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CORPORATE
MEDICINE

cine? Maybe! Certainly, cutting physician pay when the physician which model a physician decides to pursue. The objective is to im-
community does not agree and adopt vbC, as well as other laws prove the health outcomes of patients (demonstrated by objective
that interfere with the practice of medicine, is a more egregious ex- outcomes such as lowering the HgbA1c below nine (9) as an exam-
ample of diminishing physicians’ autonomy regarding their practice. ple and identified by (HEdIS) and to reduce the overall cost of a
As almost every politician has come to realize (as they tinker with population of patients assigned to a physician practice.
the healthcare system), healthcare is complicated. There may be a CMS has allowed physician practices to join an Accountable Care
place for Corporate America to involve itself in the management Organization (ACO) and to participate in a Medicare Shared Savings
of healthcare, but physicians need to be at the center of such Program (MSSP). Much like the name suggests, CMS will share
changes. The beauty of the U.S. capitalistic system is that it provides some of the savings of a Medicare population assigned to the prac-
choices; choices for physicians, payors, patients and employers. The tice if savings and improved patient outcomes are achieved. There
market can accommodate an extensive variety of solutions by of- are typically two components to this program;
fering physicians options as to how to practice medicine, while at 1. Reduce the overall costs associated with the population of pa-
the same time allowing physicians to maintain autonomy over their tients assigned to a physician, and
practice. However, autonomy is the key for physicians. Physicians 2. Improve the objective (HEdIS & NCQA) outcomes of the pa-
do not want bureaucrats telling them how to practice medicine. tients assigned to the practice in several defined metrics.
The state of Texas has revised the prohibition of CPOM (Texas
Administrative Code Title 22, Part 9, Chapter 177, Subchapter d, To the extent the practice can achieve such results, they will re-
Rule §177.17) and has allowed physicians to be an employee of a ceive additional funding from CMS via the ACO (roughly 18
hospital. Not every hospital in Texas can hire a physician, though months after they start the program). To participate in the MSSP
the list is growing; and for many physicians, being employed is an program, the practice MUST join an ACO. The ACO will often
appropriate strategy. For others, it is not. but there are choices! Pro- manage various aspects of the coordination of care for the benefit
viding options to physicians will be seen by some as essential, while of the physician and the patient. depending upon which ACO the
for others it is viewed as a continual erosion of their independence. physician joins, the ACO will participate in a portion of the shared
The challenge for the remaining independent physicians is how savings in order to help pay their administrative costs. And since
they compete effectively with the corporate-owned provider com- the amount of money that CMS determines is earned depends on
munity that controls more financial resources than do physicians. all of the physicians in an ACO, some due diligence is required by
Can the independent physician remain independent while Corporate the individual physician. If a few physicians are not actively manag-
America continues to provide a plethora of technology and re- ing their population of patients and the costs are driven up, as a re-
sources to the physicians they employ? Following are some solutions sult, then every physician in the ACO will suffer financially.
for independent physicians in the area of value-based-Care. (vbC) The financial performance is based on both the individual physi-
There is a big push by CMS and the States to move value-based cian, the performance of the group of physicians in the ACO, and
Care. The question is to whom the value inures. The vbC premise the amount of money used by the ACO for administration. The fi-
is that if physicians take on more risk for the outcomes of patients nancial upside or downside risk also plays a role and depends upon
as opposed to obtaining a simple fee for service (FFS), physicians which model of the MSSP the physician practice engages. The
are more likely to improve the result of the patient. Presumably, this model the physician practice is engaged in depends upon the con-
is done by monitoring the patient and ensuring the patient receives tracting entity, which is usually the ACO. Thus, the first question to
timely and appropriate care which produces better outcomes for ask yourself is how much risk are you willing to accept? Once that
the patient. Most physicians already strive to assure that patients re- question is answered, then the physician should find an ACO that
ceive the best care to deliver the best result. However, there has participates in the level of risk sought by the physician practice.
been quite a variety of outcomes from practice to practice. vbC The level of risk can range from shared savings with no down-
provides financial incentives for physicians to adopt the best prac- side risk, to full-risk being responsible for downside risk. If the
tices to achieve better outcomes. And often, independent physicians physician is in an ACO that fails to lower costs, CMS may deter-
can work in concert with Accountable Care Organizations (ACOs) mine the ACO, and the contracting physicians, are accountable
to achieve the necessary results without investing in the framework for the loss proportioned by the number of patients assigned to
and structure it takes to achieve such improved patient outcomes. the practice. depending upon the size of the practice, the upside
How does vbC work? There are several levels of vbC where potential can be in the millions of dollars. Contrarily, the down-
physicians can participate. The objective is the same regardless of side risk can be in the millions of dollars. Therefore, understand-

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