Wednesday, March 11, 2015

Texas Blue Accountable Care Deal Puts Physician Offices in Charge


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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