TMA PracticeEdge Helps Physicians Measure Quality, Lower Costs
Cover Story — May 2015
Tex Med. 2015;111(5):26-31.
By Kara Nuzback
Physicians have for decades earned a living based on caring for the sick. But in the new world of health care, professionals will earn money based on whether they can keep their patients healthy — a value-based payment system.
Charles Stiernberg, MD, is chief operating officer at Hillcroft Medical Clinic (HMC), a multispecialty facility in Sugar Land.
"For years, we've been a predominately fee-for-service organization, much like most Texas doctors," he said. "It's just the way medicine has been practiced for decades."
But times are changing, and Dr. Stiernberg says physicians in the clinic recently started to consider how a value-based model could keep their practice vital.
"If we didn't cut our teeth on this and start learning about it, there may be a day in the future when we regret not having done so," he said.
David Spalding, a health care executive with 15 years in the industry, says value-based care models are rapidly replacing fee-for-service contracts. Ten years from now, a fee-for-service physician will retain only one of every five patients he or she cares for today, Mr. Spalding says.
"A doctor down the street who has acquired the tools to operate in this new market will have four out of your five patients," he said.
Mr. Spalding is chief operating officer of TMA PracticeEdge — a new services company that offers primary care physicians and specialists the technology and business know-how to help them compete with large health care systems, while retaining their independent practices.
With help from TMA PracticeEdge, Dr. Stiernberg and the physicians at HMC plan to form their own physician-led accountable care organization (ACO).
The Affordable Care Act established ACOs as voluntary groups of physicians, hospitals, and other health care professionals who accept responsibility for the overall quality, cost, and care of a defined group of Medicare beneficiaries. When Medicare saves money on services because a patient population is healthy, it splits the savings with participating ACOs.
According to the Texas Academy of Family Physicians (TAFP) fall 2014 article, "Embracing Change on the Border," a group of McAllen physicians who formed the ACO Rio Grande Valley Health Alliance saved more than $6 million in their first year of participation in the Medicare Shared Savings Program (MSSP), $3 million of which was theirs to keep.
And Medicare is not the only payer with a shared savings program; most private payers now offer value-based contracts. The catch is proving you kept patients healthy and saved the payer money, which can be a challenge. Medicare, for example, has more than 30 quality measures MSSP participants must satisfy. To read more about MSSP, visit tma.tips/MSSPbenchmarks.
In January, federal Health and Human Services Secretary Sylvia M. Burwell announced a goal to tie half of all Medicare payments to ACOs and other value-based models by the end of 2018.
That's where TMA PracticeEdge comes in.
TMA PracticeEdge helps independent practices — even those with miles between them — band together to form a physician-led ACO. The practices remain independent, but they sign a participation agreement to form a new legal entity with its own tax ID so it can receive payments from third-party payers and distribute the money to physicians within the ACO.
The new company, which is controlled by the Texas Medical Association in partnership with Blue Cross and Blue Shield of Texas, offers consulting from certified professional coders, medical auditors, and compliance officers to all practices, even those uninterested in joining an ACO. But the physician-led ACO model is a prime example of how practices can thrive in the changing health care landscape.
"TMA PracticeEdge is not an accountable care organization," said TMA Chief Executive Officer (CEO) and Executive Vice President Louis J. Goodman, PhD. "Rather, it is a services company that will support physician practices and networks, including physician-led ACOs.
"While most ACOs are constrained by a specific hospital system, TMA PracticeEdge will help connect like-minded physicians centered on the needs of their specific patients. TMA PracticeEdge will offer participating physicians the means to provide coordinated, collaborative care, including prevention and management of chronic disease," Dr. Goodman, CEO of TMA PracticeEdge, said.
Corsicana dermatologist Dan McCoy, MD, sits on the TMA Board of Trustees and is divisional senior vice president and chief medical officer at Blue Cross and Blue Shield of Texas.
Dr. McCoy says the respect and leadership of TMA, combined with the extensive membership and longevity of Blue Cross and Blue Shield, allow the two entities to make meaningful change in the health care market.
"Because of our long history with TMA, we felt it would be a natural partnership," he said.
Dr. McCoy says about two-thirds of Texas physicians care for patients at independent practices. Most of those physicians don't have access to the tools they need to transition to value-based care, forcing many to align themselves with hospital systems, "even though they may not want to," he said.
TMA PracticeEdge will help those physicians remain independent and participate in the value-based market, he says.
"We think that's good for our members, and ultimately, it's good for Texas," Dr. McCoy said.
Dr. Stiernberg is former chair of the TMA Council on Practice Management, where talks about creating a physician services organization (PSO) began about three years ago. He also served on the PSO Task Force — TMA's exploratory committee that made the recommendation to proceed with creating the new company -- and the Selection Committee.
Dr. Stiernberg's own search for a value-based contract started in January. HMC initially considered contracting with a Houston-based insurance carrier — one that was owned by a much larger health plan — that entered into risk-sharing plans with several other local physician groups.
Dr. Stiernberg says hospitals had also approached physicians at HMC about joining a hospital-led ACO. But, he said, "We've seen so many doctors here in Houston jump in with both feet into hospital system ACOs and be disappointed.
"We wanted someone to partner with us," Dr. Stiernberg said. So in late January, he called Bridget McPhillips, TMA vice president of membership and business development, to see if the PSO idea had blossomed or fallen off the radar.
Dr. Stiernberg says Ms. McPhillips told him, "Your timing is perfect," and the two met to discuss whether the new company, TMA PracticeEdge, could help HMC start a larger ACO. After several discussions and a presentation from TMA PracticeEdge vendor Innovista Health Solutions, Dr. Stiernberg says HMC had found its match.
"We liked what they had to say," he said. "We trust the TMA."
If HMC had contracted with the local insurer, it would have tied them to one carrier, putting "all of our eggs in one basket," Dr. Stiernberg said. With TMA PracticeEdge, he says, HMC can enter into a variety of contracts with different payers. "We're not tied to any one carrier," he said.
TMA PracticeEdge also offers the name recognition of the state medical association. "That carries weight," Dr. Stiernberg said.
Mr. Spalding says other companies promise the same services as TMA PracticeEdge, but those companies won't necessarily be around for years to come. TMA, on the other hand, isn't going to abandon its physician clients, he says.
"You're on a journey, and who you go on that journey with is going to make a big difference in the long run," he said. "You can trust PracticeEdge. We're going to be here through the next generation and the next generation."
TMA PracticeEdge provides each physician-led ACO with a network management team and a medical management team. The network management team measures things like finances, physician and peer group performance, and patient satisfaction. The team also collects and manages data for the ACO. And when a shared savings check from Medicare or another payer comes in the mail, the network management team divides the money according to the will of the physician board. For instance, if the physicians in the ACO want the bonus divided according to individual performance, the network management team will determine who gets a bigger slice of the pie.
The medical management team or the care coordination team — a team of nurses — evaluates patient information, such as health risks and disease progression, and communicates with hospitals, social services, and other resources to ensure the patients' long-term well-being. This can include educating patients about diabetes management or arranging rehabilitation services.
Both teams work together to ensure the physicians are free to focus solely on the patients in their office, rather than scanning countless documents to make sure patients are keeping up with wellness visits or analyzing data to identify quality gaps.
Investing in the Future
Gonzalez family physician Garth Vaz, MD, says that after reading ACA, he began thinking about joining an ACO, "realizing that it would be providing better care for patients and better income for primary care physicians."
As a side note, Dr. Vaz says, he did not want his rural practice bought out by a hospital or other large health system. "I want to stay independent," he said.
About a year-and-a-half ago, The Vaz Clinic partnered with several other rural Texas clinics to form Alliance ACO. "I just felt motivated to provide a setting for my colleagues and myself where I would be able to work less yet take better care of my patients," he said.
As of March, the organization included five practices, and Dr. Vaz said he expects five more to join soon. Most payer contracts stipulate a minimum number of patients the ACO must cover. For example, MSSP requires ACOs to cover at least 5,000 Medicare patients.
Mr. Spalding says don't be concerned if your patient tally falls in the "under 1,000" category.
"We can help you meet like-minded physicians or groups in your community that are interested in the same activity," he said. Once you form an ACO, he adds, TMA PracticeEdge will use hard data to demonstrate the ACO's ability to manage the health of a patient population. This demonstration of value will then attract more payer contracts and more physicians in your community to join the ACO, he says.
Dr. Vaz says at first some physicians in Alliance ACO were concerned about sharing the responsibility for patient care with physicians they were unfamiliar with. But, he said, "The ACO does not interfere with the internal practice of an organization."
Since preparing to be part of an ACO, including becoming recognized as a patient-centered medical home, Dr. Vaz said, "My admissions to hospitals have gone down, my patients are happy, and my practice is growing."
Dr. Vaz is no slouch when it comes to increasing revenue streams. He jumped on the electronic health record bandwagon early on and has since fulfilled all meaningful use requirements. Now, with help from TMA PracticeEdge, "I expect things will get a lot easier," he said. In particular, having nurse care coordinators to follow up with patients and visit them at home will save his practice both time and money, he says.
Dr. Vaz says he is glad TMA came up with a service to help physicians take charge of their future. "Because of our busy way of life, we have been exploited," he said. Hospitals and insurers have spent time and money finding ways to profit from physicians' work, he says.
"TMA has come out to keep us independent and also to help us excel as independent practitioners," he said. "They are investing in us."
Learn more about TMA PracticeEdge online, by calling (888) 900-0334, or by email.
TMA PracticeEdge Services
- Network/accountable care organization development
- Financial management and reporting
- Population health technology and management
- Care management and coordination
- Patient engagement
- Claims administration
- Physician compensation models
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