Monday, July 1, 2013

Medicaid Gap Looms In Obama Health Care Law

WASHINGTON — Nearly 2 in 3 uninsured low-income people who would qualify for subsidized coverage under President Barack Obama's health care law may be out of luck next year because their states have not expanded Medicaid.
An Associated Press analysis of figures from the Urban Institute finds a big coverage gap developing, with 9.7 million out of 15 million potentially eligible adults living in states that are refusing the expansion or are still undecided with time running short.
That a majority of the neediest people who could be helped by the law may instead remain uninsured is a predicament unforeseen by Obama and congressional Democrats who designed a sweeping extension of the social safety net. The law's historic promise of health insurance for nearly all U.S. residents would not be fulfilled as envisioned.
It's the direct consequence of last summer's Supreme Court decision that gave states the right to opt out of the Medicaid expansion, combined with unyielding resistance to the law from many Republican state lawmakers.
Expanding Medicaid is essential to Obama's two-part strategy for covering the uninsured.
Starting next year, middle-class people without job-based coverage will be able to get tax credits to help them buy private insurance. But the law calls for low-income people to enroll in Medicaid, expanded to accommodate a largely excluded group: adults with no children at home. Expanded Medicaid would cover about half the 25 million to 30 million people who could be helped by the law.
Twenty-three states and the District of Columbia have decided to accept the expansion, which is fully financed by Washington for the first three years and phases down gradually to a 90 percent federal share.
Among those are six states led by Republican governors. But the majority of low-income Americans newly eligible for Medicaid under the law live in states such as Texas, Florida and Georgia, where political opposition remains formidable.
"Because of the Supreme Court's decision making Medicaid expansion optional with the states, we're going to see some pretty significant differences in this country from one place to another in terms of access to health care and access to health insurance," said Gary Cohen, the Health and Human Services official overseeing the rollout of the law.
Speaking this past week at the Brookings Institution, Cohen added: "We are going to have an opportunity ... to take a look at that in a year and see what difference it made, the choices that were made at the political level to do one thing rather than another.
"And that's going to be a pretty profound difference and a pretty profound choice that we get to make every couple of years about what kind of country we want to be," Cohen continued.
Elections for state offices and Congress will be held next year.
Republican state lawmakers continue to oppose the expansion for several reasons. Many believe Medicaid has too many problems already. Others worry that Washington will renege on financing, and some believe health care is an individual responsibility, not a government obligation.
"It's an ideological principle piece to us on the conservative side," David Gowan, Arizona's Republican House majority leader said recently. "We don't believe in the expansion of Medicaid itself. ... We don't believe it's the government's duty to do that." Gov. Jan Brewer, also a Republican, succeeded in getting the Arizona Medicaid expansion through the Legislature but now faces the possibility of a referendum to block the law.
GOP health policy expert Gail Wilensky says she did not expect so many states to turn down the Medicaid expansion. While critical of some main features of the Affordable Care Act, Wilensky believes it's important for the country to get uninsured people covered.
"For me, it is really is quite surprising – particularly in the years with 100 percent federal funding – that so many states are saying `no,'" Wilensky said. "This is depriving the poorest of their citizens of an important benefit." Wilensky ran Medicare and Medicaid during the George H.W. Bush administration.
The AP's continuing check of the states finds 18 not expanding and nine where the outcome is still undecided. The biggest states where the expansion is stymied are Texas, with 1.7 million potentially eligible residents; Florida, with 1.3 million, and Georgia, with more than 680,000.
Still trying to find a path forward are Michigan and Ohio, whose Republican governors support the expansion but face legislative opposition. Each has more than one-half million potentially eligible residents, according to the Urban Institute, a public policy research center.
Health and Human Services Secretary Kathleen Sebelius says she hopes that holdouts will have a change of heart.
"The door is open," said Sebelius. "If a legislature decides to reconvene at the beginning of January, and change their law, then we would welcome them in."
There is no deadline for states to decide. Next year states will have an opportunity in each calendar quarter, and if they later want to drop out they can do that.
Low-income residents of states refusing the expansion will be exempted from tax penalties for being uninsured. Those penalties also take effect next year, when virtually everyone in the country will be required to have health insurance.
Medicaid already covers more than 60 million people, including many elderly nursing home residents, severely disabled people of any age and many low-income children and their mothers.
An earlier Urban Institute analysis of the expansion found that less than $100 billion in state spending could trigger nearly $1 trillion in federal dollars over a decade.
As originally designed, the expansion was supposed to cover households making up to 138 percent of the federal poverty level, about $15,860 for an individual or $32,500 for a family of four.
Under the law, Medicaid is the only coverage option for people below the poverty line, $11,490 for an individual, or $23,550 for a family of four. The poor cannot get subsidized private coverage in the new health insurance markets coming on line next year.
"This decision will have very real human costs for the adults who are going to remain uninsured and their families," said Genevieve Kenney, co-director of the Urban Institute's health policy center. "It seriously undermines the ability of the Affordable Care Act to substantially reduce the number of uninsured in this country, at least at the beginning."

University of Louisville Hospital settles false billing claims

By Associated Press
Posted: July 1, 2013 - 4:15 pm ET

University of Louisville (Ky.) Hospital has reached a $2.8 million settlement with the federal government to end allegations that it submitted false Medicare billing claims.

The agreement announced Monday covers a time span of Jan. 1, 2006, through Dec. 31, 2010.

University of Louisville Hospital operates a unit within the emergency department to address non-urgent care. The center, FirstCare, is staffed by University Medical Center-employed physician assistants and nurse practitioners under the direction of the Department of Emergency Medicine physicians.

According to the settlement, the salaries and benefits paid to FirstCare physician assistants and nurse practitioners were claimed on UMC cost reports filed with Medicare. At the same time, University Emergency Medicine Associates physicians treated the employees as their own and at times billing and collecting from Medicare for their professional services.

UMC disclosed in 2011 to federal prosecutors that it may have violated federal law.

U.S. Spends $16 Billion Every Year To Care For Elderly Prisoners

Forbes  |  By Matt StroudPosted:   |  Updated: 07/01/2013 6:32 pm EDT
It’s no surprise that a huge amount of cash is being spent in the United States on men and women who are aging into their 70s, 80s, and 90s while in prison. On Saturday, NBC News published a fascinating look into the costs and concerns related to this elderly population behind bars. From the report:
By the year 2030, there will be upward of 400,000 elderly prisoners — nearly a third of the projected total penal population
State and federal prisons spend an estimated $16 billion taxpayer dollars a year keeping elderly convicts in the clink…. Nearly a quarter of that price tag – roughly $3 billion taxpayer dollars annually – is devoted to providing health care to sick or drying prisoners.
Although prison budgets and balance sheets vary state-to-state, certain jurisdictions offer striking evidence of the immense cost of medical care for elderly prisoners:
* In Georgia, prisoners age 65 and older command an annual average medical care cost of $8,565 — a huge leap from the annual average of $961 for inmates under age 65, according to a report by the Human Rights Watch.
* In North Carolina, the price tag on medical care for elderly prisoners is four times higher than the cost of the same care for prisoners younger than 50, according to the ACLU report — an inequality that may expand as baby boomers behind bars grey.
* In Michigan, health care for inmates age 80 and older costs prisons as much as $40,000 per person, according to the Human Rights Watch report — nearly the cost of a year of private college tuition.
federal prisoners

Unfortunately, the story, much like the debate over many prison spending issues in this country, ends with a big shrug: The ACLU says elderly prisoners need to be paroled, while victims’ rights groups say parole would offend victims. The last line goes to the ACLU’s David Fathi, who says, “We can’t keep everyone locked up forever.”
Our shared history of incarceration rates in the U.S. over the last 40 years says otherwise. And unless there’s serious debate in this country over the value of permanent punishment versus the value of a criminal justice system addicted to incarceration, there’s not much that’s likely to change.

Compliance missteps could lead to False Claims Act liability

Jeremy R. MorrisAuthor page »
As the government continues to aggressively pursue claims against health care providers for violations of the False Claims Act, recent cases demonstrate the importance of a robust compliance program. Because False Claims Act liability can arise from underlying regulatory violations, it is necessary to detect potential regulatory issues as quickly as possible in order to limit exposure to potential false claims.
Take for example, the recent settlement of C.R. Bard, Inc. (Bard). In that case, Bard agreed to pay $48.26 million to resolve allegations that it caused false claims to be submitted to the Medicare program. The government claimed that Bard provided illegal remuneration to customers and physicians as an inducement to purchase Bard’s brachytherapy seeds used to treat prostate cancer. It was alleged that Bard provided certain rebates, conference fees, marketing assistance and/or free medical equipment to customers and physicians that used Bard’s seeds in the treatment of prostate cancer.
Similarly, ISTA Pharmaceuticals, Inc. (ISTA) agreed to pay $33.5 million to settle criminal and civil liability arising from the marketing, distribution and sale of its drug Xibrom. The allegations against ISTA included claims that ISTA violated the False Claims Act by providing illegal remuneration to physicians with the intent to induce those physicians to refer individuals to pharmacies to dispense its drug. The illegal remuneration took the form of monetary sponsorship payments to a non-profit group associated with a particular physician, a golf outing, a wine-tasting, paid consulting or speaker arrangements, and honoraria for participating in advisory meetings that were intended as marketing meetings.
In both of these cases, the government alleged that the remuneration the companies provided to certain physicians constituted violations of the Anti-Kickback Statute. Effectively, the government used violations of the Anti-Kickback Statute and other regulatory violations as a predicate to claim that the False Claims Act was also violated. The government claimed that submissions to federal health care programs following such regulatory violations “tainted” all transactions related to those regulatory violations, making them false claims.
Most, if not all hospitals now have significant financial relationships with many physicians. These relationships are heavily regulated. It is imperative that all payments made to physicians be scrutinized from a compliance perspective, as small mistakes involving otherwise permissible payments can lead to significant negative consequences. As these cases demonstrate, such mistakes regarding physician relationships can lead the government to pursue recoveries under the False Claims Act.
All hospitals should take notice of these cases, and many others like them, as they make evident that violations of federal health care regulations can have significant secondary consequences. One way hospitals can seek to avoid regulatory violations, and in turn, potential False Claims Act liability, is to establish a thorough compliance program that educates all hospital staff members regarding proper compliance behavior and uncovers any potential issues as early as possible so that those concerns can be addressed. By paying close attention to its compliance program, hospitals can avoid False Claims Act liability.

Kohll's pharmacy beefs up to handle Medicare diabetic supply contract

By Bob Glissmann and Janice Podsada / World-Herald staff writers

Changes in how Medicare pays for products used by people with diabetes have made David Kohll's life much busier.
Kohll, who co-owns Kohll's Pharmacy & Homecare in Omaha with his brother Justin, has hired 27 new workers and anticipates hiring more, installed 70 new phone lines and set aside 2,000 square feet for a call center to handle orders for diabetic testing strips.
Kohll's is one of 18 companies nationwide that have been awarded three-year Medicare contracts to provide diabetic supplies, including test strips, lancets (used to draw a small amount of blood for the test) and blood glucose monitors, through a new Medicare mail-order system.
Companies with contracts
A sampling of Nebraska companies awarded Medicare competitive bid contracts for medical equipment. Note that some operate under several different names. For the latest list and a list of supplies each carries, go to
>> Lincare Inc.
8310-8314 F St.
>> Focus Respiratory Inc.
10167 J St.
>> AHP-MHR Home Care/American Homepatient
5300 S. 73rd St., Bay 3
>> Apria Healthcare Inc. 
5505 F St.
>> Helget Home Care
8609 F St.
>> Kohlls Pharmacy & Homecare
3427 S. 84th St.
>> Option Care Enterprises/Walgreens Infusion Services
10924 John Galt Blvd.
>> Coram Alternate Site Services/Coram Specialty Infusion Services
11111 Mill Valley Road
>> KCI US 
5338 F St.
>> PSI Health Care
8656 F St.
>> Heartland Health Therapy Inc.
5061 S. 111th St.
>> Walmart Stores
10504 15th St.
>> United Seating and Mobility
5621 S. 50th St., Suite 4
Grand Island
>> Braden Partners/Science Pacific Pulmonary Service
723 N. Custer Ave.

Changes coming July 1
Medicare recipients with diabetes who get their diabetes supplies through the mail will be affected by a change going into effect July 1.
Q: What's the big change?
A: Until now, hundreds of mail-order companies could bill Medicare for the test strips, lancets and other supplies that diabetics use to measure and track their blood sugar. Under the new national program, Medicare patients can order from only 18 mail-order companies that won government contracts and will be subject to more oversight. (The change doesn't apply to Medicare Advantage patients.)
Check the list or by calling 800-MEDICARE. Some companies operate under multiple names.
Q: What if the new companies don't sell my brand?
A: Medicare's list shows different suppliers sell a mix of top-selling brands as well as generics. You're not required to change your existing monitor. But you may need to shop around or get a doctor's note that specifies you need a specific type, so plan ahead.
Q: What's the price difference?
A: Medicare has paid about $78 for 100 test strips and lancets, just over a month's supply for someone who tests his or her blood sugar three times a day. That rate was higher than other insurers typically pay. Starting July 1, that reimbursement will drop to about $22. The patient copay is 20 percent, so it will drop from about $15 to less than $5.
Q: What if I want to buy at my local drugstore instead?
A: Ask if it accepts “Medicare assignment,” meaning it has to honor the July 1 prices. Some large chains are reassuring customers that they're participating. But pharmacies that aren't enrolled in Medicare are allowed to charge patients more.
Source: The Associated Press
Kohll's, a family-owned business that opened in 1948, is the only Nebraska-based company to be awarded a national diabetic supply contract.
Kohll's bid was accepted, as were bids from companies in Arizona, California, Florida, Michigan, Missouri, North Carolina, Ohio and Virginia.
The diabetic supplies program — Medicare's first national program — goes into effect Monday, but sales already are picking up, said Laurie Dondelinger, the company's marketing director.

“We knew that there would be an increase — there's 4.5 million customers among 18 companies,” Dondelinger said.

The contract has also been a boon for the area's U.S. Postal Service, which Kohll's uses for deliveries. “A couple weeks ago we were mailing 30 packages a day, now it's up to 75 and it's expected to increase,” Dondelinger said
The diabetic supply program is one of several Medicare competitive bidding programs intended to save taxpayers nearly $26 billion over the next decade by cracking down on waste and fraud in the medical equipment industry.
A Medicare program that provides medical equipment also launches July 1, but for now is limited to 100 major metropolitan areas around the country, including Omaha-Council Bluffs, Wichita, Kan., Minneapolis, Chicago, St. Louis and major cities in other states. The program is scheduled to be available nationwide by 2016, under the 2003 Medicare Modernization Act.
Kohll's and other Nebraska medical equipment companies also are among those who won contracts to provide medical equipment, such as home oxygen gear, walkers, hospital beds and other supplies, to Medicare recipients.
Lincare Inc., Focus Respiratory Inc., AHP-MHR Home Care, Apria Homecare, PSI Health Care, and Helget Home Care were among the Omaha-area firms awarded Medicare medical equipment contracts.
Medicare recipients currently can order diabetic-related products from hundreds of suppliers, but prices can vary widely.
Kohll said diabetic test strips, which are used to test a person's blood-sugar levels, cost about $33 for a box of 50.
Under the government's mail- order program, the price for a box of test strips is set at $10.40, and Medicare pays 80 percent of that.
Medicare recipients who want to be reimbursed for diabetic supplies delivered to their home will have to use one of the 18 designated mail-order suppliers.
Patients still can opt to purchase diabetic supplies from their local drugstore, but to be reimbursed the pharmacy must honor Medicare's mail-order prices as payment in full. If the pharmacy doesn't participate, the recipient won't receive any reimbursement. As a result, people should check with their pharmacy to see if it accepts Medicare reimbursement as payment in full, agency officials say.
“Those who like the face-to-face interaction with the pharmacist have that choice,” said Jonathan Blum, Medicare deputy administrator. “We want to preserve both options.”
Critics of the competitive bidding programs, including People for Quality Care, a Waterloo, Iowa-based advocacy group, say the new diabetes and medical equipment programs will limit consumer choice, delay delivery and repair of beneficiaries' medical devices and force small medical equipment firms that cannot match prices offered by contract suppliers to cut staff or close their doors.
The group, which advocates for senior citizens and people with disabilities, said that 93 percent of all medical care providers will not be awarded contracts, resulting in the closure of more than 40 percent of those firms.
“Contract-winning providers are located many states away from beneficiaries and may not be experienced in selling and servicing the equipment they won a contract for,” the group said in a press release, citing a Kansas Medicare beneficiary who waited three months for his scooter to be repaired because none of the area's winning providers were capable of servicing his brand of scooter. The advocacy group and others are promoting an alternate system.
Medicare's competitive bidding program was piloted in nine cities, including the Kansas City metro area, beginning in 2011.
Helget Home Care in Omaha was among those chosen to provide certain types of medical equipment under Medicare's competitive bidding program. Owner Tom Victor said he's glad his bid was accepted but said he doesn't yet know the impact on his company.
“It's hard to forecast how this comes out. Some other organizations have grown rapidly and increased their volume,” said Victor, referring to medical equipment companies doing business in one of the nine metropolitan test areas.
The selection of certain suppliers, Victor said, may result in patients having to go from one firm to the next to get all the medical equipment they need.
“It's more of a hassle for patients,” he said. “It's saving some money but also costing some money in the meantime.”
Kohll's, a third-generation family business, was founded in 1948 by Louis and Leona Kohll. The couple opened their first drugstore and pharmacy, which had a soda fountain, at 29th and Leavenworth Streets. That location still exists today.
The pharmacy and medical supply chain operates eight stores in the Omaha area and a ninth in Malvern, Iowa. The company expanded its offerings to include medical equipment in the 1990s.
About 10 family members currently work part time or full time at Kohll's, including David and Justin's father, Marvin Kohll, who is in his 80s and works about three days a week.

For years, Kohll's has been delivering test strips to people who are homebound or live in assisted-living facilities.
Such deliveries will be prohibited under the program's rules, and that ban spurred Kohll to submit a bid.
“I thought, 'You know what? I'm going to aggressively bid on this thing because I don't want to lose my customers and my patients,' ” Kohll said.
He hopes the venture pays off.
Although the lower price he bid doesn't leave much of a profit margin, Kohll said, winning the bid has resulted in thousands more customers for Kohll's.
One group of pharmacists in Wisconsin, for example, is moving 8,000 of its customers to Kohll's because they want to connect to a pharmacy instead of a mail-order company, Kohll said. Kohll's is the only pharmacy-based company among the 18 firms that were awarded three-year diabetes mail-order contracts.
“If I do everything just right,” he said, “I'll end up nice and profitable. If I do something wrong, I can lose millions.”
But Kohll is happy he won the bid.
“It's a challenge. I love challenges. It's exciting. We're talking to people from all over the country.”
This report includes material from the Associated Press.

A Rap Sheet For Medicare’s Prescription Drug Program

by Tracy WeberCharles Ornstein and Jennifer LaFleur
ProPublica, July 1, 2013, 1:45 p.m.

A lot has happened since our investigation in May showed that Medicare wasn’t watching out for dangerous or fraudulent prescribing by doctors and others in its popular prescription drug program. In the past two weeks:
The inspector general has found fault with Part D’s oversight almost since its inception. Below are summaries of its most recent reports, as well as significant earlier ones.
Illegitimate prescriptions
Last Monday, the inspector general reported that Medicare paid for 417,000 prescriptions purportedly written by massage therapists, athletic trainers, interpreters and others who aren’t allowed to prescribe drugs. While just a small fraction of total drug spending in the program, it raises questions about how closely Medicare officials are tracking the validity of prescriptions or questioning those that appear suspicious.
High-prescribing doctors
On June 20, the inspector general cited more than 700 general-care physicians who wrote prescriptions for elderly and disabled patients in highly questionable and potentially harmful ways. They were very extreme outliers in one of several areas: prescriptions per patient, brand name drugs, painkillers and other addictive drugs or the number of pharmacies that dispensed their orders.
Scant Analysis
In January, the inspector general found that Medicare’s fraud integrity contractor did little to proactively analyze prescribing data for indications of fraud and abuse. Between April 2010 and March 2011, the contractor only referred 19 cases to law enforcement based on its proactive analysis of Part D data.
Questionable Pharmacy Billing
In May 2012, the inspector general identified more than 2,600 pharmacies with questionable billing practices. “Little information is currently available about Part D billing,” the report said. “There are no data about how pharmacies typically bill Part D, or about questionable billing. Identifying these data is an important first step in detecting potential fraud, waste, and abuse.”
Banned Prescribers
In December 2011, the inspector general identified $15.1 million in drugs paid by Medicare Part D from 2006 to 2008 that apparently had been prescribed by health professionals banned from the Medicare program. The report cited “inadequate internal controls” at the Centers for Medicare and Medicaid Services (CMS).
Inappropriate Drugs
In May 2011, the inspector general found that Medicare Part D had paid for antipsychotic prescriptions for elderly nursing home residents for uses not approved by the U.S. Food and Drug Administration. The drugs specifically carry a warning that they can increase the risk of death in patients with dementia. The inspector general recommended that Medicare require prescriptions to carry a diagnosis code to help flag drugs given for inappropriate reasons, but Medicare said no.
Invalid Prescribers
In June 2010, the inspector general found that $1.2 billion in drugs paid by Medicare in 2007 lacked valid identification for those who prescribed the drugs. “Without valid and accurate prescriber identifiers, CMS and its contractors have difficulty performing oversight functions, such as verifying the prescriber's licensing information, determining whether the prescriber has been the subject of disciplinary actions for inappropriate activities, or tracking potential overprescribing issues,” an inspector general official told Congress.

ACOs strike it hot in healthcare

John Andrews, Contributing writer
June 28, 2013
The hottest letters in healthcare right now are A, C and O. And while together they stand for accountable care organization, industry analysts say providers need to look beyond the acronym in their efforts to build a new business model.
Nick Sears, MD, chief medical officer for Atlanta-based MedAssets, understands that there is some confusion and trepidation among provider groups about how to start an ACO. As a veteran observer of industry trends over the past quarter-century, Sears realizes the magnitude of change that is being required of healthcare providers and the daunting task associated with making the necessary modifications.
“At this point, providers shouldn’t worry about what an ACO looks like, but instead focus on the building blocks that go into it,” Sears said. “Although it is part of the Affordable Care Act, which is currently under scrutiny in Congress, the intent of ACOs will continue even if parts of the ACA are stricken. So providers have to identify their risks in the whole value-based purchasing model because if they don’t they are in trouble.”
As the new healthcare model has emerged over the past couple of years, Jeremy Belinski, director of operations at MedAssets, has taken to call ACOs by another acronym – CIO, for clinically integrated organization. The description seems more apt for the machinations of putting groups together, he says.
“As we’ve dug into the process, we’ve found it is easy to form a legal entity, yet each group has its own model for doing things,” Belinski said. “But just because they’ve joined together doesn’t mean they can make it work. Making it operational has been a challenge. They have to get good at managing costs and aligning physicians, which is easier when you’re part of an organization. The challenge is to extend beyond the four walls of the hospital.”
Managing metrics
Ken Perez, director of healthcare policy for Emeryville, Calif.-based MedeAnalytics, has been studying the metrics associated with ACO configuration in both the Medicare and commercial insurance domains, developing a comprehensive report and a series of informative videos on the subject. His research found that ACO metrics can be divided into six categories: pediatric, ambulatory, prevention, acute care, outcomes, and utilization of services.
“As more ACOs become multi-payer, it is increasingly important to understand — for the sake of leverage and organizational alignment — the general themes and commonly used metrics used in ACO agreements,” Perez said. “This strategic understanding will help shape emerging best practices for successful ACOs.”
In discerning between commercial and Medicare ACOs, Perez found that commercial organizations place greater emphasis on areas of integration, pronounced cost reduction and resource utilization while Medicare ACOs are focused more on quality outcomes.
“There is a lot of variability between commercial and Medicare ACOs because of different programs and models and you have to choose what game you’re going to play,” he said. “The end game for the provider has got to be multi-payer, so whether you start with Medicare or commercial, you will have multiple payers, you must leverage costs across the board and implement a standardized level of care.”
The 9 C’s
“Medical Home” is another moniker associated with the ACO concept and while some see them as interchangeable, Tom Doerr, MD, does not. A general internal medicine practitioner who focuses on geriatric patients, Doerr also serves as director of innovation research for St. Louis-based Lumeris.
The difference between the Medical Home blueprint and a true ACO, he says, is that the Medical Home design does not go far enough in determining how care is delivered.
“There are nine key elements to care called the ‘9 C’s’ and the Medical Home only incorporates the first four elements,” Doerr said. “We architect how care is delivered at the physician practice level with workflows, metrics and behavioral strategies to convert to value-based delivery. The first four C’s are part of the primary care model, but they are not new. An accountable primary care model should include all nine elements.”
The 9 C’s as Doerr explains them are as follows: Contact with the healthcare system; Comprehensive care; Continuous care that is longitudinally focused; Care coordination; Credibility and trust with the physician; Collaborative learning between payers and providers; Cost effective care; Capacity expansion through technology; and Career satisfaction.
“Beyond the 9 C’s they need to have the collaborative payer model,” he said. “The collaborative payer model makes the payer an ally of the provider.”
Doerr appreciates the irony in his advocating alliances between two traditional adversaries, but maintains that a cooperative spirit can occur when each side sees mutual benefit.
“The national movement toward ACOs has legs and is gaining traction,” he said. “It is blending the role of payer and physician; both quality and cost. While some still aren’t comfortable with it, as the movement gains momentum, that resistance will drop.”