Massive Medical Network Should Help Ease Medicare Transition

Lilo H. Stainton | May 18, 2016 | Health Care
A practice transformation network with some 11,000 physicians is being set up to deal with changes in how Medicare pays doctors for services

elderly wheelchair
Doctors and other healthcare providers across the nation have been bracing for enormous changes to the way they are paid by Medicare to treat seniors, as the federal government shifts to a system that rewards quality instead of quantity.

In the Garden State this transition could be tempered by the work of a new peer-exchange physician group that was formed to identify best practices and help build a unified system of effective quality metrics.

The New Jersey Health Care Quality Institute joined the New Jersey Innovation Institute Tuesday to announce a partnership to develop a practice transformation network over the next three and a half years. The Innovation Institute, a corporation connected with the New Jersey Institute of Technology, received a $50 million federal grant last fall when it was selected as one of 29 sites nationwide to organize such a network.

The peer-network program is one of several efforts the federal government has launched to help doctors, hospitals and other healthcare providers cope with an avalanche of changes in the way they get paid to treat patients. It results from a 2015 law that calls for an overhaul to the Medicare payment system, but also reflects the goals of the 2010 Affordable Care Act, which –among other things — was designed to keep patients healthy and reduce overall healthcare costs.

Earlier this month the Centers for Medicare and Medicaid Services proposed two payment systems that would tie Medicare reimbursements to specific quality benchmarks or positive patient outcomes, both significant departures from the current fee-for-service model that pays doctors for each treatment they provide. The regulations, open for comment until late June, are expected to be adopted this fall.

“This is not something that is going away,” said Linda Schwimmer, president and CEO of the Health Care Institute. “This is the future of how we are paying for medical care in America.”

Tomas Gregorio, senior executive director of healthcare systems innovation at NJII, said doctors are overwhelmed by the changing landscape and the patchwork of new requests from government payers, like Medicare and Medicaid, as well as private insurance companies, for data on quality patient outcomes.

“They have so many initiatives they have to be a part of,” he said. “We need to create that one-stop shop.”

[related]The practice transformation network will directly involve 11,500 doctors, a mix of primary-care providers and specialists; these physicians must agree to share clinical data and participate in group discussions designed to tease out how providers can best meet quality metrics, Schwimmer explained. The new CMS regulations reward hospitals that reduce readmission rates and infection rates, for example, and penalize doctors when patients miss follow-up appointments or don’t take their medications.

NJII has already recruited thousands of doctors and the Health Care Quality Institute will help pull in additional participants and connect the group with other industry leaders, she added. The network also hopes to learn from Accountable Care Organizations, provider groups set up to focus on quality outcomes, and private insurance companies about the value-based metrics they are using in an effort to identify a consistent set of quality measurements for all patients, regardless of who is paying for their care.

In October, network members will also start to spread the gospel of their findings, and Schwimmer said the New Jersey Academy of Family Physicians will lead much of the on-the-ground work. Transformation coaches will be dispatched to help individual practices provide care that meets these metrics, and learning groups, conferences, and webinars will help disseminate the information to providers across New Jersey and beyond. Each of the 29 project sites is connected through various professional networks to colleagues nationwide, she noted.

Gregorio also envisions a web portal that would allow physicians to enter quality clinical data once that could then be automatically shared with all payers who require such metrics.

“We’re building that gateway to allow for that integration to happen and the reporting that these doctors are going to do for the rest of their lives,” he said.

While Patient Transformation Networks are fairly new, other efforts to bend the cost curve by rewarding quality have already had a positive impact. According to Sean Cavanaugh, who leads the Medicare program at the Centers for Medicare and Medicaid Services, these initiatives are already saving money and keeping patients healthier.

Medicare, which covers some 55 million seniors, cost the federal government almost $600 billion in 2014 and that figure will only rise as more baby boomers become eligible. But Cavanaugh told industry officials gathered for the Health Care Quality Institute’s spring conference earlier this month that, based in part on programs to improve value, the cost projection for 2020 is already $200 billion less than experts anticipated six years ago, when the ACA was approved.