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The Integrated Model of Care: Examining the Hurdles To Achieving The Triple Aim (part 2) Print E-mail
Written by Michael Casanova, MBA   
Monday, 26 August 2013 00:00

Click HERE to view Part 1

Many underestimated the transformative impact meeting the Affordable Care Act's requirements for an integrated MOC would have on our healthcare system, as well as, fundamentally altering our national healthcare strategy, and our traditional models of care. Perhaps the greatest accelerant in this paradigm shift is our reimbursement formula moving rapidly away from volume, fee-for-service (FFS), toward value, shared savings, pay-for-performance (P4P) schemes. No one really knows the ultimate outcome for sure, but we are a nation of law and order and therefore must stay the course, and hope for the best, because we either all succeed or all fail together.

Yet another catalyst is the profound proliferation of ACO's and Medical Homes. To illustrate, less than a year ago there were only 25 ACO's nationally. Today, there are over 500 and counting, and Florida has the greatest number of ACO's. This represents a 95% increase in less than a year. One wonders if this is a harbinger for the demise of the solo-practitioner.

ACO's are defined as local healthcare organizations, with a related set of providers (at a minimum, primary care physicians, specialists, and hospitals) that agree to be held accountable for the cost, and quality of care delivered to a defined population for a specific benefit plan design. The knitting of ACO's is to reduce costs through enhanced preventative care, disease management, and quality through enhanced care coordination across the care and benefits continuum, and develop the necessary infrastructure, skills, and resources to meet the triple aim goals. ACO's that achieve their improved quality, satisfaction and cost reduction targets will receive what could be a substantial performance bonus, at least in theory.

As healthcare shifts to a more integrated model of care emphasizing more accountable care, technology will be an integral part of the formula for success.  A report published by the Institute for Health Technology Transformation (iHT2) entitled Population Health Management: A Roadmap for Provider-based Automation in a New Era of Healthcare details the different ways providers must embrace these varied technologies, and leverage them for increased efficiencies and improved outcomes. A potential game changer is the ability to utilize big data to drive innovations in care while applying evidence-based decision making in order to achieve the triple aim, and care that is patient-centered.

Part 3 will appear in the next issue of FHIweekly.

About the author:
Michael Casanova, FACHE, MHSA, MBA is a healthcare executive and consultant. Should you wish to opine or collaborate, please contact at or 305-606-3409.

Last Updated on Friday, 06 September 2013 08:06
HR Issues for the Small Business: Disciplinary policies Print E-mail
Written by   
Sunday, 25 August 2013 00:00

Let's face it, disciplining employees can be distasteful and this discomfort leads managers to follow the "let's ignore the problem and see if it goes away" course of action.  Not a good idea!  Every business should have a standardized written policy that covers performance standards and disciplinary steps.  In addition to having these policies, managers must make sure that they have been communicated to every employee and that they are being followed.  The best approach is to discuss the organization's disciplinary policies in the orientation of every new employee.  We encourage you to read our blog about orientation, an area that should not be overlooked.

Disciplinary policies sound negative to many managers, but their primary purpose should be to motivate and encourage your employees to perform at the acceptable standards you have set.  This often proves successful and the employment relationship is positive; however, sometimes a disciplinary plan must be established to deal with problem employees.  The plan, and associated policy should include coaching and giving the employee time to improve, a clear expectation of what will happen if no improvements are made and a consistent commitment by management to follow through with these steps.  All employees should be held to the same performance standards and policies must be applied to all members of your team with consistency.  Inconsistency in a disciplinary process accounts for a large percentage of the claims lodged with the EEOC and can result in hefty damages if they result in a lawsuit.  

Click here to read more.
The Integrated Model of Care: Examining the Hurdles To Achieving The Triple Aim (part 1) Print E-mail
Written by Michael Casanova, MBA   
Monday, 19 August 2013 08:50

Ladies and gentleman what I'm about to reveal in this article may be shocking to you, horrifying to some, and totally captivating to others.  Regardless of your reaction, everyone involved in the healthcare transaction has to answer the questions for themselves. We can no longer afford to sit quietly on the sideline doing nothing, because at the present time the U.S. healthcare system is economically unsustainable and on the verge of collapse. Moreover, the Accountable Care Act (ACA) has begun to mutate the very DNA of how healthcare is delivered and reimbursed in this country. Our objective here is to inform and suggest  a basic strategy to facilitate achievement of the triple aim. One thing we can all agree on is improved quality, increased satisfaction and reduced costs are generally good aspirations for our healthcare system.

Unbeknown to many there is a quiet, but dramatic transformation underway within the U.S. healthcare system. The most recent catalyst has been legislative changes.  These new laws come in the form of the Affordable Care Act (ACA) and one of its offspring, the Medicare Improvement Physician and Patient Act (MIPPA), and are driving the metamorphosis. The  fundamental building blocks, even our core beliefs are being challenged, and they have been found lacking. 

One bright spot where both pundits and critics agree is the removal of antiquated regulations that inhibit our system improving upon qualitative and quantitative performance metrics.    For example, our current system has a history of poor synchronization among government payers i.e., Medicare, Medicaid for dual eligibles enrollees causing expensive duplication of services, poor or no coordination of benefits and care, over/under payments, outdated and wholly inadequate benefit designs resulting in total market dissatisfaction, and worst of all suboptimal care outcomes. It is hoped that these and other improvements will help achieve the triple aim of improved healthcare quality, satisfaction, and cost reduction.

For decades a consensus has existed that our traditional allopathic model of care (MOC) is wholly inadequate to address the needs of a 21st century population, and worse financially unsustainable. Clearly, the system's biggest shortcoming is that it is 50 years old, outdated, and it’s the most expensive in the world. Sadly, expecting this system to address complex, multi-symptoms of chronically ill, frail, and elderly populations with ever increasing special needs (that it was never envisioned nor designed to address) is just wishful thinking. For instance, our current MOC does not account for the whole person. The model simply does not address all three life dimensions, i.e. Bio-Psy-Soc needs of the whole person, nor does it  effectively navigate or coordinate the continuum of care and benefits. Nor does it effectively orchestrate community resources like family and other nonpaid care givers and other support and social services. Nor does it address all these requirements under  a patient-centered paradigm with the focus of achieving improved satisfaction by all participants within the healthcare transaction, quality outcomes, and cost cuts for each defined population and thereby bend the per capita cost curve .

Part 2 will appear in the next issue of FHIweekly and posted to on August 26.

About the author: Michael Casanova, FACHE, MHSA, MBA is a healthcare executive and consultant. Should you wish to opine or collaborate please contact at or 305-606-3409.

Last Updated on Friday, 06 September 2013 08:12
Surgeon Weighs Pros and Cons: Joining vs. Maintaining Independence Print E-mail
Written by Steven Podnos MD, MBA, CFP   
Friday, 09 August 2013 00:00

Q & A with Dr. Podnos

    As I suspect is the case in many areas of the country, the hospitals in my local area have been acquiring medical practices hand over fist.  What are the implications for my independent specialty surgical practice?

A:    You are absolutely correct in your observations.  More than half of all physicians are now working for hospitals and other health care delivery systems.  The impetus to acquire practices has in a large part been a mixture of traditional and Obamacare associated motivations.   Traditionally, hospitals acquired physician practices to "capture" referrals.  The hospital could then benefit from the use of their operating rooms, diagnostic equipment and ambulatory surgery centers, often at higher reimbursement than independent physicians could obtain.  With the advent of Obamacare a few years ago, a new reason to acquire practices arose-the appearance of the accountable care organization (ACO).  In the new health care legislation, there is a strong reference towards both private insurance and government insurance (Medicare, Medicaid, VA) contracting with large ACOs that would provide health care on a per patient per month charge.  Much like the Clinton Health Reform legislation in the 1990's, the government in particular would benefit by laying off financial risk to the ACOs.

Hospitals today have rushed to build large medical groups, both on an inpatient and outpatient basis with which to be able to offer ACO contracts if Obamacare persists as written.  Efforts to provide an integrated health care delivery system in the 1990s mostly failed, as hospitals were unable to control physician behavior, and sought to maintain "referral friendly" relationships with unaffiliated physicians.  In addition, there was significant pushback by physicians and patients against the idea of large HMOs mandating care.

It appears that much has changed in the last two decades.  The government has pushed physicians into the arms of the hospitals by making it extremely difficult and expensive to run an independent practice.  The amount of paperwork and regulation for a small practice is daunting.  Think about how few (if any) physicians have moved to your area and set up an independent practice in the last few years.

So, physicians have mostly capitulated to being employed.  As the percentage of necessary physicians in a given area reaches a certain threshold, there is no effective competition.  Hospitals truly control their referrals both inward and outward, as well as the parameters of the care they offer.  Physicians that "don't play the game" can be replaced like a commodity product.  It is not so necessary to cultivate the referrals of the few remaining independent specialty physicians, as the hospital system now provides most of their referrals, inpatient and outpatient. Those independent specialists can be "asked" to join the employed physician ranks, or alternatively be replaced with a new hire.  Existing referral relationships by ER physicians, hospitalists, and primary care physicians employed by the hospital can all be shifted with "persuasion."

Who loses?  The patients have lost an independent advocate.  There are volumes to write about his, but we'll focus on your initial question.  Independent practices must consider whether they are likely to generate competitive hospital owned practices.  In some cases, it may be smarter to join the crowd.  Every geographic region is a little different, but it seems prudent to carefully examine the likelihood of future hospital owned physician growth for your practice on a pro-active basis.

Many concerns exist with being employed, including downward salary pressures in future years.  However, remaining independent will be no bed of roses either in a health care system that is spending more than it can.  Advantages of being employed includes higher reimbursement due to large scale contracting, as well as a diminution of the hassle of maintaining employees.  The guaranteed referral nature of large group practices is often a plus for surgical specialists as yourself.  I wish you the best of luck in our rapidly changing practice environment!

To learn more about the author, click HERE.

Last Updated on Monday, 12 August 2013 08:41
Physician-Hospital Integration Strategies Print E-mail
Written by Todd Rodriguez   
Sunday, 04 August 2013 00:00
As the implementation of the federal Affordable Care Act (ACA) continues in fits and starts, healthcare providers are scrambling to best position themselves to accommodate anticipated and developing payment models. Unfortunately no one really knows what these new payment models will look like or how they will ultimately work. It is apparent, however, that most of them (such as the accountable care organization model and bundled payment models) will require some level of increased clinical or legal integration between and among providers. Given the general state of confusion around payment reform, it is not surprising that many physicians and other providers are perplexed over how best to integrate.   Despite the common thinking among many physicians, integration does not necessarily mean that all physicians must be employed by hospitals. In fact, there are a number of potential integration strategies worth evaluating before making the leap to hospital employment. Some of these models include the following...


Source:  Physician Law Blog

Last Updated on Saturday, 24 August 2013 09:47
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