Wednesday, September 19, 2018

How to Save Primary Care and Family Practice.

An absolutely amazing discussion of how to transform primary care medicine, and how to stop the “moral injury” of doctors that causes them to burnout and leave the profession.

The enclosed video is supplied by ZdoggMD, a well known vlogger. The discussion with Dr. John Bender is excellent, discussing Direct Primary Care, fee for service, and the impact of increasing regulation. He discusses the credibility of current quality measures by various insurance companies, medicare and other standards organizations.

Dr. Bender estimates the administrative load requires 40 hours of time per day, which is not achievable.

How To Save Primary Care (w/Dr. John Bender) | Incident Report 185

John Bender presents an articulate description of the current state of health finance. As a member of Doctors for Patient Care he presents an alternative method for affordable health care. Currently there are formidable barriers imposed by CMS which are encouraged by myths propagated by the insurance industry.

Some comments from viewers of the video,

Placing patient care and improved outcomes first? Incorporating a holistic approach beginning with the “primary” (care) provider? Encouraging stronger and better client/patient - healthcare provider relationships? Promoting fiscal stewardship? Striving toward excellence in quality outcomes? Developing a healthcare model which is attractive and beneficial to patients, employers, insurance companies, facilities, communities AND the healthcare providers (primary as well as specialty)? Radically exceptional! As a RN with 40 years of “practice” in a variety of clinical settings, including mental health, I thank you for having already demonstrated the new model’s feasibility ... “Change for the better” ... It’s just what the doctor ordered! Hugzzz!

Monday, September 17, 2018

The Hidden Secret: New Film 'Pulls Back Curtain' on Physician Suicide |

New Film 'Pulls Back Curtain' on Physician Suicide

And doctors, med students march for victims for National 

Suicide Prevention Week

 Nearly 200 clinicians, residents, and patients filled the Angelika Film Center here on Wednesday for a screening of "Do No Harm," a documentary on the national suicide crisis among physicians, who kill themselves at a rate twice the national average.
And on Thursday, hosted by the film's director, Robyn Symon, and physician suicide prevention advocate Pamela Wible, MD, a group of physicians, residents, and students gathered at the Watson Hotel here and marched to Mount Sinai Hospital in honor of doctors lost to suicide.
"Do No Harm" largely follows two families -- the Dietls and Mechams -- facing the consequences of the pressure-filled and stress-inducing demands of medical education, training, and practice, which leads an estimated 300 to 400 physicians to take their own lives each year.
"I believe this is the first film to pull back the curtain on the toxic medical culture that doctors have been trapped in for decades, but have been too disempowered to speak out on because of the fear of consequences to their career," Symon told MedPage Today. "The goal of this film is to open a dialogue because dialogue is the first step to change."
In the film, Hawkins Mecham, DO, attests to the unrealistic hours expected of residents, the highly competitive nature of medical programs, and his immense fear of making a mistake and losing it all. Eventually these factors -- along with the pressure of being hundreds of thousands of dollars in debt -- caused him to be stuck in what he described as a "tunnel vision," where in seeking a way out during his fourth year of residency, he made an attempt on his life.
During a panel discussion following the screening that featured Symon and Wible, as well as John and Michele Dietl (who lost their son Kevin to suicide 3 months before he would have graduated from medical school), Mecham described the path that led him there.
"I finally got to my first rotation of my fourth year and it hit me when I started getting interview requests and realized, just to be able to attend interviews, I had to take out private loans because I'd already maxed out my federal loans," he said. "It overwhelmed me among other things, and got to the point where I thought it wasn't worth it. The only way to erase this for [my family] was for me to die. That was part of my thought process in my spiral downwards."
Mecham got in touch with Wible, who connected him with the Dietls. The parallels between Kevin and Mecham gave John and Michele Dietl an opportunity to heal, allowing them to ask Mecham questions they were no longer able to ask their son. Namely, why?

"When we started doing this film I was very hesitant because I was afraid of Kevin's legacy -- what would he think of everyone in the world knowing what happened to him?" Michele Dietl said at the panel. "I want these students to know from a younger age: Get help. Don't wait until it's a crisis situation and you're ready to kill yourself because you think you're trapped and you have all this debt and you're never going to be able to get your license. I hope he'd be proud of us and not ashamed."

Also on the panel were Thomas Madejski, MD, president of the Medical Society of the State of New York (MSSNY), and Michael Myers, MD, author of "Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared."
When asked what the MSSNY is doing to help alleviate some of the stressors physicians face, Madejski cited the Physician Wellness and Resilience task force, which his predecessor Charles Rothberg, MD, created, as well as a collective negotiation bill they are working to pass. Additionally, he hopes to increase the number of physician-led health systems.

"Do No Harm" will be shown throughout 2018-2019 at various locations.

If you or your organization would like to sponsor these events, please contact 

Robyn Simon, Producer. email 

Due to a technical error this blog post may not display properly.

New Film 'Pulls Back Curtain' on Physician Suicide | Medpage Today: And doctors, med students march for victims for National Suicide Prevention Week

Friday, September 14, 2018

An 'epidemic of nicotine addiction' among kids prompts FDA to get tough on e-cigarette makers

An 'epidemic of nicotine addiction' among kids prompts FDA to get tough on e-cigarette makers: Responding to an “epidemic of nicotine addiction” among American youths, the FDA announced a comprehensive crackdown on e-cigarette manufacturers, directing the industry’s giants to draw up detailed plans for halting sales to minors and threatening to pull a wide range or products from the market.

In response to a nationwide undercover investigation of brick-and-mortar and online stores over the summer, the FDA levied civil fines ranging from $279 to $11,182 on e-cigarette retailers found to have sold their products to minors and issued more than 1,300 warning letters.
What’s more, Gottlieb said the vaping industry appears to have turned a blind eye to the online practice of “straw purchasing” by retailers and individuals intent on buying vaping products and reselling them to minors.
The agency also ordered 12 online retailers to halt their continued marketing of e-liquids resembling kid-friendly products like candy and cookies. Although the FDA had acted in May to limit the sale of such products, they were still being offered, with the offending labeling and advertising, by the 12 online retailers, several of whom were also cited for sales to minors.
The new enforcement actions mark the start of a “sustained campaign to monitor, penalize and prevent e-cigarette sales in convenience stores and other retail sites” to minors, Gottlieb said. He promised, too, that the FDA would be keeping close tabs on manufacturers’ own internet storefronts and distribution practices to detect sales to minors.
“The FDA has at its disposal both civil and criminal remedies to address demonstrated violations of the law,” he said.
The actions were greeted with defiance and derision from the vaping industry.
“Thousands of small-business vape shops across America do not engage in irresponsible marketing practices and don't even sell the products being targeted by the FDA with threatening letters,” said Gregory Conley, president of the American Vaping Assn., a nonprofit organization that advocates for what it calls sensible regulation.

Sunday, August 26, 2018

Inspired By Wine Uncorking Demo, Car Mechanic Invents Device For Difficult Childbirth

Whatever Happened To ... The Car Mechanic Who Invented A Device To Pop Out A Baby?

Jorge Odón, inventor of the Odón Device — described in a past NPR story as a tool for "popping a baby out like a cork."
Pearl Mak/NPR

Back in 2006, Jorge Odon was a 52-year-old mechanic who ran an automobile alignment and wheel balancing service center in Lanus, Argentina, a city just south of Buenos Aires. On the side, he liked to tinker around with car-related inventions in his garage.  One day, very different inspiration struck after watching two employees compete to get a loose cork out of the bottom of a wine bottle using a technique they'd seen on YouTube.

It's just a few steps: Insert the closed end of a plastic bag into a bottle, tilt the bottle until the cork is touching the bag and blow into the open end of the bag. The bag will inflate like a balloon and envelop the cork. Then give the plastic bag a hard tug. The bag and the cork should come out together.  And this random idea popped into Odon's head: He wondered, could you use a similar method to help women having complications in labor? A bag could wrap around the baby's head, and voila, out comes the kid.

“Many inventions get to the prototype stage, but that’s maybe 15 percent of what needs to be done,” Mr. Cohen said. “There’s finalizing the design for manufacture, quality control, the regulatory work and clinical studies. Absent that, they don’t see the light of day.”
So far, the device has been safety-tested only on 30 Argentine women, all of whom were in hospitals, had given birth before and were in normal labor.

The W.H.O. will now oversee tests on 100 more women in normal labor in ChinaIndiaand South Africa, and then on 170 women in obstructed labor.

Odon device for instrumental vaginal deliveries: results of a medical device pilot clinical study

Feasibility and safety study of a new device (Odón device) for assisted vaginal deliveries: study protocol

Odon device for instrumental vaginal deliveries: results of a medical device pilot clinical study.


Of the 49 women enrolled, the Odon device was inserted successfully in 46 (93%), and successful Odon device delivery as defined above was achieved in 35 (71%) women. Vaginal, first and second degree perineal tears occurred in 29 (59%) women. Four women had cervical tears. No third or fourth degree perineal tears were observed. All neonates were born alive and vigorous. No adverse maternal or infant outcomes were observed at 6-weeks follow-up for all dyads, and at 1 year for the first 30 dyads.


Delivery using the Odon device is feasible. Observed genital tears could be due to the device or the process of delivery and assessment bias. Evaluating the effectiveness and safety of the further developed prototype of the BD Odon Device™ will require a randomized-controlled trial.

Friday, August 24, 2018

The Tapeworm of Health Care

When Amazon, Berkshire Hathaway, and JP Morgan (AmBerGan) announced their health care partnership, Berkshire CEO Warren Buffett declared “the ballooning costs of health care act as a hungry tapeworm on the American economy.”  He is right. Our broken system is infested with tapeworms. Tapeworms are parasites; they exploit their hosts, drain resources, and suck the life out of their prey. Unfortunately, Buffet failed to call attention to the tapeworms specifically; they are insurers, hospital conglomerates, pharmaceutical companies, and pharmacy benefit managers.
As health care costs continue to skyrocket, Americans increasingly find themselves struggling to make ends meet. Direct primary care (DPC) is a tapeworm-free medical concept whereby: 1) a periodic fee is charged for comprehensive primary care services; 2) the arrangement is free from billing through third parties; and, 3) if additional fees are charged, those are less than the monthly fee.  Depending on age, fees range between $60-150 per month. Patients gain direct access to their physician coupled with unprecedented levels of affordability.

DPC physicians provide protracted office visits, after-hours appointments for emergencies, and occasionally, even home visits. DPC practices can dispense chronic medications at wholesale prices, perform basic procedures in-office, and when outside testing is necessary, these physicians can negotiate discounted “cash” prices on behalf of their patients.  This model goes a long way toward restoring the sacred relationship between a patient and their physician. It is no wonder patients are leaving the health care system in droves.
The last obstacle facing expansion of the DPC practice model is their misclassification as an “insurance” product rather than a “health care” entity. Legislation, known as the Primary Care Enhancement Act, already exists to repair this mistake and has 29 cosponsors. H.R. 365/ S.R.1358 would allow for two things: 1) Taxpayers participating in a DPC arrangement may qualify for an HSA plan; and, 2) HSA funds could be used for monthly fees for a DPC arrangement. According to the Moran Company, this legislation is nearly “deficit neutral.”
Why has this legislation floundered? Because corporate interests, like those of the Amazon group and CVS-Aetna, have left Congress a little dazed and confused. Enter capitated primary care (CPC) from stage left, an entirely different medical practice model, where a pre-negotiated rate is paid monthly by a third party for unlimited primary care services. This model welcomes the third-party back with open arms.

To make things more confusing, the Centers for Medicare and Medicaid Services (CMS) jumped on the DPC bandwagon by introducing a “direct primary care prototype,” is anything but direct primary care. The CMS concept requires physician enrollment in Medicare and submission of patient data to receive capitated payments of $90 to 120 per month. This innovative model is certainly intriguing, but is another example of capitation, not DPC. Data on capitated payment for health care services is equivocal at best, an indication that cost containment is difficult to achieve with third party involvement.

Following CMS footsteps, the Amazon group hired Martin Levine, MD, a geriatrician formerly of Iora Health, a Boston-based CPC entity focused on providing comprehensive services for the over-65 crowd, indicating they may be intrigued by the CPC model as well. Corporate entities should not lose sight of the fact that Qliance and Turntable Health went bankrupt last year after offering team-based CPC services to the masses.
Tapeworms represent third parties who have ingratiated themselves into the patient-physician relationship in the interest of the almighty dollar. As the distance has grown between patients and physicians, costs have spiraled out of control. By inviting extra layers of bureaucracy, CMS and other corporations are essentially slapping lipstick on the tapeworm and trying to make CPC look as attractive as Direct Primary Care, but that is an illusion. Cost-containment can only be achieved by bringing the patient and physician in closer proximity and eliminating the tapeworm infestation currently sucking the life out of the health care system.
Niran S. Al-Agba is a pediatrician who blogs at MommyDoc. This article originally appeared in the Health Care Blog.

Medical board releases physician license alert app for patients

The Medical Board of California recently released its first mobile app, currently available on Apple iOS devices. The technology notifies patients about changes to their physician’s license status,

The Medical Board of California recently released its first mobile app, currently available on Apple iOS devices. The technology notifies patients about changes to their physician’s license status, rather than patients having to actively seek out that information.
Physician profiles have long been available to the public on the board’s website.  The new app will notify users when their physician’s license is updated or there are changes to the physician’s address, practice status, specialty, disciplinary actions and much more.
The California Medical Association (CMA) has long advocated for a comprehensive, effective and well-functioning regulatory process for physicians. CMA believes this new app will make it easier for patients to choose their health care practitioner.  It also has the potential to increase transparency and improve patient trust and quality of care.
For more information on the app, visit the board’s iOS App webpage.  Users can download the app by visiting the Apple Store and searching for “Medical Board of California.”  A version for Android devices will be available in the near future.
CMA encourages physicians to periodically check their profiles for accuracy and to advise the board of any corrections, especially their addresses of record.  The Board cautions physicians about using their home address as their address of record, however, because it becomes widely available on the Internet.

Medical board releases physician license alert app for patients:

Tuesday, August 14, 2018

How California hopes to halt the revolving door to the ER

The state budget that kicked in last month devotes more than $100 billion to Medi-Cal, California’s health system for the poor. The bulk of that money will be spent on a tiny fraction of patients. And although they’re in need of help, they’re not the sickest people.

Inappropriate use of the ER falls into two main categories, said Jacey Cooper, an assistant deputy director at the state Department of Health Care Services, which oversees Medi-Cal and the pilot programs. Some patients don’t need emergency care and use the ER like they’re visiting a friend. Some have a genuine emergency, often because they’ve delayed care of a problem or illness until it reached a crisis. At that point, it’s difficult to treat—and more expensive.

Many such patients are homeless, Cooper said. “They have no circle of support; they often have mental health issues or substance use problems.”
Cooper said some counties in the pilot program reach people as they’re released from jail, assigning them a care manager because they’re at high risk for homelessness, drug abuse and frequent use of the health system. And someplace a health professional in the ER to find and coordinate care for high users. It can be easy to identify them there, because personnel may greet them by name, she said.  
That was the case for   *******  , a former Illumination Foundation resident who now lives in Riverside. “I was in the ER all the time,” Miller says.   She’s sitting in the dining area of her small apartment, her perky Australian terrier-mix dog in her lap. She’s been sober for nine months—and counting. But in 2015 and 2016, she went to the ER regularly for episodes of severe depression, and for nerve pain so bad she couldn’t walk, which she attributed to drinking. She went several times after falls, which she said were due to lost consciousness after drug use.
“And one time I went to the ER just because I didn’t want to sleep on the street,” she says, laughing now. “I don’t remember what I told them was wrong with me. But I just wanted a bed to sleep in.”   Homelessness contributes greatly to unneeded ER visits.

Treatment of her physical and psychological problems, along with help obtaining county and state services after she transferred to an Illumination Foundation center, have helped turn her life around. She used to teach at community colleges and hopes to get back to the classroom soon.

How California hopes to halt the revolving door to the ER | CALmatters: More than half the state’s health care budget will be spent on just 5 percent of its patients—and they’re not the sickest people. Officials are staging an intervention.

Monday, August 13, 2018

Physician Practice Roundup—Doctors give patients 11 seconds before interrupting; first practice guidelines for Alzheimer’s disease and more news | FierceHealthcare

Doctors give patients 11 seconds before interrupting

A new study found that doctors give patients only an average of 11 seconds to explain the reason for their visit before interrupting them.
Researchers from the University of Florida conducted the study to explore clinical encounters between doctors and patients. The study found primary care doctors allowed more time than specialists for patients to talk, as specialists generally know the purpose of a patient visit.
“The results of our study suggest that we are far from achieving patient-centered care,” researchers said, adding multiple barriers include time constraints, limited education about patient communication skills or physician burnout. (Journal of General Internal Medicine study)

In a recent study reported in the New England Journal of Medicine, 

the following key points are explained.
The medical interview is a pillar of medicine. It allows patients and clinicians to build a relationship.1 Ideally, this process is inherently therapeutic, allowing the clinician to convey compassion, and be responsive to the needs of each patient.2,3 Eliciting and understanding the patient’s agenda enhances and facilitates patient-clinician communication.2,3 Agenda setting is a conversational strategy that allows clinicians and patients to negotiate and collaborate to clarify the concerns and expectations of both parties. This results in a constructive alliance that leads to focused, efficient, and patient-centered care.4,5 A review of the literature, evaluating communication and relationship skills, identified six studies in general clinical practice, in which setting the patient’s agenda enhanced communication efficiency.5 However, despite these potential benefits, the use of this communication skill in general clinical practice appears to be limited. In a landmark clinical communication study published in 1984, Beckman et al. found that in 69% of the visits to a primary care internal medicine practice, the physician interrupted the patient, with a mean time to interruption of 18 s.6 Fifteen years later, Marvel et al. found that physicians solicited the patient’s concern in 75% of primary care visits and interrupted this initial statement in a mean of 23 s.7 Similarly, Dyche et al. found in 2004 that in approximately 60% of general medical visits, the clinician inquired about the patient’s agenda, that only 26% of the patients completed their statement uninterrupted, and that the mean time to interruption was 16.5 s. In addition, failure to elicit the patients’ agenda was associated with a 24% reduction in the physician’s understanding of the main reasons for the consultation.8 Although the prevalence of agenda setting has been studied in general medicine clinics, the prevalence of agenda setting in specialty care remains relatively unexplored. One study evaluating psychiatric consultations found agenda inquiries in 90% of these visits, with 67% of these proceeding without interruption.9 These studies, performed decades apart, suggest that clinicians often fail to elicit the patient’s agenda and when they do, they promptly interrupt patients.
Patient-centeredness is considered an important dimension of health care quality. It describes a culture where a partnership among practitioners, patients, and their families is established to ensure medical decisions respect patients’ wants, needs, and preferences, and that patients have the education and support they require to make medical decisions and participate in their own care.10 Shared decision-making (SDM) is a process that enables patient-centeredness.2,11,12 Patients and clinicians, who engage in SDM, work together to understand the patient’s situation and determine the best course of action to address it. In this process, an important first step is for patients and clinicians to determine which problems require attention through collaborative conversations.13,14 Patient decision aids and conversation aids are tools that can support SDM. They often provide a summary of the clinical evidence regarding a medical decision and relevant clinical management options.13 A systematic review of 105 randomized trials of SDM tools found that they improved patient knowledge and risks perception, helped patients clarify their values, and increased the proportion of patients involved in medical decision-making.11 Although, these SDM tools, particularly conversation aids, are designed to support treatment and diagnostic conversations between patients and clinicians; their impact on other aspects of patient-centeredness, such as agenda setting, has not been studied directly. Clearly identifying the presence of alternatives to deal with a clinical situation is considered an important step for SDM, and agenda setting could be associated with this step. Kunneman et al. evaluated 100 encounters between rectal/breast cancer patients, and their clinicians and found that only in 3% of the encounters, the clinician set a treatment choice agenda.15 Moreover, in a secondary analysis of studies evaluating SDM, clinicians indicated a treatment choice agenda in 44% of the encounters without SDM tools versus 62% in those where SDM tools were used (p = .34).16
To our knowledge, there is no current assessment of the prevalence of agenda setting in general and specialty practice despite substantial changes to the clinical encounter and to the definition of high-quality medical care. For example, time constraints and the use of electronic medical records can hinder patient-clinician interaction. Patient-facing interactions (in contrast to computer-facing ones) account for about 50% of the clinical time, potentially limiting the opportunity for agenda setting conversations and promoting more frequent interruptions.1718,19 On the other hand, policymakers have emphasized the importance of patient-centeredness and of SDM in high-quality care, activities that may start from setting a patient-focused agenda.10,17,19
The objectives of this study were to determine the frequency of encounters in which clinicians elicited the patient’s agenda, the proportion and timing of interrupted answers, and the effect of SDM tools and clinical setting on these outcomes.
In comparison with previous literature,678 the proportion of medical encounters in our sample in which clinicians elicited the patient agenda was not better: 40 to 75% in the literature, 36% overall, and 50% in primary care in our sample. We found that interruptions occur extremely early in the patient’s discourse and that patients are given just a few seconds to tell their story. Previous studies have shown that when allowed to describe their concerns, most patients complete spontaneous talking in a mean of 92 s.31,32 Our estimate is much briefer perhaps because many completed statements correspond to patients indicating that they had no concerns. It is possible that the frequency of interruptions is not only dependent on physicians’ practices but also related to the complexity of each patient. Moreover, it can be argued that if done respectfully and with the patient’s best interest in mind, interruptions to the patient’s discourse may clarify or focus the conversation, and thus be beneficial to patients.33Yet, it seems rather unlikely that an interruption, even to clarify or focus, could be beneficial at such early stage in the encounter.34

Eleven Second Clock                     Ninety-Second Clock

Physician Practice Roundup—Doctors give patients 11 seconds before interrupting; first practice guidelines for Alzheimer’s disease and more news | FierceHealthcare: A new study found that doctors give patients only an average of 11 seconds to explain the reason for their visit before interrupting them, and more physician practice news.

Friday, August 10, 2018

Pathways To Success: A New Start For Medicare’s Accountable Care Organizations

For many years we have heard health care policymakers from both political parties opine about the need to move to a health care system that pays for the value of care delivered to patients, rather than the mere volume of services.  While disagreements may arise on how we get to value, the need for this transformation is not in dispute.
This need is born from the reality that our health care spending is growing at an unsustainable rate.  If we continue on our present path, by 2026 we will be spending one in every five dollars on health care.  This will crowd out other public funding priorities like public safety, infrastructure, national defense, and education. It will also strain small businesses, preventing them from investing in growth or creating new jobs.  And finally it will lead to higher premiums, copays, and deductibles that will hit every American’s household budget.
From the moment I became Administrator of the Centers for Medicare & Medicaid Services (CMS), I have been committed to using every tool at my disposal to move our health care system towards value-based care.  This is not only a priority for CMS, but under the leadership of Secretary Azar and President Trump, the entire administration is aligned towards achieving this goal.
To this end, over the past year CMS has been evaluating all existing value-based payment models in order to assess performance and identify opportunities for improvement.
One set of value-based payment models that CMS has been closely reviewing are initiatives involving Accountable Care Organizations (ACOs).  ACOs can provide a path away from fee-for-service medicine and represent one of the first and most widespread efforts to make value-based care a reality.  Many providers view participating in an ACO as an opportunity to deliver better care in a coordinated fashion, while focusing on patient outcomes instead of processes.
ACOs are made up of groups of health care providers that are accountable for the quality of care and total health care spending for their assigned patients.  This is typically understood to mean that an ACO shares in savings if it keeps total health care spending for its patients below its given target, but the ACO has to repay CMS if spending for its patients exceeds its target.
Despite their laudable aspirations, however, the reality is that most Medicare ACOs do not actually operate this way.  In this post I will unpack key features of Medicare’s ACO initiatives and provide an overview of CMS’s new proposal for the Medicare Shared Savings Program, called “Pathways to Success.”

History Of Medicare ACOs

The majority of Medicare’s ACOs (561 of all 649 Medicare ACOs in 2018) are in the Medicare Shared Savings Program (Shared Savings Program or “MSSP”), which was launched in 2012.  10.5 million beneficiaries in Fee-for-Service Medicare (of the 38 million total Fee-for-Service beneficiaries) are in a Shared Savings Program ACO.  The Shared Savings Program and requirements around it were established by law in the Affordable Care Act.  Multiple tracks currently exist in the program, with ACOs taking on varying amounts of risk based on their track.
In addition to the Shared Savings Program, the Center for Medicare and Medicaid Innovation (Innovation Center) has developed other ACO initiatives, including the Next Generation ACO Model and the Comprehensive ESRD Care Model, in which the remaining 88 of the 649 Medicare ACOs are participating in 2018.  ACOs in the Innovation Center’s models generally take on greater levels of risk than ACOs in the Shared Savings Program.
Within both the Shared Savings Program and the Innovation Center’s ACO models, ACOs can be composed of hospitals, physician practices, and/or other types of health care providers.   Medicare beneficiaries are generally assigned to an ACO based on whether they obtain primary care services from the ACO’s health care providers.  Beneficiaries are assigned if they get the plurality of their primary care services from health care providers that are in the ACO, or beneficiaries can voluntarily align with an ACO by designating a physician or other practitioner in the ACO as their primary clinician.  Beneficiaries may not always know whether they are assigned to an ACO, or how participating in an ACO may change their health care providers’ incentives.
Assignment to an ACO does not limit a fee-for-service beneficiary’s choice of health care providers – beneficiaries can still obtain care from any health care provider they choose.  Thus, an ACO’s health care providers typically do not provide all health care services for their assigned beneficiaries, but they are responsible for these beneficiaries’ total Medicare Part A (inpatient) and Part B (outpatient) spending and for quality outcomes.
In addition to Medicare ACOs, ACO arrangements also exist among private payers.

Are you lost yet ? Want more?

Upside-Only Versus Two-Sided ACOs

At the end of each year, the total Medicare Part A and Part B spending for an ACO’s assigned beneficiaries is summed and compared to the benchmark level of spending that was calculated for the ACO.  The ACO’s benchmark is an estimate of what the total Medicare Part A and Part B spending is expected to be for the ACO’s assigned beneficiaries.
A growth rate is applied to an ACO’s benchmark to calculate its target for the next performance year.  In some cases, the benchmark growth rate is based on the rate of spending growth in the ACO’s local market.  Therefore, if the ACO reduces the rate of spending growth for its market, the ACO can be penalized as the growth rate for its benchmark would also decrease.  That is, the ACO would be held to a lower target in the next year than it would have been held to if it had not decreased spending in its local market.
If spending for the ACO’s beneficiaries is below the benchmark by at least the applicable minimum savings rate, and if the ACO also meets certain quality thresholds, then the ACO receives a portion of the difference between actual spending and the benchmark as a shared savings payment.  Although ACOs have a financial incentive to keep spending down while meeting quality thresholds, a beneficiary who is assigned to an ACO does not share in those savings.
If spending for the ACO’s beneficiaries is above the benchmark, then what happens next differs between the two different categories of ACO tracks.  ACOs in “two-sided” tracks with spending that exceeds the applicable minimum loss rate have to pay CMS back some or all of the difference, but ACOs in “upside-only” tracks are not accountable for paying CMS back any of the difference.
The majority of Medicare’s ACOs – 460 of the 561 or 82% of Shared Savings Program ACOs in 2018 – are in the upside-only “Track 1” of the Shared Savings Program, meaning that they share in savings but do not share in losses.  Currently, ACOs are allowed to remain in the one-sided track for up to six years. 
All ACOs, including those in upside-only tracks, have access to waivers of certain federal requirements.  These include waivers of specific fraud and abuse laws, including the physician self-referral law and the Federal Anti-Kickback Statute.  The Next Generation ACO Model provides physicians and practitioners in participating ACOs with waivers from current statutory requirements to allow them to bill for certain telehealth services, as an opportunity to provide high-quality services at a low cost.  However, flexibility to bill for telehealth is limited in the Shared Savings Program.

Please stop here if you are having any of the following symptoms.
Nausea, vomiting, diarrhea, double vision, confusion, vertigo, intense stomach pains, tingling in your fingers and/or prolonged erections.  If you are not having any of these symptoms, please read on.