Q: Tell me about SCCIPA’s experience in taking on risk for managing the care of a population?
Lori Vatcher: Our 800 physicians cover all specialties and are affiliated with seven different hospitals in the county, which is located in the very populous Silicon Valley. We’ve been an IPA for 20-plus years and work within a fully delegated HMO model, meaning we take on full risk under global payments.
We know so much more now in terms of data; there is less risk on the institutional side. A lot more metrics are available for performance improvement plans, and we are more knowledgeable about our population’s health and risk.
Q: The Patient Protection and Affordable Care Act establishes a Medicare program for accountable care organizations, which will be responsible for the care of a certain population. As SCCIPA has experience in this type of care management, has it taken any steps to develop a formal ACO?
LV: I don’t know that we’ve ‘developed’ an ACO, but we do meet all the criteria for a level 3 ACO by virtue of the fact that we’ve been managing a very distinct population for 15 to 20 years. [Editor’s note: While the PPACA does not define levels for ACOs, the idea has been proposed by various health policy analysts]. We haven’t determined a lot of specifics yet, though, such as what the compensation model would be or how we’d manage, track and report measures within this program. We are just in the discussion phases, which is probably the same as the majority of the healthcare community. [Editor’s note: CMS has yet to release regulations on ACOs, but they are expected by the end of the year]. I remember when we started first hearing about ACOs. Those of us in managed care thought, ‘Oh, that’s what they’re going to call us now.’ Ultimately, the goal or the intent behind the ACO is clinical integration, and we’ve been working to create true clinical integration all along.
Q: What do you anticipate as the biggest challenges for your ACO, assuming you do move ahead with developing one?
LV: For many, I think it will be managing the infrastructure and technical tools. We are in a fortunate position, because we have 100-percent adoption of software throughout the IPA. We can share information with hospitals and vice a versa. We’ve created a truly clinically integrated sharing model. Another challenge, or rather best practice, is going to be not focusing on the dollar. To chase the dollar without a clear path for clinical integration is a mistake. If we get wrapped up in compensation and payment method before we get wrapped up in intent and goals, we won’t be successful. Focus first on the intent, then look at the reality of the costs.
Q: In markets with large physician groups and IPAs, it is possible and perhaps likely that these groups, rather than hospitals, will lead ACO development. As a result, there has been talk among the hospital community that the more expensive hospitals could get shut out of ACOs due to focus on driving down costs. Any thoughts on this?
LV: We have good relationships with our hospitals, not a vendor relationship. Our physicians manage a very large population, and each hospital plays a unique role in that. The diversity of our hospitals matches the diversity of the populations we manage. We have no plans to in any way hurt or put any hospital in our county at risk. Rather, we see it as an opportunity to work together to map out ideas and work on models to improve care and efficiency.
Q: SCCIPA has been managing care for years. However, to many hospitals, managing care is a whole new ballgame. For those without an integrated and aligned medical staff, success in an ACO could be extremely challenging. Are these hospitals doomed?
LV: A lot of groups or hospitals may be at square one [when it comes to managing population health]. They may either play or sit on the fence. Some may wait and see what the risks are. I don’t think [not participating in the program] is a game changer.
Q: The goals of an ACO are similar to the goals your organization has had for many years in terms of managing population health. Are you excited to see this model expand?
LV: The opportunities to manage population health have thus far been unique to HMOs. I think the move toward this on a wider scale could start to break down some of the stigma attached to HMOs, which is nice. There are a lot of really great things the HMO environment provides, such as prevention and wellness, the focus on managing chronic diseases and pay-for-performance metrics. Expanding this outside HMO patients will benefit a greater portion of the population.
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