelerate Care Transformation

PA. Medicaid Managed-Care Expansion Plans Struggle to Sign Providers

More Providers, Insurers Showing Appetite for Narrow Networks

Summit Medical Group Will Develop Cancer Center with MD Anderson

United Health’s Optum to Buy MedSynergies

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Cover Story

Cyber Liability The Looming Threat for Doctors and the Health Care Industry A

lmost daily, the news reports

of the latest hacking incident to many big corporations and the federal government from a myriad of unknown sources. In some cases it’s the simple infecting of a system by a malicious virus or Trojans implanted by others of unknown origins, but in many cases it’s the hacking of individuals and patient’s records maintained by organizations and third party operators of individuals record used by organizations. Doctors and health care facilities will become particularly vulnerable as new rules require patient’s records and be maintained electronically in their data bases, and their relation to strict HIPPA laws when it comes to securing patient records. Healthcare facilities and doctor’s offices are increasingly becoming targets of hackers for the theft of patient records for various purposes. These records can be hacked directly from facilities and doctor’s systems, or through lost or stolen laptop and other computer devices. The hacking of records requires strict HIPPA law reporting to the state attorney general, hard letters sent to all the patients informing them of the breach, a call center be set up, forensic work to reveal why the breach occurred and the mandatory offering of 1 year free credit reporting to each record involved in the breach. The average cost estimated from industry experts is between $100-$200 per record, a cost born by the facility or doctor, even when a third party operator maintains the records. When one tallies the number of records any one facility or doctor can have on file, the potential cost can be astronomical. So what can be done? Careful examination of security for the systems in place

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is step one, including firewalls, anti virus, proper passwording, and limited user access is paramount. Health care related entities should be careful to fully examine their exposures by security professionals and follow all protocol. Even with the best security, systems are still breached every day and records hacked in almost every business, as evidenced by the virtual constant reports in the media. It’s important to note, most don’t even get reported, so the threat is large and growing. From a secondary protection standpoint, the insurance industry has also stepped up and is now offering “cyber” insurance coverage for this exposure from a number of insurance carriers. The coverage covers both third party exposures, (damage to other’s systems and suits brought by others) and first party coverage (damage to the insured’s systems and reimbursement due to expenses incurred if a breach occurs). Coverage is generally subject to deductibles and sublimits with respect to the reimbursement coverage for record breaches. Policies can range from a few thousand dollars to much higher premiums, depending on exposures. Many medical mal practice policies now build in some cyber coverage with basic limits of $50,000. However it is important to note, this would be considered inadequate when considering the potential costs, so a separate cyber policy should be purchased if the medical mal practice policy cannot raise limits to more adequate levels. Typical limits would be $1,000,000 for third party exposures and sublimits of $100,000 to $1,000,000 for privacy breaches and stolen patient record requirements. Deductibles can range from $1,000 to $25,000 in most cases.

The coverage is typically written as follows: Network security and privacy insurance — coverage for both electronic and physical information, virus attacks, hackers, identity theft, and defense costs for regulatory proceedings. Regulatory fines and penalties insurance — coverage for administrative fines and penalties a policyholder is required to pay as the result of an investigation conducted by a federal, state, or local government agency resulting from a privacy breach (such as HIPAA, HITECH, and state or federal notification requirements). Patient notification and credit monitoring costs insurance — includes all necessary legal, IT forensic, public relations, advertising, call center, and postage expenses incurred by the policyholder to notify third parties about the breach of information. This coverage will also pay for credit monitoring for all affected parties. Data recovery costs insurance — includes all reasonable and necessary costs to recover and/or replace data that is compromised, damaged, lost, erased, or corrupted. Multimedia insurance — coverage for both online and off-line media including claims alleging copyright/trademark infringement, libel/ slander, advertising injuries, and plagiarism. Cyber extortion — coverage for a threat involving a party demanding cyber extortion funds or they will: • release confidential information of a third party;

• introduce malicious code; • corrupt, damage, or destroy the policyholder’s system; • restrict or hinder access to system including denial of service attack; or • electronically communicate with policyholder’s patients or customers claiming to be the policyholder in order to obtain personal confidential information.  This coverage pays cyber extortion expenses, but such expenses can only be incurred with TMLT’s consent. The coverage would also reimburse cyber extortion funds paid (with TMLT’s consent) to terminate the threat.

Cyber terrorism — coverage that pays for acts of terrorism, meaning a use of force or violence for political, religious, ideological, or similar purposes, including the intent to influence a government or put the public in fear. John Forrester is a Vice President at Boynton & Boynton, one of the tri state’s leading medical malpractice insurance firms, insuring over 4,000 doctors with offices located in New Jersey and Pennsylvania.jforrester@boyntonandboynton.com 1-800-822-0262

x 1185.+

The Importance of Checking the OIG’s Exclusion List By Beth Christian Just as you would do with any business transaction involving your practice, it is important to do your due diligence when hiring or contracting with individuals or entities to perform services on behalf of your practice. As discussed below, there can be draconian consequences for your practice if you fail to do so and either hire, or contract with, a person or entity that is excluded from Medicare or Medicaid. Under federal law, the HHS Office of Inspector General (“OIG”) has the legal authority to exclude individuals and entities from participation in Medicare, Medicaid and other federal health care programs. If a person or entity is subject to an OIG exclusion, no federal health care program payment may be made for any items or services furnished by, or at the medical direction or on the prescription of, that person or entity. The exclusion and the payment prohibition follows an individual even if he

or she switches from one health care profession to another during the period of the exclusion. The payment prohibition applies if the individual’s time is billed directly to the Medicare or Medicaid programs. The payment prohibition also applies if the excluded individual’s services are billed directly or indirectly as a part of a bundled payment, capitated payment, DRG payment or other payment system. Most importantly, the payment prohibition applies even if the payment for the excluded individual or entity’s services is made to a person or entity that is not itself excluded from Medicare or Medicaid, and can apply whether an individual is an employee or an independent contractor. The exclusion is applicable for items and services that go beyond direct patient care, and can also apply to administrative and management services (including billing and claims processing services) even if they are not separately billable.

The risk to your practice if you employ or contract with an excluded individual or entity are significant. First, because no federal health care program payment may be made for services rendered by an excluded individual or entity, your practice cannot be paid by Medicare or Medicaid for services rendered by that individual or entity during the period of exclusion. If your practice is paid for such services, all such funds will constitute an overpayment and will have to be returned to the governmental payors. In addition, federal law authorizes the imposition of civil monetary penalties against providers that employ, or enter into contracts with, excluded persons to provide items or services payable by federal health care programs. If a health care provider arranges or contracts (by employment or otherwise) with a person that is excluded by the OIG, the employing or contracting provider may be subject to civil monetary penalty liabil-

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ity if the excluded person provides services which are payable (directly or indirectly) by a federal health care program. The penalties are significant. The base penalty is up to $10,000 for each item or service furnished by the excluded person for which federal program payment is claimed, as well as an assessment of up to three times the amount claimed, as well as Medicare and Medicaid program exclusion. Because claims billed for services rendered by excluded individuals may be viewed as false claims, potential criminal liability can also arise from your employment of an excluded person or entity. Obviously, the repayment of all claims for services rendered by the excluded individual, potential criminal liability, the payment of civil monetary penalties and treble damages, and potential Medicare/Medicaid exclusion could have a catastrophic impact on the financial viability of your practice. The OIG maintains a List of Excluded Individuals and Entities (“LEIE”) on the OIG website. If your medical practice participates in Medicare and/or Medicaid, it is your responsibility to review the OIG web-

site each time you hire or contract with an individual or entity if that individual or entity will provide services that may be billable (directly or indirectly) to Medicare or Medicaid. The LEIE data base can be found here: https://oig.hhs.gov/exclusions/. Your obligation to review the OIG data base extends not only to permanent contractors but also to temporary ones. It is also important to periodically check the LEIE data base for the purpose of verifying that your current employees and contractors are not excluded. Federal law does not mandate the frequency within which providers must recheck the OIG data base. However, the New Jersey Medicaid program has issued a newsletter which specifies that providers should be checking both the OIG LEIE data base and other related New Jersey licensure and Treasury Department data bases on a monthly basis. https://www.njmmis. com/downloadDocuments/20-22.pdf In addition to checking the federal exclusion data base, if your practice sees patients who are non-residents of New Jersey, you should also review available New Jersey,

New York and Pennsylvania data bases listing excluded individuals to ensure that no state level exclusion has been imposed. A list of data bases is included at the following link maintained by the New Jersey Office of the Medicaid Inspector General. http:// nj.gov/njomig/disqualified/ It is crucial for your practice to have policies and procedures in place mandating that the exclusion status of any new employee and contractor be checked prior to their provision of items or services through your practice. In addition, you should be regularly checking the exclusion lists to verify that there are no Medicare/Medicaid exclusions of your current employees. If you fail to do so, if an employee or contractor provides services through your practice that is billed to Medicare or Medicaid while they are excluded, you risk the imposition of both criminal and civil monetary penalties, treble damages, overpayment liability, the denial of any claims for services rendered by such individuals, and potential Medicare/ Medicaid exclusion.

ACOs struggle with advanced IT, interoperability, survey shows By Darius Tahir

“Most ACOs are still at the stage of basic care-coordination capabilities,” said Bryan Bowles, Premier’s vice president of population health solution management, Wednesday on a call discussing the survey. “The challenges of blending disparate data have hindered uptake of more advanced functions.”

other platforms. Capabilities like remote monitoring devices lag behind in adoption (26%). Indeed, using health IT to deliver care at a distance was, in general, rarely adopted with only 38% of respondents using referral management and 34% phone-based telemedicine. Video-based telemedicine lagged even further behind, at 26%. That lack of adoption is particularly concerning for ACOs with rural or under-resourced members, Tracy Okubo, the eHealthInititative’s senior director of health IT stakeholder outreach, stated.

For example, while 86% of respondents have an EHR system and 74% have a disease registry, other important IT capabilities lag. Only 28% of respondents can build a master patient index, for example, while 58% have a clinical-decision support system.

But ACOs who used health IT generally found positive results. For example, 66% of respondents felt it improved clinical quality (with 7% saying it worsened it), and 55% felt it improved health outcomes, compared with 6% who say it worsened.

ACOs “can’t succeed if they can’t identify patients in their population,” Bowles said.

Some categories, however, reflected challenges with health IT: more ACOs (35%) felt health IT worsened patient satisfaction than improved it (29%). And a large number of respondents felt it worsened provider satisfaction (22%) and didn’t reduce ER visits (27%).

Many accountable care organizations are struggling with advanced IT functions and interoperability, a survey of 62 ACOs conducted in July and August 2014 by Premier and the eHealth Initiative shows.

The reasons ACOs gave for their IT shortcomings include cost (95%), lack of funding or return on investment (90%), and interoperability (95%). All respondents said access to external data was a challenge, and 88% identified integration and blending of disparate data from other EHR platforms and other sources as a barrier. As a result, 46% of respondents pull data from between one and 10

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The eHealth Initiative is a not-for-profit that does research and advocacy for healthcare IT. Charlotte, N.C.-based Premier is a company that provides group purchasing and performance services to hospitals.

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Pioneer ACOs get high marks from patients, mixed grades on quality By Melanie Evans Medicare’s first and most sophisticated accountable care organizations scored highly with patients for easy access to care and clear communication with doctors. The ACOs’ success at preventing potentially avoidable hospital stays was decidedly more mixed, as was quality performance in areas such as diabetes management and patient involvement in healthcare decisions. Individual performance data for ACOs in the CMS Innovation Center’s Pioneer program—launched nearly three years ago under the Patient Protection and Affordable Care Act—were published for the first time this week. Not only did the public get its first look at results for each organization, but so did ACOs participating in the ambitious initiative known as the Pioneers. The release detailed quality scores and financial performance for each ACO in each of the first two years, triggering a rush of analysis by policy experts and consultants for clues to whether accountable care can help transform U.S. healthcare financing. “We’re hoping to learn a lot,” said Larry Kocot, an attorney and visiting fellow with the Brooking Institution who began poring over the data this week. CMS posts long-awaited Pioneer ACO quality and financial results The answer is unclear and depends on the degree to which ACOs—formed by various combinations of hospitals, health systems and medical groups—improve healthcare’s inconsistent quality and lower its painfully high costs. The results are mixed. The Pioneer ACOs lowered Medicare spending by $817 million during the first two years—

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although some saw costs go up instead of down—and quality scores vary widely. Accountable care offers providers incentives to meet quality and financial targets. The incentives structures differ between the two Medicare ACO programs, the Pioneer model and the Shared Savings Program. Pioneers agreed to stronger incentives with potential for financial penalties as well as bonuses. The chance of losing money prompted several Pioneers to drop out. Nine exited after the first year and of those, eight had negative financial performance, as did three of the four that dropped out after the second year. Financial performance is measured by whether ACOs’ patient care costs is lower or higher than Medicare’s target. Bonuses go to those with savings. ACOs with costs above target face penalties. “There’s mixed news on the savings,” Kocot said. Among those that finished the first two years, 14 of the 20 ACOs with final numbers slowed spending and aggregate scores for quality improved in the second year. “We’re encouraged that quality seems to be increasing,” he said. Quality improved significantly for treatment of chronically ill patients, increasing 10%, a Brookings analysis shows. Pioneers were scored against benchmarks for quality performance starting in the second year. The first year, Pioneers were simply required to supply the CMS with their results. “They seem to be managing the conditions of their populations,” Kocot said. “That’s kind of what we were hoping they would rise to the occasion to do.”

Indeed, a dozen Pioneers ranked in the nation’s top decile for performance on a composite of five diabetes-care quality measures in the second year. Notably, Pioneers with poor financial performance were far more likely to rank among the nation’s top performers on diabetes management, including Beacon Health, which saw spending accelerate 5.6% above target for penalty of $2.89 million. The Pioneer with the biggest bonus, the Montefiore ACO in New York, ranked in the top decile for smoking intervention and use of beta blocker therapy, but scored in the 40th percentile nationally for its diabetes management scores. Diabetes management is a new target for improvement, said Dr. Andrew Racine, senior vice president and chief medical officer for Montefiore. Montefiore will dedicate entire clinic days to diabetic care with primary care, specialists and diabetic educators available to see patients in one location at one time, he said. Racine said that will enable immediate treatment or intervention when providers identify a need, instead of referring patients for future appointments. Racine said past improvement efforts have shown results. Efforts to increase access to behavioral healthcare increased depression screening rates from 28.4% to 40% in one year. At 40%, Montefiore outperforms eight out of 10 U.S. providers. The Pioneers’ performance on quality scores for avoidable hospital admissions was spotty. Pioneer scores were more like-

ly to rank below the 30th percentile —the minimum threshold required for Pioneers’ performance to count toward a financial award—than in the top decile on a measure of avoidable admissions for asthma and chronic obstructive pulmonary disease. Nine ACOs ranked below the 30th percentile nationally. Three scored in the top decile. For a measure of avoidable heart failure admissions, scores for nine Pioneers ranked in the bottom third nationally and none placed in the top decile.

Meanwhile, patients scored Pioneers favorably for access and rated their doctors even more highly. Pioneers performed well when patients were asked whether they could make an appointment when needed and gain access to specialists. Doctors earned high marks for listening to patients and explaining things clearly. Patients asked to rate their doctor overall did so glowingly. Nearly all Pioneers earned top scores for asking patients whether they smoke and offering them help to quit.

The Pioneer participants say the availability of performance data for their peers is crucial. When the numbers were posted, Dr. Dave Krueger, executive director and medical director for Bellin-ThedaCare Healthcare Partners in Wisconsin, immediately contacted Pioneers with strong scores in areas where Bellin-ThedaCare was weaker. It is the first time he has had access to such data. “At least now we can look around and say, ‘How do we do this?’ ” Krueger said.

Medicare’s Pioneer program down to 19 ACOs after three more exit By Melanie Evans Three years after CMS carefully selected 32 accountable care organizations deemed best able to manage the Pioneer program’s financial risks, three more decided they no longer want to. The new departures—the program is now down to 19 ACOs—suggest even the most sophisticated health systems may be unwilling to take losses as policymakers test new payment and delivery models. Franciscan Alliance in Indianapolis, Genesys PHO in Flint, Mich., and Renaissance Health Network in Wayne, Pa., have exited the program, which is now in its third year. The ongoing trickle of departures from the Pioneer program underscores the broader tension and debate among providers and policymakers health systems exploring ways to overhaul the way Medicare pays hospitals and doctors—attempts that have rippled through private markets as commercial health plans follow suit. In August, Sharp HealthCare, San Diego, announced its decision to pull out after determining “the model was financially detrimental” despite the ACOs’ performance managing quality and healthcare use. ACOs struggle with advanced IT, interoperability The Pioneer program was Medicare’s first test of accountable care under the Patient Protection and Affordable Care Act, designed and administered by the CMS Innovation Center. It launched in 2012 with 32 organizations willing to accept potential losses with the goal of earning bonuses tied to performance on quality measures and their ability to slow health spending. The loss of participants has raised concerns for the center, according to an article published in the Journal of the American Medical Association by the agency’s director, Dr. Patrick Conway, and other officials. But they also said the program is “on

an upward trajectory” and is yielding valuable lessons toward ACO development and the potential for national expansion. Conway and his colleagues noted that the organizations that left during the first year did not abandon accountable care and that providers “must make decisions most appropriate for their particular market and strategic circumstances.” Some executives, though, have criticized Medicare’s formulas for rewarding ACOs as skewed in favor of ones that operate in markets that have above-average health spending, where hospitals and doctors have more opportunities for savings, said Eric Hammelman, vice president for Avalere Health. That raises questions about Medicare’s ability to recruit or retain ACOs in markets where there isn’t as much opportunity. And as ACOs grow more efficient and Medicare adjusts savings targets accordingly, it may also grow increasingly difficult for ACOs everywhere to earn savings. Nine participants dropped out after the first year—seven of them switched to the Medicare’s larger and less risky accountable care initiative, the Shared Savings Program.

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Medicare’s ACO programs so far have produced inconsistent results, some of which policy experts and ACO executives have blamed on how Medicare calculates how much ACOs potentially saved the program. Last week, the CMS announced that the initiatives saved Medicare $817 million through 2013. Dozens of participants shared $445 million of that amount, but three-quarters of ACOs saw nothing after failing to do sufficiently well against the financial benchmarks. Eleven Pioneer ACOs earned bonuses in the program’s second year, with savings that ranged from $1.2 million to $13 million, the JAMA article said. Six generated losses and will be required to repay Medicare. The mean score on measures of quality increased to 84% from 73% among the 23 ACOs in year two. Genesys PHO will repay Medicare $1.9 million because the ACO failed to hold down spending during the second year, according to the organization’s CEO, Michael James. James said the Flint, Mich.-based ACO was at a disadvantage because the Pioneer model failed to adequately adjust for the severity of patients’ poor health. The formula also discounts the role that socioeconomic factors play in health, which he described as significant for the patient population in Flint.

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Genesys PHO will now apply to the shared savings model to maintain access to patient data that the CMS furnishes to ACOs and Genesys found useful in identifying gaps in care. “We still believe that our seniors are working through a disorderly healthcare system that does not improve the quality of their health or the quality of life,” James said. Franciscan Alliance likewise plans to join the Medicare Shared Savings Program, said Jennifer Westfall, Franciscan’s regional vice president for Franciscan Alliance Accountable Care Organization. The ACO did not get to share any savings in the Pioneer program’s second year and anticipates no bonus in the third year, which prompted the organization to leave. “Results from 2013, our second performance year (PY2) in the Pioneer ACO, are now available from CMS,” she said. “Overall, our Pioneer ACO received a quality score rating of 83.7%. While this is indicative of strong performance, we did not do as well in meeting our benchmark for reducing the costs of patient care.” Genesys PHO and Renaissance Health Network could not be reached immediately for comment.

At home with the specialist: Oncologists and other specialists launching patient-centered medical homes By Andis Robeznieks Solo practice endocrinologist Carol Greenlee is one of a small number of specialist physicians in the country who operate their practice as a patient-centered medical home, a model pioneered by primary-care doctors. She has expanded the medical home into a medical â&#x20AC;&#x153;neighborhood.â&#x20AC;? From her office in Grand Junction, Colo., Greenlee studies patientsâ&#x20AC;&#x2122; medical records and questions their other doctors so she is thoroughly familiar with their health issues before they arrive for visits. She also consults with other doctors electronically on difficult cases, which often makes it unnecessary for patients to come in for visits to her office.

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But for now, she receives no additional payments from insurers for these patient-management services, despite having earned patient-centered specialty practice recognition this year from the National Committee for Quality Assurance. “We communicate back with the primary-care doctor after every one of our patients’ visits,” Greenlee said. “But some of our patients might not use a primary-care doctor, so we have to look after them a little more.”

Greenlee hopes her NCQA recognition will inspire other small physician groups to transform their practices, and send a message to Medicare and private insurers that they should financially reward doctors for offering this higher level of service to patients. Despite tensions between primary care and specialist groups over what types of practices should serve as medical homes, a growing number of specialist practices, insurers and health systems are moving toward the patient-centered specialty home model. Despite tensions between primary care and specialist groups, a growing number of specialist practices, insurers and health systems are moving toward the specialist-based medical home model. But much depends on more insurers paying for the extra services. The NCQA’s patient-centered medical home recognition program has about 8,400 participants, mostly primary-care practices. Its Patient-Centered Specialty Practice recognition program, launched in March 2013, has gotten off to a slow start, however. Tampa, Fla.based HealthPoint Medical Group was the first to gain recognition in February. Thirty other specialty practices have since followed. The list includes 10 oncology, four endocrinology and two cardiology groups. The NCQA expects interest among specialist physicians to increase, though the group may have to refine its medical-home criteria to better fit with clinical approaches and patient characteristics of the different specialties. Leah Kaufman, who heads the NCQA’s outreach efforts, predicted the program would grow when more insurers introduce payment mechanisms to reward the extra work that goes with being a medical home. “We’re starting to see some payer support,” she said. “They are interested in cardiology, endocrinology, oncology and some OB-GYN.” Some oncologists also have adopted the medical-home model, which is based on the principles of enhanced communication and coordination of care, expanded access through evening and weekend office hours, as well as phone and electronic contact, provider teamwork, proactive assistance to help patients manage their own health, and continuous performance tracking and quality improvement.

At the New Mexico Cancer Center in Albuquerque, CEO Dr. Barbara McAneny calculates that her medical home-style practice model has reduced the hospitalization rate for the 7,200 cancer patients participating in the seven-state oncology medical-home demonstration project she leads from 25 to 18 days per 1,000 patients. Her Community Oncology Medical Home, which she calls Come Home, has established evening and weekend hours so cancer patients can come in and see familiar providers in a comfortable setting.

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Patients “are thrilled with the idea of not having to go to the emergency department for eight hours or more and then being seen by someone who’s unfamiliar with them,” said McAneny, who is also chair of the American Medical Association board of trustees. “If you know your remaining number of days is limited, the last place you want to spend them is waiting in emergency.” But the primary-care physician groups that spearheaded the medical-home movement say specialist practices generally cannot function as true medical homes. They argue that one of the core principles is a “whole-person orientation,” and that specialists don’t fit with that orientation given their focus on particular organ systems and disease conditions. “If (specialists) are seeing someone every day, they’re probably managing an acute problem, but that doesn’t constitute a patient-centered medical home,” said Dr. Reid Blackwelder, president of the American Academy of Family Physicians, which, along with the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association, developed the medical-home joint principles.

NCQA recognizes medical home In response, Dr. John Sprandio, whose nine-doctor oncology and hematology practice in the Philadelphia area became the first non-primary-care practice recognized by the NCQA as a patient-centered medical home, said oncology practices are fully capable of meeting the medical-home criteria in that they provide acute, chronic, preventive and end-of-life care. He added that cardiologists, nephrologists and rheumatologists also provide chronic-care management to their patients over a long term. McAneny agreed. “When a person gets diagnosed with cancer, all their other problems go on the back burner and cancer becomes their main focus,” she said. Dr. David May, a board member of the American College of Cardiology, said that for patients with heart transplants or end-stage renal disease or who require complex pharmacology, specialists are the heart of the care team. “In that environment, it should be the primary-care physicians who are the consultants,” he said. Some insurers are moving ahead with specialist-based medical homes despite the professional disagreements. Aetna is launching an oncology medical-home network on Jan. 1 as a pilot project, said Dr. Michael Kolodziej, Aetna’s national medical director for oncology strategy. It will involve 20 to 25 oncology practices and more

than 100 patients in Atlanta, Dayton, Ohio, and Fort Worth, Texas. Aetna will focus on patients with breast, colon and lung cancer because those cancers account for 50% to 60% of patients utilizing chemotherapy. The insurer hopes to improve the patient experience by managing medication toxicity, reducing hospitalizations and trimming costs by 10% to 15%. While the number of patients is small, it’s enough to test the concept because of high hospitalization rates for cancer patients, Kolodziej said. Sprandio praised Aetna’s effort overall but disagrees with the insurer’s focus on only breast, colon and lung cancers. That may cover most cancer patients, but those types of patients are not the ones who use the most resources because they tend to be younger, have more standardized treatment protocols and experience fewer ED visits, he said. Pittsburgh-based UPMC Health Plan, owned by the UPMC health system, which already operates 384 primary-care medical home practices serving 255,000 patients, also is launching a specialistbased medical-home model. It will examine which disease states best lend themselves to the model, said Sandy McAnallen, senior vice president of clinical affairs and quality performance for UPMC’s insurance services division. UPMC Health Plan’s first such effort will be headed by Dr. Miguel Regueiro, a gastroenterologist who is launching a medical home oriented to inflammatory bowel disease for patients with ulcerative colitis and Crohn’s disease. McAnallen said the practice will take a team-based approach and include a primary-care nurse practitioner and a psychiatrist. Among health systems, the Eastern Maine Medical Center in Bangor has four specialist practices that have earned NCQA recognition as patient-centered specialty practices, including its centers for diabetes and endocrine care, gastroenterology, vascular care and rehabilitation. Its cancer care and women’s health centers also have applied for recognition. “It is time-consuming, but it’s absolutely worth it,” said Elizabeth Perry, Eastern Maine’s lead quality analyst and physician practice administrator.

Patient-centered specialty home to-do list • Define care-team roles,standardize evidence-based practices and free doctors from clinically non-essential tasks. • Use clinical registries and certified electronic health records. • Establish processes to track and coordinate referrals. • Enhance patient access and communication with evening/ weekend hours and secure electronic messaging. • Create care plans and support self-care. • Document care goals developed though shared decisionmaking.

“Variable” quality efforts But insurers’ recognition of Eastern Maine’s medical home-based quality efforts has been “variable,” said Dr. James Raczek, the system’s senior vice president of operations and chief medical officer. Anthem Blue Cross and Blue Shield, in particular, pays above and beyond typical office- visit reimbursement. McAneny in Albuquerque received a $19.8 million Health Care Innovation demonstration grant from the Center for Medicare and Medicaid Innovation to expand her oncology medical home model to centers in Florida, Georgia, Maine, New Hampshire, Ohio and Texas. Under the threeyear project, participating oncology practices will provide 24/7 access, care management, patient education and team-based care. The goal is to produce more than $33.5 million in savings for Medicare and Medicaid beneficiaries with lymphoma or breast, colon, lung, pancreatic, skin or thyroid cancer. McAneny expects to have 8,022 Medicare patients in the program plus 1,530 patients covered by Medicaid or commercial insurance. She has projected a 6.3% savings per patient, or $4,178 a year. Cardiologists will also join the movement to medical-home practices, the American College of Cardiology’s May predicted. The medical home “fits hand in glove” with accountable care organizations, he said. But he expects that cardiologists’ participation in NCQA’s recognition program will be “abysmal” as long as the group’s performance criteria focus on care processes rather than outcomes. His own cardiology practice in suburban Dallas already uses medical home techniques, such as involving patients’ family members in their care management. Researchers are studying the quality and cost benefits of specialist-based medical homes, funded by the Patient-Centered Outcomes Research Institute. The NCQA is spearheading a $2 million study evaluating the performance of oncology medical homes in southeast Pennsylvania. In addition, Denise Hynes, a University of Illinois Chicago professor of public health is leading a $2.1 million study evaluating a medical home for end-stage renal disease patients served by the U-I Hospital and Health Sciences System dialysis center and Fresenius Medical Care. Also, a new recognition program is competing with the NCQA for specialty-based medical homes. The Washington-based Community Oncology Alliance is working with the American College of Surgeons’ Commission on Cancer to develop standards and performance measures for oncology-based medical homes. The effort is being piloted at 10 oncology practices—including the seven participating in McAneny’s innovation project. The goal is for the ACS commission to begin accrediting oncology medical homes in 2016. McAneny said much depends on more insurers paying specialist practices for the extra services medical homes offer patients, preferably through a per-member, per-month fee. For example, at her practice, when patients telephone, a live operator always answers. “Patients who are sick and scared talk to a human immediately,” she said. “That is not something you can bill for in the current feefor-service system.” Plus, the open scheduling system and keeping the center open late and on weekends mean higher staffing costs. “Most (insurance) medical directors get it loud and clear,” she said. “But their contracting arms don’t always understand that keeping patients out of the hospital is in their best interests.”

• Measure and improve performance.

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HHS extends Stark, anti-kickback waiver for ACOs By Lisa Schencker

HHS will allow Medicare accountable care organizations to continue operating outside of federal kickback and physician self-referral laws for at least another year. Experts say it’s just the latest move toward more flexibility as healthcare shifts from the traditional fee-for-service model to one focused more on quality and efficiency. Waivers to the federal anti-kickback statute and the federal physician self-referral law, also known as the Stark law, for ACOs participating in the Patient Protection and Affordable Care Act’s Shared Savings Program will be extended through Nov. 2, 2015, HHS’ Office of the Inspector General and the CMS said in the interim final rule. The waivers, which have been in place for nearly three years, were otherwise set to expire in November. Without the action, the waivers would have expired, the agencies said, “creating legal uncertainty for ACOs participating in the Shared Savings Program and potentially disrupting ongoing business plans or operations of some ACOs.” The Shared Savings Program was one of the first initiatives implemented under the ACA and was designed to help boost quality and lower costs for individual Medicare beneficiaries and the Medicare program. Under the program, ACOs may share in the savings they generate within Medicare. Experts said they weren’t surprised Friday to see the waivers extended. “In a nutshell, if the waivers had not been extended, the entire Medicare Shared Savings Program would have immediately collapsed,” said Joe Lynch, a partner at King & Spalding in Washington. The waivers allow ACOs the flexibility they need to coordinate care for patients across providers. Charles Buck, a healthcare attorney with McDermott Will & Emery in Boston, said the anti-kickback and Stark laws are designed to prevent abuse in a fee-for-service context but “otherwise can act as a barrier to hospitals and health systems working closely with physicians and physician groups and other providers.” He said it’s a matter of balancing the need to continue to prevent abuses in traditional systems while also making sure new models have the flexibility they need to be successful.

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“All of this sort of reflects the underlying tension between a recognition that these laws were originally designed to protect the program or the beneficiary,” Buck said, “(but) because of the different structure and incentives in the Medicare Shared Savings Program, again, the laws are not, on the one hand, as important in protecting the program and beneficiaries, and, on the other hand, actually can act as barriers to incentivizing the kind of performance and behavior that CMS is trying to get out of ACOs.” Lynch said he believes more state and federal waivers will become necessary in coming years as healthcare continues to evolve. Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform in Pittsburgh, said, if anything, he found Friday’s announcement “troubling” because it didn’t go far enough. He said he’d like to see the waiver regulations finalized, not merely extended for another year. He also said the current waivers are too narrow and “do not go nearly as far as they need to in order to enable providers to redesign care effectively.” Miller said the extension “introduces additional uncertainty into the ACO program at a time when there are serious concerns about its ability to succeed.” He said he worries that uncertainty could deter additional providers from entering the ACO program. The rule announced Friday explains that the agencies decided to extend the waivers for a number of reasons. For one, the CMS is now developing its own rule regarding the Shared Savings Program. Also, the CMS and OIG want time for input from stakeholders on the effectiveness of the waivers. “We believe that an extension of the (waivers) will avoid impediments to the development of innovative care models envisioned by the Shared Savings Program and new approaches to the delivery of healthcare for beneficiaries,” according to the new rule. The decision to issue another interim final rule rather than a final rule, the agencies said, “should not be viewed as a diminution of the department’s commitment to establish waivers” that foster the success of the ACO program and its goals.

CMS launches $840 million initiative to accelerate care transformation By Melanie Evans The CMS Innovation Center will spend $840 million in coming years to help doctors and hospitals do more to teach each other how to improve quality and cut wasteful practices. The four-year effort is expected to include 150,000 clinicians working in networks where they will swap ideas, trade information and learn from others’ mistakes and successes. The investment is a gamble that sharing care-improvement experiences among medical groups, health systems and others will push the industry more rapidly toward more efficient models of care. Dr. Patrick Conway, deputy administrator for innovation and quality and chief medical officer for the CMS, said the effort is projected to save $1 billion to $5 billion over four years and could prevent 5 million avoidable hospitalizations. Networks of providers, associations, agencies and others will draw on and disseminate successful public and commercial strategies to deliver less costly, more effective medical care and enable others to learn from those successes. “We will take good ideas and best practices from anywhere we can find them,” Conway said. The new program, called the Transforming Clinical Practice Initiative, was conceived to complement federal efforts already underway that establish new incentives for quality and efficiency, and bolster the use of information technology to increase clinicians’ and patients’ timely access to medical records and other crucial data, Conway said. “This is part of a larger strategy for health system transformation,” he said. Networks will fall into two categories: Practice Transformation Networks, which will pair providers who have had prior success with quality improvement and cost containment with those who need help; and Support and Alignment Networks, which will include associations and other organizations with the ability to broadly communicate and educate providers. Practice Transformation Networks will receive the bulk of the CMS funding, up to $670 million, and the Innovation Center estimates it will award 35 grants ranging from $2 million to $50 million. That funding can be used for health information technology, but health IT cannot account for more than 10% of the total award. The Support and Alignment Network program will distribute another $30 million to as many as 30 networks. The amounts are expected to range from $1 million to $3 million. Applicants for the Support and

Alignment Networks will include medical and specialty associations, and patient safety and quality improvement organizations. The Innovation Center, which was created by the Patient and Protection and Affordable Care Act and received $10 billion in funding from the law, will largely fund the awards. The initiative is one of the latest announced by the Innovation Center that seeks to build capacity among providers without the experience or financing to invest in health delivery changes or the ability to bear the risk of new incentives to do so. The center said earlier this month that the program would target small and rural providers, offering them capital loans to become accountable care organizations. Officials are seeking Practice Transformation Network applications that have at least one-fifth of their participating clinicians practicing in small groups or rural or medically underserved communities. The infusion of funding follows new Medicare programs created under the healthcare reform law that pay providers under accountable care contracts and other experimental payment models, such as bundles. Early progress has been uneven and publicly available information on results has been limited and delayed. The first Medicare ACOs, which launched in January 2012, saw quality and financial performance results for their peers for the first time this month. Many stand to gain from the new initiative, but it’s not likely that all of the participants will be able to capitalize on the networks. For organizations that have already sought education from others or shared their experiences, the federally funded networks could help to subsidize those efforts, said Dr. Kavita Patel, managing director for clinical transformation for the Brookings Institution. And, for independent physician groups that hope to avoid a merger with a better-capitalized hospital, newly funded networks may supply the needed expertise and investment to stay solo and revamp their practices, she said. But the funding may be out of reach for organizations that have done little planning ahead of the announcement because of a tight application deadline, Patel said. Applications are due Jan. 6. The award criteria underscore areas that federal officials have targeted for improvement, such as proposals to reduce unnecessary testing by specialists and reporting of core performance measures identified by each network. Multiple networks’ measures will be expected to converge eventually, the Innovation Center said.

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Pa. Medicaid managed-care expansion plans struggle to sign providers By Virgil Dickson Medicaid managed-care plans providing coverage under Pennsylvania’s Medicaid expansion are struggling to find enough hospitals and physicians for their networks. Insurers say the problem is false expectations created by the administration of Republican Gov. Tom Corbett and the state Department of Public Welfare that the plans would pay providers more than traditionally low Medicaid rates. “The problem is it’s not funded as a commercial-type offering,” said Patricia Darnley, CEO of Gateway Health Plan, one of nine plans chosen for the so-called Healthy Pennsylvania demonstration program to expand Medicaid to as many as 500,000 adults with incomes between 100% and 138% of the federal poverty level. Providers “are looking for commercial funding and in our state commercial funding is nowhere near Medicaid funding.” Dennis Olmstead, chief strategy officer for the Pennsylvania Medical Society, said doctors also are balking based on the rate issue. “Absolutely, some may decline being part of the networks if they are given a choice, while others may feel it’s their moral duty to serve these individuals,” he said. But he added that some doctors may not be able to decline because they have “all product” clauses in their contracts with insurers, requiring them to serve members of all plans offered by that insurer, including a Healthy Pennsylvania plan. The healthcare and political stakes are high. The Medicaid plans have until Oct.

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17 to receive certification from the state that they have enough providers to offer adequate access to the expanded Medicaid-eligible population. Enrollment is scheduled to begin Dec. 1. The state needs the plans to be certified by Oct. 17 to begin outreach and enrollment. Both Corbett, who is trailing in the polls in his November re-election contest, and the Obama administration have a lot invested in seeing Healthy Pennsylvania succeed. Corbett has been criticized by his Democratic opponent, Tom Wolf, for not promptly expanding Medicaid and costing the state hundreds of millions in federal Medicaid dollars. And the Obama administration badly wants more Republican-led states to follow Pennsylvania’s example and expand Medicaid under the Patient Protection and Affordable Care Act, including through conservative-oriented models like Corbett’s. The CMS approved Corbett’s alternative Medicaid expansion model in August. As part of the initiative, the state is building a second Medicaid managed-care system, separate from the existing Medicaid system serving about 1.6 million residents who are not part of the expansion population. Those currently in the state Medicaid program will not have access to these new plans. Starting in 2016, enrollees in Healthy Pennsylvania with incomes above 100% of the poverty level must pay monthly premiums of up to 2% of their household income. There are nine designated regions of operation for the Healthy Pennsylvania plan across the state. The Corbett administra-

tion set a goal of having at least two plan options per region. As of Monday, there were some regions that had no plans certified as having adequate networks, said Michael Rosenstein, who coordinates the Pennsylvania Coalition of Medical Assistance Managed Care Organizations, an association of the state’s Medicaid plans. He declined to identify those regions. Leesa Allen, the state Medicaid director, said so far three or four plans have been certified as having adequate provider networks, but that she is confident the other plans also will qualify for certification. “They still have nearly two weeks and they’re making good progress,” Allen said. “We’re feeling confident at this point.” Officials from other plans, including Geisinger Health Plan, confirmed they too were facing the problems in lining up an adequate provider network. The four-hospital Lehigh Valley Health Network, based in Allentown, said it has not yet contracted with any of the five Medicaid plans covering its region. It and other hospital systems say their rate expectations were based on procurement documents released by the state when it was looking for insurers to participate in the Healthy Pennsylvania program. In those documents, state officials said they were developing rates to allow plans to pay providers at “a midpoint between Medicaid and commercial pricing.” Pennsylvania officials said this was necessary because there would be limited

buy-in from providers if plans offered the same rates as those paid by the state’s current Medicaid managed-care insurers. “Because reimbursement rates in Medicaid have been historically lower than Medicare or commercial rates, many providers in Pennsylvania accept only limited numbers of Medicaid patients,” the state said in its original waiver proposal to the CMS. “Other providers cross-subsidize their Medicaid patients by charging more to their privately insured patients. As such, the 1115 Demonstration will seek to stabilize provider payments across payers, expand provider access, and reduce the need for providers to cross-subsidize.” Allen said that when the state initially developed rates for the Medicaid plans, it wanted enough so the plans could pay providers closer to what they were receiving from private health plans on the Obamacare insurance exchange. But she said that during the Corbett administration’s negotiations with the CMS, the federal agency only agreed to allow plans to reimburse at levels slightly higher than what was currently being paid for Medicaid beneficiaries. Corbett administration spokeswoman Christine Cronkright said “the original proposal to the federal government did request that rates be as close to private rates as possible” but that request ultimately did not get approved. A CMS representative did not ately respond to a request for comment.

immedi-

Under federal law, the CMS can only approve waivers for demonstrations that are not projected to cost the federal government more on a net basis than the existing program. And private Medicaid managed-care plans have the leeway to set their provider payment rates based on their own business calculations of what’s needed to earn a profit. So it’s not clear how the Corbett administration thought it could ensure that providers would receive closer-to-commercial rates. Officials from Corbett’s office and the Department of Public Welfare did not respond to a request for comment on that issue. Last month, Department of Public Welfare officials held a conference call with more than 150 hospitals around the state to discuss the rate issue, said Paula Bussard, senior vice president for policy and regulatory services at the Hospital & Healthsystem Association of Pennsylvania. On the call, state officials blamed the CMS, saying federal officials insisted that the state pay lower rates to the plans than what the state was seeking, Bussard said. Nevertheless, Bussard said her organization’s members and Medicaid plans are trying to work out deals allowing hospitals to participate in Healthy Pennsylvania. Rosenstein, with the state health plan coalition, said some hospitals say they still expect plans to pay closer to commercial rates. “We feel that a written document from the department would clear up any misgivings and we’ve asked for that, and we’ve yet to see it,” he said.

More providers, insurers showing appetite for narrow networks By Bob Herman A new health plan collaboration in Wisconsin between a hospital system and an insurer is the latest sign that providers and insurers are betting on narrow networks even as controversy continues over whether these plans offer adequate provider access for consumers. Aspirus, a not-for-profit health system based in Wausau, Wis., and not-for-profit health insurer Arise Health Plan this week unveiled their co-branded health plan for individuals and small businesses with fewer than 50 workers, said Brett Davis, vice president of provider relations at WPS Health Insurance, Arise’s parent company. WPS covers about 250,000 people across the state. Consumers and employer groups that purchase the plan will receive discounted in-

network care at Aspirus’ six hospitals and from any physicians employed by Aspirus or doctors who contract with the system. Executives said the plan will have “affordable” monthly premiums but declined to be more specific. They declined to say whether the plan will be offered on Wisconsin’s insurance exchange under the Patient Protection and Affordable Care Act. Relat Narrow networks draw few complaints from consumers: study Other providers and insurers across the country also partnering to launch narrownetwork plans. The Mayo Clinic, Rochester, Minn., and Medica will be offering a narrow-network plan on and off Minnesota’s exchange for 2015; its monthly premiums are mostly in line with other exchange options. In September, Anthem Blue Cross

and seven Los Angeles-area hospital systems announced a joint venture HMO to better compete with Kaiser Permanente and other narrow-network plans. The ACA is driving much of the shift toward these narrow-network products, said Gerald Kominski, director of the UCLA Center for Health Policy Research in Los Angeles. The healthcare reform law standardizes health plan benefits and sets caps on out-of-pocket costs. So providers and insurers are using unique networks as a differentiator. “If you’re competing on price and you can’t vary copayment structure or deductibles, the only thing you can do is try and keep your networks as affordable as possible,” Kominski said. It’s not surprising to see providers and insurers try to copy Kaiser Permanente, said

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Peter Lee, executive director of Covered California, the state’s insurance exchange, at a virtual conference Wednesday organized by Modern Healthcare. “People understand when you pick Kaiser, you get a designated set of (care) delivery. I think it’s a very healthy thing for the entire health system to compete on delivery.” But experts caution that Kaiser has half a century of experience in operating a staff-model HMO, and other providers and insurers won’t be able to replicate that model quickly. So they say it will take unique and appealing plan benefits and participating providers to attract consumers who are accustomed to broader choices of hospitals and doctors. Medica hopes that offering Mayo’s prestigious network will appeal to consumers. For Aspirus and Arise, gaining traction involves emphasizing preventive-care benefits. Members who choose the plan will receive coverage with no copay for prescription drugs for certain chronic conditions such as diabetes and hypertension. Aspirus and Arise also will reimburse members up to $30 a month if they visit a participating fitness center at least 10 times per month. Executives said the strategy is to remove patients’ financial barriers to care, incentivize the right behaviors and provide a network that all parties can trust. “When patients leak or go outside of network, we have no control over that cost of care or quality,” said Dr. Christopher Reising, executive medical director for Aspirus Network, the system’s physician-hospital organization. “We need to get control of that.” The plan also talks up its data analytics capacity. Providers often have patient data stored in their electronic health records, but insurers rely on their claims database. Combining those two tools and analyzing patient-care trends “are critical to reducing cost and improving the quality of healthcare,” Reising said. Narrow network plans have been mostly discussed in the individual market, where roughly half of all plans sold on the exchanges in 2014 were narrow-network products. But that group only represents 6% of the entire nonelderly population, while employer plans cover about 56% of nonelderly people. Still, UCLA’s Kominski said everyone is looking for ways to keep

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health benefits affordable, including his own employer, UCLA, which recently adopted a narrow network for its self-insured plan. “If this is the direction at least a piece of the market is going, the bigger group market may follow suit,” Kominski said.

Minnesota’s PreferredOne premiums to skyrocket The Star Tribune reports that PreferredOne, the provider-owned health plan with the highest enrollment share in Minnesota’s Obamacare exchange and that exited the exchange for 2015, will be raising monthly premiums to members by an average of 63% in 2015. PreferredOne had offered some of the lowest rates to exchange customers for 2014. But the insurer said in a written statement that the increases were a “significant step at stabilizing our rates” and were necessary considering it was paying far more in medical costs than it was collecting in premiums. Minnesota said earlier this month that the average 2015 rate increase for exchange plans was 4.5%. But that figure only factored plans that stayed in the exchange. Thousands of Minnesotans who had enrolled in PreferredOne through the exchange this year will have to switch insurers if they want to keep their Obamacare premium subsidies for 2015.

Why uninsured Coloradoans aren’t buying health insurance More than four out of five uninsured Colorado residents declined to buy health coverage in the ACA’s first open-enrollment period because of the high costs of plans, according to a report from the Colorado Health Institute (PDF). Data from the Colorado Division of Insurance show monthly premiums in 2014, before factoring in federal subsidies, ranged from $233 to $667 for a 40-year-old person buying a silver-tier plan on the exchange. Colorado’s monthly premiums with the same parameters for 2015 are similar, ranging from $202 to $641. Other reasons uninsured Coloradoans didn’t buy insurance: They lost coverage (such as when a family member lost a job), or they didn’t think they needed health insurance.

Hospital Rounds

Summit Medical Group will develop cancer center with MD Anderson By Beth Fitzgerald The Summit Medical Group and Houston-based MD Anderson Cancer Center have signed a letter of intent to develop a joint, outpatient cancer center as an extension of MD Anderson’s partnership with Cooper University Health Care. The center would provide an integrated, multidisciplinary approach to oncology care in northern New Jersey. The agreement is the first of its kind between MD Anderson and a physician-owned and governed multispecialty group. Summit Medical Group and MD Anderson will work together to plan and develop the new outpatient center. MD Anderson will provide clinical oversight and management for the program, which will include radiation oncology, medical oncology, infusion and diagnostic imaging. “We are thrilled to have MD Anderson, a national and global leader in cancer care, bring its unique knowledge and unparalleled expertise to this relationship,” said Dr. Jeffrey Le Benger, chairman and chief executive officer of Summit Medical Group. “Together with our multidisciplinary model that is transforming how health care is delivered in New Jersey, we are better positioned to provide comprehensive, world-class cancer care to patients and their families.” “Since partnering with MD Anderson Cancer Center, Cooper has had an overwhelming response, which shows the value that MD Anderson brings to the people of New Jersey,” said George E. Norcross III, chairman of the board of Camden-based Cooper. “MD Anderson Cancer Center at Cooper is a hugely successful partnership that delivers MD Anderson’s proven model of cancer treatment, care and research to South Jersey patients,” said Dr. Thomas Burke, executive vice president of MD Anderson Cancer Network. “We look forward to extending our partnership with Cooper and building a relationship with Summit Medical Group to further elevate cancer care in northern New Jersey and advance our mission to end cancer.” Summit Medical Group would become a member of MD Anderson Cancer Network, the institution’s program to elevate the quality of cancer care in communities throughout the nation and the world. The relationship will enable Summit Medical Group to be operationally and clinically integrated with MD Anderson and contribute to the institution’s mission to end cancer. The relationship also will provide Summit Medical Group patients access to MD Anderson’s world-renowned treatment protocols, extensive clinical trials and cutting edge research, while remaining in the care of their Summit Medical Group primary care physicians, oncologists and other health care specialists. Summit Medical Group will be able to provide comprehensive cancer care to its patients from diagnosis to survivorship, ensure strong communication between all treating physicians and preserve the patient-physician relationships that have existed for many years. Located at the University of Texas in Houston, MD Anderson is the largest freestanding cancer center in the world. For the past 25 years, it has ranked as one of the top two cancer treatment centers in the United States, according to U.S. News & World Report’s “Best Hospitals” surveys. MD Anderson employs more than 20,000 people, including more than 1,800 physicians and scientists. Summit Medical Group is the state’s largest multispecialty physician group, with more than 500 practitioners in 50 locations throughout central and northern New Jersey and a headquarters campus in Berkeley Heights.

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UnitedHealth’s Optum to buy MedSynergies By Bob Herman

ptum,

a consulting and analytics division of the country’s largest health insurer, UnitedHealth Group, has agreed to acquire physician practice consulting firm MedSynergies. The deal is significant for UnitedHealth as it looks to grow its position as more than just a health insurance company. Optum already serves about 4 out of every 5 U.S. hospitals, providing revenuecycle management, compliance guidance, data analytics, accountable care modeling and health information technology services. In 2013, Optum’s $37 billion in revenue made up about 30% of UnitedHealth’s total. The division is on pace for more than $45 billion in MedSynergies, a privately held company headquartered in Irving, Texas, provides billing, collections, revenue-cycle and other busi-

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ness and consulting services to more than 9,000 physicians and healthcare professionals. It had about $100 million in revenue in 2012, its most recent available data. The company also has several joint ventures with large health systems, including Texas Health Resources, Arlington, and Catholic Health Initiatives, Englewood, Colo. “This relationship will position Optum to be an even stronger, more valued partner to care providers as they evolve, adapt and pursue new opportunities in a changing environment,” Optum CEO Larry Renfro said in a release. Officials from Optum and MedSynergies weren’t available for further comment by deadline. Financial terms of the transaction were not disclosed. The deal is expected to close this year.