Dermatology World July 2011 : Page 33
of managing physician groups, do not necessar-ily want to get in the game, Speed said. He does not anticipate that ACOs will be dominated by employment models, but rather will resemble one large series of contracts with specialists. Whatever that entity turns out to be, dermatolo-gists should make a point to form a relation-ship with it, Speed said. In markets dominated by small physician groups, doctors will likely get together by specialty, noted Jeff Wasserman, a Woburn, Mass.-based health care consultant. In many markets, he is be-ginning to see the formation of clinical integration organizations, which are basically large physician groups intended to accomplish many of the same goals as ACOs. does suggest that more dermatologists become active in the development of guidelines and quality measures. uncertain risk Not only is the formula used to determine risk confusing, Dr. Wisco said, it is unclear how dif-ferent providers will share in the costs and risks or how ACOs will internally distribute income; the rules do not spell this out. With that kind of uncertainty, dermatologists may question whether participation is worth the risk in the initial stages. “The issue isn’t which of the current models is better, but whether you should participate at all at this time,” he said. “The ACO model clearly wants to move risk from the payers to the provider, the more risk the better from the payer standpoint,” Dr. Swerlick, noted, adding, “The opportunity to get a bonus is small. The opportunity to fail to meet some key metric is almost a certainty.” Given that, it is hard to conceive there will be a major incentive for sub-stantial numbers of dermatology practices to align with ACOs in any major way, he said. Moreover, Dr. Swerlick believes that the proposed rule will need to be tweaked to make it more attractive to the general medical community. Dr. Swerlick is not alone in his assessment. The upfront investment to form an ACO for pre-vious pilot programs was $1.7 million, on average, according to a recent study published in the April 7, 2011 issue of the New England Journal of Medi-cine — and the return on that investment was not strong. Eight out of 10 ACOs participating in the CMS Physician Group Practice Demonstration, upon which the proposed rule is based, were in-eligible to receive any money from the SSP in the first year. Six out of 10 didn’t receive such pay-ments in the second year. Only half were eligible in the third year. The study authors suggest that the high upfront investment makes the model a poor fit for most physician group practices, add-ing that the timeframe in which they can expect a reasonable return on their initial investment is more than five years. The Everett Clinic, one of the PGP Demonstration participants that actu-ally garnered a small bonus, has already declined ACO participation, Dr. Swerlick said, citing a lack of financial reward for high achievement. “There is real concern that attendance at the ACO ‘party’ will be scarce,” he added. Adding to the risk equation is the potential antitrust issues that may arise from participation Dermatology WorlD // July 2011 Measures Given that the quality measures included in the proposed rule are driven by primary care, dermatologists who have reviewed the proposed rule wonder how they fit into the measurement metrics. Assuming that ACOs become prevalent, CMS will start including measures that cover a larger spectrum of specialties, including dermatol-ogy, Speed said. A handful of measures addressing patient experience, preventive health, and care coordina-tion are pertinent to all physicians, Wasserman noted. He suggested that dermatologists familiar-ize themselves with these to ensure that they can meet the measures. CMS has published a list of them at https://www.cms.gov/MLNProducts/ downloads/ACO_Quality_Factsheet_ICN906104. pdf; the first several measures on the list, Was-serman said, relate to patient experience and are broadly applicable. They measure the timeliness of care, appointments, and information; how well physicians communicate; how helpful, courte-ous, and respectful office staff are; how patients rate their physicians; how health promotion and education is provided; and how decision-making is shared. While dermatologists await specialty-specific measures for ACOs, Dr. Wisco recommended that they begin incorporating outcomes mea-sures into their practices by looking at, for example, how effectively they biopsy for basal cell or squamous cell carcinoma, although he noted that he wouldn’t want dermatologists to be judged solely on outcomes measures because there are too many patient variables that cannot be controlled. To improve the process, Dr. Wisco 33
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