ACOs seek to incentivize culture of quality, efficiency
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Accountable care organizations willing to reward dermatologists who produce both

Accountable care organizations (ACOs) are springing up across the country and they are looking for dermatologists who are team players with a desire to enhance quality of care and improve cost effectiveness as well as an understanding that they will be compensated for their efforts under new payment systems.

Dermatologists should think about how they can improve quality, patient safety, and cost effectiveness because that’s where the value is driven, said Mark Shields, MD, MBA, senior medical director at Rolling Meadows, Ill.-based Advocate Physician Partners. These efforts, which can be accomplished alone or, better yet, in collaboration with other physicians, create the opportunity to earn additional payment in the world of ACOs. 

Membership requirements

Providing care with the overall impact on the health system in mind is essential to ACO participation. Like all specialists participating in an ACO, dermatologists must meet membership requirements, such as passing credentialing standards, attending various meetings, and sharing in risk contracts, noted Robert Janett, MD, medical director at the Mount Auburn Cambridge Independent Practice Association (MACIPA) in Boston. They have to understand and adhere to the culture of quality and efficiency by lending support to initiatives looking to improve both. Among the 520 physician members in MACIPA are 26 dermatologists practicing in a total of eight offices. They range from one large group with 10 dermatologists to solo practices.

To support its quality efforts, MACIPA uses data and reports provided by the health plans with which it contracts in addition to conducting its own analyses. For example, as part of its Alternative Quality Contract (AQC) with Blue Cross and Blue Shield of Massachusetts, an innovative model that combines a per-patient global budget with significant performance incentives based on quality measures, MACIPA receives AQC reports that show variations in physician practice patterns. These reports contain rich data comparing physicians in terms of cost and utilization with others in their specialty in their health plan and across the network, Dr. Janett explained; the reports are tied to regional norms and the rankings of the physician within the region and within MACIPA are both reported. Such ranking, he warned, needs to be interpreted with caution, because small numbers can skew results. Still, he noted, physicians know where they stand within the spectrum of utilization for specific clinical conditions. If the data reveals, for example, that a particular dermatologist performs more biopsies per referral than his or her peers, the data are presented to the dermatologist. “Our data are used not to penalize, but to educate and improve,” he said. “We have a deep understanding of the differences in practice patterns. One explanation may be that the dermatologist is the go-to surgeon in the group. When we meet with our specialists and talk about their practice patterns, it helps them to be self-reflective.”[pagebreak]

Additionally, the clinical pharmacist at MACIPA meets routinely with physicians to provide information and advice about alternative and less-expensive medications as well as education about new and existing drugs. The pharmacist also disseminates and interprets individual and group prescribing data. For example, the pharmacist may review usage rates of generic creams and ointments versus brand names at a dermatology group meeting, Dr. Janett said.

All MACIPA specialists are required to conduct an annual quality improvement project. For example, one dermatology group conducted a retrospective review of cultures and therapies to ensure that patients were treated with appropriate antibiotics. Another dermatology group’s project involved implementing a pre-procedure checklist to enhance communication among the provider, patient, and medical assistant; reduce inpatient and specimen identification errors; and reduce post-operative adhesive or topical ointment-induced contact dermatitis. The group also tracked occurrences of post-operative bleeding that resulted in a return to the office. “Projects like these are much better done at the group level than externally,” Dr. Janett said. “It carries so much more credibility when a group studies its own practice patterns.”

At Advocate Physician Partners, physicians must meet membership requirements ranging from board certification and use of its Web-based disease registries and other online tools, such as those for patient education, to threshold scores on annual performance report cards. The physician hospital organization (PHO), which has 3,900 member physicians and is affiliated with Advocate Health Care (which employs 1,000 of those members), has negotiated a common set of performance measures with all managed care organizations with which it has contracts. The measures are nationally recognized and include measures endorsed by the National Quality Forum (NQF) and others. The measures comprise five categories: clinical effectiveness, cost effectiveness, patient safety, patient experience, and use of key technology.

Measures most applicable to the 36 dermatologist members address physician access, including how long it takes to get a routine and/or urgent appointment, and follow-up care including communication with the referring physician as well as the patient, Dr. Shields said. The PHO has a number of risk-adjusted tools to track practice patterns, as well. The data are used to determine, for example, the overall cost of care for patients with dermatologic episodes and dermatologists’ use of generic medications. “We set targets based on utilization across the network of dermatologists,” he said. Advocate Physician Partners employs two pharmacists who provide evidence-based education to physicians to promote the use of clinically appropriate generic drugs. Also, specialists’ performance as rated by the referring physicians is tracked. In addition, all physicians must complete an outpatient safety assessment.

The PHO would welcome dermatology-specific measures endorsed by NQF, Dr. Shields said, and noted that one of Advocate’s measures strongly resembles the biopsy measure included in Medicare’s Physician Quality Reporting System, one of four in that program specific to dermatology. MACIPA, whose contracts also include tracking performance with regard to quality measures endorsed by NQF and the National Committee for Quality Assurance, would also welcome more dermatology-specific measures. But Dr. Janett acknowledged that the rarity of many of the most serious dermatologic conditions is a structural impediment to having commonly used dermatology metrics. “Until we had the Pioneer ACO contract, Medicare metrics were not part of the standard MACIPA reporting infrastructure,” Dr. Janett said. “Now that MACIPA is a Medicare Pioneer ACO, we will be looking very closely at the Medicare quality reporting programs for all specialties, including dermatology.”[pagebreak]

Team effort

The notion that specialists must closely collaborate with primary care physicians (PCPs) and even other specialists is another tenet of ACO participation. For example, at Advocate Physician Partners dermatologists are teaching PCPs how to treat minor dermatologic problems and provide follow-up care. “These are opportunities for dermatologists to work with other physicians to optimize patient care and work as part of a team,” Dr. Shields said. A successful ACO must have a core of committed PCPs and specialists, he added.

Dr. Janett concurred. “Our specialists understand that the only way we will have these contracts is by having satisfied patients who choose our primary care physicians and are then referred to our specialists,” he said, adding, “Our primary care physicians and specialists are deeply linked.” Under MACIPA’s ACO contracts, he said, it is very important to reduce leakage of referrals to specialists and facilities outside of the group. There are two reasons for this: care coordination and cost efficiency. “Care coordination is essential to the success of an ACO,” he said. “Patients who are referred to MACIPA specialists continue to benefit from enhanced communication that can result from shared electronic records, shared labs and imaging facilities, case management services, and collegial relationships that develop between providers over time. Moreover, under some contracts, fee-for-service payments to non-IPA facilities can be significantly higher resulting in higher costs for services that could be readily provided within the organization.” Dr. Janett noted that dermatology is a specialty with one of the highest referral leakage rates in the IPA. “The principle driver of dermatology leakage is the lack of open appointments with resultant waits and delays for service. PCPs both respect and trust the clinical skills of their dermatology colleagues and would prefer to refer the vast majority of their patients to in-IPA specialists. Helping the IPA achieve open access for dermatology care would be seen as a great benefit to the organization.”

Works both ways

Collaboration between referring physicians and dermatologists was critical to improving patient access issues at the Medical Dermatology Clinic of Massachusetts General Hospital, which is a founding member of Partners HealthCare, an integrated health care delivery system-turned-ACO. A few years after a model designed to increase urgent access was implemented, dermatologist Alexa Boer Kimball, MD, MPH, noticed that the number of urgent referrals had recently increased so much that they were beginning to overwhelm the system. The clinic tracked the data and determined that many of the diagnoses being called “urgent” were, in fact, not. “We sent feedback to the primary care physicians explaining that they need to be more judicious about determining which patients are urgent,” she said. “We don’t expect the referring physicians to be right all the time, but we do expect them to be right a fair proportion of the time, not necessarily about the diagnosis, but about the urgency.” After sharing the data with the PCPs, they adjusted their behavior and there was a substantial improvement in the referral of urgent patients. “You really have to work with your referring population to manage these types of issues, but it can be done,” she said.[pagebreak]

Patient access

With an average national wait time of nearly 34 days for new patient appointments and approximately 18 days for established patient appointments, according to the AAD’s 2009 Dermatology Practice Profile Survey, it’s not surprising that physician access has been targeted by ACOs. “Even though we have 26 dermatologists in eight offices, there is a perception that dermatology appointments are difficult to come by,” Dr. Janett said. Moving toward a more open-access scheduling model would be a great advantage for dermatologists, he noted — one that ACOs in which they participated would notice and reward.

Dermatologists looking for a workable model might look to Massachusetts General. The dermatology clinic there developed and implemented a model of outpatient scheduling to ease long waiting periods in addition to addressing urgent visits. First, data on approximately 2,400 patient visits was reviewed. A literature review was also conducted; it revealed a lack of evidence-based recommendations regarding follow-up times for most dermatologic diagnoses. Next, the clinic’s dermatologists devised a model that allows a practice to determine how many new patients it can accommodate by altering the rate at which it schedules follow-up visits for established patients. By extending the time between follow-up appointments for a number of non-urgent issues, the clinic has decreased its wait times by 40 percent, an improvement that has been sustained.

“For cost-saving efforts, you can either look at changing utilization patterns or the cost of care,” Dr. Kimball said. “You can change the per capita cost per patient if you reduce the frequency of visits. If you’re not changing outcomes, then that should be a benefit to the system.” (The Massachusetts General experience was explored in-depth in the January issue of Dermatology World.)

Moreover, this strategy may be applicable for other dermatology patients. According to a recent study in the Journal of Clinical Oncology (2011 Dec 10;29(35):4641-6. Epub 2011 Nov 7), decreasing the number of follow-up visits for melanoma patients with stage one or two disease does not negatively impact outcomes.

Other strategies to more effectively manage patients are occurring that are not only patient-centric but cost effective. While these strategies are being pursued outside of ACOs, they represent the sort of efforts an ACO model could reward.

For example, at Mayo Clinic in Rochester, Minn., Randall Roenigk, MD, the Robert H. Kieckhefer Professor in the department of dermatology, frequently removes 20-plus skin cancers at a time from immunosuppressed patients. Patients prefer not having to come back to the office multiple times and that opens up the schedule to see other patients, he said. “On occasion I take these folks to the OR if they have 50-100 or more lesions, which usually happens in patients who have genetic issues such as BCC nevus syndrome,” he said. “They have lots of wounds postoperatively but appreciate the prolonged periods when they do not need surgery.” This treatment choice may not maximize his reimbursement under the current system, Dr. Roenigk said, but “the bottom line is that surgical decision making is based on patient need, not how I can maximize income.”

Utilizing properly trained nurses to manage certain dermatology patients, such as those with acne, dermatitis or psoriasis, by telephone is another option. “By asking key questions, they can manage these patients and refill their medications without having to make an office appointment,” Dr. Roenigk explained. Of course, the initial diagnosis would have to be made by the dermatologist who would also address flare-ups and specific issues. Another option is to manage these patients using teledermatology. Again, Dr. Roenigk said, this is entirely driven by patient need. “We still hospitalize severe psoriasis patients but most don’t need that and many simply need their steroid cream refilled. We use standardized protocols and communicate freely between providers via our electronic medical record and other online resources developed by Mayo,” he said.

“The problem with fee-for-service is that you don’t get paid for these kinds of activities,” he said. There’s a disincentive to treat more than one skin cancer at a time because of Medicare’s multiple surgery reduction rule. In the other scenario, the doctor doesn’t get paid unless the patient comes in for an office visit, even if all the patient really needs is a prescription refill. If the incentives were different, as in the case of a global payment system like ACOs, Dr. Roenigk contends that these patients could be managed differently.[pagebreak]

ACO payment incentives

In ACOs, physicians who lower costs while meeting quality measures are financially rewarded.

“Advocate Physician Partners operated a clinically integrated network for nine years before venturing into a shared savings program. We were able to enhance physician payment through our value-based bonuses,” Dr. Shields said. With the new shared savings program, dermatologists receive a base compensation paid fee-for-service and have opportunities for incentive payment. “Every quarter, dermatologists receive a report card on their clinical integration measures,” he said. “These determine their distribution of the incentives.”

Dr. Janett noted that MACIPA has a 25-year history of distributing surplus to its members based on the group’s success in controlling costs and improving quality. According to MACIPA’s complex surplus distribution methodology, member physicians receive a percentage of this surplus based on a number of factors including their participation in MACIPA activities and initiatives as well as achieving quality goals and other parameters that help the group meet its objectives.

Dermatologists navigating these new entities should really become engaged in the culture of an accountable care organization, and especially with PCPs, Dr. Janett advised. “Dermatologists are in high demand, but it would be a mistake to be complacent about that. They need to become educated about changes in payment systems and learn about new ways of being compensated. The world will change.”

Dermatologists remain concerned

While ACO administrators (including the ones quoted in the article above) talk about quality and efficiency, the metrics they describe often involve cutting costs and getting patients seen more quickly, leading to concern and frustration in the dermatology community. These are often two things that may not be in dermatologists’ power to control. Quality of care in dermatology, though, is harder to measure. A patient with severe disease may not respond to a low-cost cream, whether generic or brand-name. But without the broadly applicable and quantifiable measures available in other specialties — dermatology has no equivalent of a hemoglobin A1c test to tell if a patient is doing better — ACOs, like insurance tiering programs before them, are likely to judge dermatologists based on cost-related metrics. That this rewards the prescription of that cream, effective or not, and may not accurately reflect the quality of care delivered, is the concern of many dermatologists when considering this potential development in health care. Dermatology World believes, however, that hearing the perspective of ACO administrators is important for dermatologists, so that they are aware of current happenings and thoughts in the health care community.

AADA analysis of ACO rule

The American Academy of Dermatology Association analyzed the final rule on accountable care organizations, published Oct. 20, 2011. Learn more about it in the Health System Reform Resource Center.



Dermatologists remain concerned
AADA analysis of ACO rule
Dermatologists remain concerned
AADA analysis of ACO rule