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Tampa Bay doctors preparing to cross a new frontier of care

Allergist Mona Mangat measures the results of an allergy skin test on the back of patient Cara Vavolotis. Mangat, a solo practitioner in private practice at Bay Area Allergy and Asthma, thinks ACOs could help provide better care at reduced costs.

CHERIE DIEZ | Times

Allergist Mona Mangat measures the results of an allergy skin test on the back of patient Cara Vavolotis. Mangat, a solo practitioner in private practice at Bay Area Allergy and Asthma, thinks ACOs could help provide better care at reduced costs.

Over pizza and PowerPoint slides, doctors huddled with an attorney last month in Clearwater seeking answers to this question: Should I sell my practice?

Then last week, hundreds of Hillsborough County doctors received an e-mail urging them not to panic and not to sign away their independence.

Why the scramble?

The government wants to encourage doctors to join a new kind of care organization that could redefine the practice of medicine. Inspired by leaders such as the Mayo Clinic, these new groups have the ambitious goal of improving the quality of health care and eventually cutting costs. But just how they would work in communities such as Tampa Bay hasn't been fully defined.

This new approach would get its start next year, in the Medicare program, though providers are not required to participate. Details of how they would work are expected in the coming weeks. But doctors, hospitals and insurers already are jockeying for position, eager not to get left behind.

Here's how it's envisioned: Imagine visiting your primary care doctor and instantly connecting to a seamless network of specialists and providers that coordinate your checkups, hospital visits and even home health care.

Working in large groups, with financial incentives to keep patients as healthy as possible, doctors could afford to invest in healthy basics such as nutrition counseling. No longer would your doctors order duplicative tests or prescribe medications in harmful combinations, because they weren't talking to each other.

But the scheme has plenty of critics, who say it's unrealistic and could inspire doctors to skimp on care in order to save money. Yet even skeptics admit the concept already is blazing major changes, hastening the trend toward hospitals buying out doctors in private practices, and large practices swallowing up independents.

Solo practices may not survive, experts say, a daunting prospect for doctors in small offices who provide most of the nation's care — and the patients who rely on them.

"The patients are in the middle," said Dr. David Weiland, an internist and president of the Pinellas County Medical Association, which organized the after-hours pizza and legal session.

While many physicians are worried about strategic alignments and financial stability, he believes those that stay focused on patient care will come out fine.

"What people are trying to do is guess what the future holds," he said.

•••

Driving the buzz is a dull-sounding acronym — ACOs, or Accountable Care Organizations — given to this new health care model.

The concept earned a place in the health care reform law for its promise to wean the country from the current payment system that rewards doctors for ordering up lots of tests and procedures.

But no matter what happens to President Barack Obama's signature legislation, many expect the model to remain a potent force in health care, eventually affecting private insurers as well as Medicare patients. That's because even most opponents of the president's plan agree health care costs too much.

So Tampa Bay area doctors, hospitals and other players are preparing for change but can't be certain how it will look.

After the Pinellas session, an emergency room physician asked the attorney for advice. He's in a practice of three doctors but is looking at joining a larger group. Should ACO's weigh into his decision?

The lawyer's advice: Get ready, but don't commit yet.

"It could literally become a system where there is no such thing as a solo provider anymore," said Michael Igel, a health care attorney with Trenam Kemker. "But it's difficult to advise anybody, when we don't have any answers right now."

The doctors at his presentation also talked about rumors that the BayCare Health System, which owns 10 local hospitals, is trying to acquire Suncoast Medical Clinic, a multispecialty practice in St. Petersburg. BayCare won't talk about any deal publicly; Suncoast acknowledges the two parties have been talking.

After hearing local doctors already are being asked to join ACOs run by hospitals, the president of the Hillsborough County Medical Association sent an e-mail to members warning them to "not panic by signing a contract regarding this issue.''

"Who's holding the reins — that's where this has become a financial and also really a power struggle," said Dr. Kenneth Louis, a neurosurgeon and association president.

ACOs would be large — each would need to accommodate the primary care needs of at least 5,000 Medicare patients.

Some observers expect that groups may one day receive a lump sum for each patient. If less is actually spent, the ACO would keep a share of the savings, but they could also see more financial risk.

Some doctors, already familiar with the hassles of having bureaucrats dictate care, are eager to be in control of decisions. But even they question the possibility for bias in the system.

"It could be really problematic ethically to know that the less you do, the more you make," said Dr. Madelyn Butler, a Tampa ob-gyn in private practice, who thinks many ACOs could end up losing money and fail.

She's also the president of the Florida Medical Association, which is looking into forming doctor-run ACOs. But such collaborations would require doctors to come together, share responsibility for patients and give up some independence — all things many practitioners historically have spurned.

•••

Allergist Mona Mangat doesn't know where she will fit into the new order. She's the only doctor at her St. Petersburg practice, Bay Area Allergy and Asthma, doesn't have hospital privileges and rarely works with other physicians.

At least in theory, she likes the notion of large networks.

"Because they offer a hope of maintaining some cost control and better care to patients, it might behoove me to join them," said Mangat. But, she added, the notion of bonuses for quality "sounds kind of pie in the sky to me."

Still, Mangat is overwhelmed by the thought of starting an ACO, even though her husband, a radiologist, thinks doctors could benefit financially.

Across the nation, about 80 percent of doctors are practicing in groups of five or less, said Dr. Robert Brooks, a professor of medicine and public health at the University of South Florida.

Small practices don't have time or money to form new organizations. And they're less likely to be using electronic health records, a requirement for ACOs that will help share patient data and measure quality of care.

"How are you going to have an ACO if you a two- or three-member family medicine or pediatric practice in Sumter County?" he asked.

The situation also is unclear for big practices. In Largo, the Diagnostic Clinic, a multispecialty practice that includes about 80 doctors, is considering whether to become its own ACO.

"There's nothing inherently wrong with them. They push quality, push prevention," said Dr. Charles Campbell, the group's president and CEO. "But I would confess that we're sort of stuck, until we see the actual rules."

He expects dozens of ACOs will start up in the Tampa Bay area. "Hospitals are getting ready by buying doctors. Insurance companies are getting ready by talking to companies, seeing how many doctors they have lined up," he said.

But like the alphabet soup of models that have come before them, ACOs could go the way of HMOs and PPOs — only to be replaced by something else.

"We survived 40 years by adapting to whatever curve balls the government sent us," Campbell said of his practice. "And we'll adapt to whatever changes come down the road."

Contact Letitia Stein at lstein@sptimes.com, and Richard Martin at rmartin@sptimes.com.

What is an accountable care organization (ACO)?

It is a group of doctors and other health care providers that will be paid to care for a set group of Medicare beneficiaries, beginning in January 2012 as part of the federal health reform law. Prospective ACOs must have enough primary care physicians to serve at least 5,000 Medicare beneficiaries, and they must have systems in place for electronic medical records and for evaluating the quality of care. If the ACO meets certain quality standards, it can receive a share of any cost savings it achieves.

Why do they matter?

As envisioned, they will change the way the majority of Medicare beneficiaries receive their care. They will be assigned to receive the bulk of their primary care from an ACO. Enrollment would be invisible to patients, who would receive the same Medicare benefits and remain free to choose their health care providers. But doctors and healthcare experts say the model could one day be used for the rest of the population. Even if the health law fails in court, the ACO model is expected to live on due to the need to bring down costs and raise quality.

What are the advantages?

Doctors and health care providers will be encouraged to work together to improve patient health, while also reducing costs. While traditional fee-for-service Medicare creates incentives for doctors to test and treat more, ACOs will create financial incentives to limit unnecessary tests and treatments, while also encouraging prevention.

What are the drawbacks?

The cost-saving measures could backfire, creating incentives for doctors to not provide needed care for patients. It can also create challenges for solo practice or small group physician practices, which represent the bulk of medical practices in the U.S. The costs of serving large numbers of patients and electronic health record systems could compel many to join with large practices or hospitals.



What is an accountable care organization (ACO)?

It is a group of doctors and other health care providers that will be paid to care for a set group of Medicare beneficiaries, beginning in January 2012 as part of the federal health reform law. Prospective ACOs must have enough primary care physicians to serve at least 5,000 Medicare beneficiaries, and they must have systems in place for electronic medical records and for evaluating the quality of care. If the ACO meets certain quality standards, it can receive a share of any cost savings it achieves.

Why do they matter?

As envisioned, they will change the way the majority of Medicare beneficiaries receive their care. They will be assigned to receive the bulk of their primary care from an ACO. Enrollment would be invisible to patients, who would receive the same Medicare benefits and remain free to choose their health care providers. But doctors and healthcare experts say the model could one day be used for the rest of the population. Even if the health law fails in court, the ACO model is expected to live on due to the need to bring down costs and raise quality.

What are the advantages?

Doctors and health care providers will be encouraged to work together to improve patient health, while also reducing costs. While traditional fee-for-service Medicare creates incentives for doctors to test and treat more, ACOs will create financial incentives to limit unnecessary tests and treatments, while also encouraging prevention.

What are the drawbacks?

The cost-saving measures could backfire, creating incentives for doctors to not provide needed care for patients. It can also create challenges for solo practice or small group physician practices, which represent the bulk of medical practices in the U.S. The costs of serving large numbers of patients and electronic health record systems could compel many to join with large practices or hospitals.

Tampa Bay doctors preparing to cross a new frontier of care 02/05/11 [Last modified: Saturday, February 5, 2011 10:00pm]

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