Reprinted from THE AIS REPORT ON BLUE CROSS AND BLUE SHIELD PLANS,
a hard-hitting independent monthly newsletter on new products, market share,
strategies, conversions, financing, profitability and strategic alliances of
BC/BS plans. (Not affiliated with the Blue Cross and Blue Shield Association or
its member companies.)
By Steve
Davis, Managing Editor
March 2015 Volume
14 Issue 3
Blue Cross and Blue Shield of Texas
(BCBSTX), a division of Health Care Service Corp., struck a deal with the
nation’s largest physician group, the Texas Medical Association (TMA), in a new
incarnation of the accountable care organization (ACO) model, the two groups
said on Feb. 5.
The partnership, which incorporates
48,000 TMA physicians and more than 5 million BCBSTX members, is significant in
that it represents a break in the tradition of insurers partnering with ACOs
led by sizeable health systems, instead bringing tech-challenged independent
doctors into the fold of value-based care. In Texas, more than two-thirds of
doctors operate in small private practices, but the overall number of
independent physicians is declining. The number of physicians considering
selling their practice increased from 21% in 2013 to 24% in 2014, cloud-based
health care platform CareCloud reported in its 2014 Practice Profitability
Index And the number of physicians who wanted to remain independent fell from
60% to 53%.
While the venture, TMA PracticeEdge,
LLC, allows physicians to access some of the resources of a large insurer, it
also presents new technological hurdles. A health system generally is somewhat
contained, with limited locations and a pre-existing IT infrastructure.
PracticeEdge, by contrast, will try to unite thousands of independent practitioners
throughout Texas, who may or may not be participating in the program. Dan
McCoy, chief medical officer for BCBSTX, tells The AIS Report that
PracticeEdge will solicit bids from IT vendors that can solve the particular
challenges of incorporating so many independent practices across such a large
geographical area.
“Part of the early success of these
programs is going to depend on both educating and providing strategic resources
that teach physicians what’s necessary to create these programs, how to aggregate
enough critical mass within their community to deliver population health and
then finally an entity that can customize technology that will be useful to
that physician and employ that technology,” McCoy says.
Marianne Fazen, executive director of the
Dallas-Fort Worth Business Group on Health, says while she’s excited about the
potential for independent doctors, she’s concerned with how quality measures
will be tracked. If a patient comes in with back pain and the PracticeEdge
physician refers him to a non-participating radiology clinic, she says, that
puts a hole in the data.
“If that independent MRI or radiology
group isn’t connected into it, how would they coordinate care so that the next
time the patient needs something else, they don’t do another MRI?” she asks.
Price Tag Is Steep
But the fact that doctors will be able
to access these resources at all is a boon to the private physician community,
Fazen says, and price transparency tools will make them more cost-sensitive.
The complexity of the program is reflected in its steep start-up price tag,
which TMA President Austin King, M.D., estimates to be between $5 million and
$10 million.
The benefits will be worth it, King
says, because it returns to physicians control over tasks such as defining quality
indicators and deciding how to manage their high-risk populations.
“The problem with other systems is
either other people, insurance companies or the government defines what quality
is, and we feel physicians should be doing that,” King explains. Participation
is purely voluntary, and doctors can choose their level of commitment.
“PracticeEdge is really a services organization,” he adds. “A physician can
participate at several different levels; they can either take advantage of
office management systems, primarily which doctors that are specialists will
probably do, or go all the way up to a truly integrated model, which would be
like an ACO.”
Not all TMA members are thrilled with
the decision, however. A few doctors have expressed concern that the partnership
doesn’t help preserve physicians’ independence. King responded on TMA’s website
that the decline in private practices requires doctors to take steps to
“rewrite the history of health care.”
King said TMA would always retain the
majority stake in PracticeEdge, and that the Texas Blues Plan’s role is to
“bring the knowledge, technologies, and contracting expertise to help
physicians succeed in accountable care environments.”
“It will help physicians prove value.
No physician has to be a part of this, but it offers those who want to
participate a new path forward,” he said.
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