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In a land of crazy costs, these docs say hold us accountable

by in DoctorsACO
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1387

BOYNTON BEACH — 

Horror stories of medical costs gone wild abound in South Florida, such as a $40,000 list of charges for a two-day hospital stay to check out a Boynton Beach man’s muscle bruise. His wife called that “ridiculous.”

But 29 groups of doctors across the country have received bonuses for lowering costs to taxpayers while keeping patients happy — and two based in Palm Beach County accounted for one in eight dollars nationally in savings shared with Medicare.

 Palm Beach Accountable Care Organization in Palm Springs and Accountable Care Options in Boynton Beach say they saved taxpayers more than $30 million combined last year. They split the savings with Medicare, reaping more than $15 million of the $126 million in bonuses issued nationally under an Affordable Care Act program.

“It’s not difficult to save money,” said Palm Beach ACO chairman Arthur Hansen. “It’s difficult to save money with quality.”

The government tracks Medicare spending for particular patients, and if it goes down compared to past years — and the care meets standards for quality and patient satisfaction — then the doctor groups share in the savings.

Not everyone buys that this will work on a large scale, and statistics suggest it is not easy to pull off. Slightly less than half the 114 accountable care organizations formed in 2012 managed any savings after a year and about a quarter got bonuses for significant savings.

Doctors with the Palm Beach County groups say it can work — though it often means providing a lot more attention to patients, not less, at the primary-care level, in an effort to head off more expensive care like a hospital stay later.

Take a 68-year-old diabetic patient, said Francisco Perez-Mesa, a doctor with the Boynton Beach-based group. Primary-care doctors might increase her normal office visits, emphasize prevention or lifestyle changes, or even see her several times in a week — if it avoids, say, a trip to the hospital for an ulcer on her leg.

“It’s a total change in approach,” Perez-Mesa said. “The primary care physician is rewarded for looking past the patient’s immediate issue and aggressively addressing all of the patients’ chronic conditions. This, combined with early screening, prevention and education can result in significant savings to Medicare and performance bonuses to the physician.”

Officials with Palm Beach ACO, which has about 250 doctors including a number of specialists serving 34,000 patients, say they are not aware of any doctor group in the country that achieved higher savings in total dollars — $22 million over a year.

Affordable Care Options, with 30 primary-care doctors serving 6,800 patients, said its savings per patient is the highest it knows about.

Federal officials said they could not confirm savings numbers for individual organizations, though more information may be available later in the year on a program that has grown to 338 ACOs nationwide.

“These ACOs are showing promising initial results and are providing insights as to how to improve and reform our country’s health care system,” said Centers for Medicare & Medicaid Services spokesman Alper Ozinal.

Accountable-care organizations of various kinds serve about 4 million of 50 million Medicare beneficiaries, according to published reports. Supporters see them as the wave of the future as the country wrestles with health costs that threaten to overwhelm the rest of the budget if not contained. Florida has about 3.5 million people on Medicare, the most of any large state in proportion to its population and second in absolute numbers only to California’s 5 million.

Skeptics are not so sure. The plan is based on assumptions that “aren’t realistic” about behavior by doctors, patients and others, two Harvard professors and a research fellow wrote last year in the Wall Street Journal. For example, accountable-care organizations must invest a lot of money in setting up for this system, but many may find themselves on the hook for patients who don’t comply with recommended treatment or lifestyle changes, warned Clayton Christensen, Jeffrey Flier and Vineeta Vijayaraghavan.

Even if the 32 most advanced accountable care groups achieved their goals, the Congresssional Budget Office estimated the savings would be about $1 billion over five years — a small amount in a total Medicare budget of $468 billion, they wrote.

Still, others see reason for optimism and detect a real change in the culture. Hospitals and other providers might not necessarily love accountable-care initiatives if their revenues suffer, but there’s emerging evidence the program can be good for patients and taxpayers, said Accountable Care Options CEO Richard Lucibella.

“It would be all hype if I couldn’t prove it worked,” Lucibella said.”You either believe there’s fat in the system or you don’t. I’ve been in it since 1978, and there’s fat in the system.”

His group saved taxpayers more than $8 million and got a check for $4.2 million from the Centers for Medicare and Medicaid Services, he said.

If a patient with shortness of breath needs to go to the hospital, then he goes, said Mitchell Perelman, a doctor in the Boynton Beach-based group. But for every case that can be managed successfully at the primary-care level, it saves a hospitalization charge that likely starts at $10,000.

“We’re going to do as much as we can,” Perelman said. “We might bring that patient back every day for a week.”

The Palm Beach Accountable Care Organization in Palm Springs saved $22 million in Medicare funds and shared savings of $11 million, officials said. Some of the money goes to the doctors and part is reinvested in technology to coordinate care better, they said.

As for the risk patients might feel shortchanged or steered from expensive care, surveys of patient satisfaction are an essential part of the program — plus people can vote with their feet if they do not think they are getting good care, said Dr. Rohit Dandiya. He is a Palm Beach Gardens internist who is chairman of Palm Beach ACO’s executive committee.

“This county has very educated, successful, sophisticated patients,” Dandiya said. “They’re free to leave us if we don’t earn their trust.”

Federal officials “did a really good job supporting this,” said David Klebonis, the group’s chief information officer. For example, for the first time they provided ACOs data showing how many of the group’s patients made emergency-room visits, he said. That made doctors realize they did not know about many of these trips, some of which they concluded were not needed or led to expensive, duplicative testing. The doctor group made a concerted effort to coordinate care better with hospitals when patients do go there, Klebonis said.

Lou Morgenier, who describes himself as a developer of seven accountable care groups in Florida and the Southeast, said savings often come from reducing redundant tests or using independent imaging centers for scans, which can be significantly less expensive than those in hospitals, he said. The result is “better for Medicare and for patients,” Morgenier said.

Safeguards such as measuring quality of care and patient satisfaction are “essential” to make sure patients are getting a good deal, said Joseph Ouslander, professor and senior associate dean at Florida Atlantic University’s College of Medicine in Boca Raton.

But a big ACO advantage may lie in reducing “fragmented” care, he said. A fundamental problem with the traditional fee-for-service system is doctors, other health professionals and hospitals often have little incentive to work together, to avoid repeat hospitalizations or tests or to coordinate on treatments and prescriptions, he said: “I feel strongly that the ACO model has more potential upsides for Medicare beneficiaries than downsides.”

Don’t get Betty Morris of Boynton Beach started about hospital bills. She calls “ridiculous” a $39,684.02 listing of charges to check out her 89-year-old husband’s bruised groin muscle during a two-day hospital stay this year at JFK Medical Center in Atlantis.

He had a fall in the house and called 911, she said. Tests to make sure the injuries were not more severe might be understandable, she said, but the statement included a $4 aspirin, a $3 multivitamin tablet, a $115 statin pill and plenty of pricey hours under observation— all for what turned out to be a bruised muscle.

The Morrises had questions about the $234.10 they were billed, but also wondered what kind of tab Medicare was getting. She said she has worked in doctors’ offices for years and has never seen “anything as outrageous as this bill.”

The hospital declined to comment on a patient’s specific case, but noted charges listed in a statement may not be what Medicare or the patient actually pay, said spokeswoman Lisa Gardi.

Such statements of charges are “sometimes used as a benchmark or reference list price to negotiate payment rates with insurers” but are “irrelevant to the vast majority of patients,” a Federation of American Hospitals blog last fall noted.

As for whether ACOs are a good idea, the hospital federation declined comment.

At least two groups of doctors in Palm Beach County think early returns are promising.


Accountable Care Organizations

*Accountable Care Organizations (ACOs) are groups of doctors and other health care providers who try to reduce costs while meeting standards for quality of care and patient satisfaction. Goals include avoiding duplicate or unnecessary services and reducing expensive hospital stays. Some split savings with Medicare.

*114 ACOS were formed in 2012

*54 cut costs last year

*29 shared savings with Medicare, splitting $126 million

*128 million net savings to Medicare

Source: Centers for Medicare & Medicaid Services

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Guest Wednesday, 21 February 2018

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