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Health Care Reform to Thrive

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Regardless of your answer and response to the question above, you will soon feel the effects of health care reform.

Health care reform is no longer being driven by the Affordable Care Act. Payment reform is now the driver that allows every primary care physician in the country to utilize care coordinators. Care coordination is transformational in the health care system. For the first time, patients have an advocate that helps them navigate the healthcare system in an efficient way. Care coordinators allow primary care physicians to not only increase their income, but also see more patients, and get better clinical outcomes. 

Between the Comprehensive Primary Care Initiative Plus program and Medicare's new care coordination codes, almost all primary care physicians in the country are either delivering or in the process of implementing the delivery of fully coordinated care. It is essential that any eye care provider who wants to continue to see diabetic patients and/or provide medical eye care understands how to become part of the coordinated care delivery system. One of the first things that almost all care coordinators take on as a responsibility is to schedule the specialty exams, including eye exams, for all coordinated care patients. You risk losing access to these patients unless you learn how to interact and participate with the care teams that are rapidly emerging.

Our goal at OD Excellence is to demystify health care reform and guide you through a step-by-step process to foster success for your practice. As the health care landscape continually evolves, so will our program. Instead of losing patients due to increasing insurance related challenges and exclusion from big health care, you will learn how to open doors for yourself and increase your patient load by establishing yourself as the vision component in your community.

Through OD Excellence’s health care reform program, we outline for you a personalized roadmap to success. We include an on-going orientation to key terminology which you will need to confidently speak the language of health care reform. You will be guided through the process of expanding your presence as the vision component in your community and implementing critical changes in your practice based on health care reform concepts.

As you follow this process, you will be supported not only by a knowledgeable staff at OD Excellence, but a group of like-minded peers across the country who are excited to share their experiences, challenges and successes related to health care reform.

Let's get started! Every practice, community and practitioner is different. The process below outlines the key steps for success under health care reform considering the nuances of your individual practice and community. 

Click on the sections below to see expanded descriptions of each.

OD Excellence members have the option to learn and collaborate with others who are participating in the program via the webinars which will be hosted each month. Each webinar is hosted twice - once on the second Tuesday of the month and once on the fourth Thursday of the month - always at 8pm ET.

We hope this schedule will allow you to participate live so you can engage in dialogue with your colleagues. This is your chance to ask questions, discuss your successes and brainstorm with your colleagues about solutions to roadblocks you may be facing. Members will receive an invitation via email each month with the links to register.

If you are not able to participate live in one of the webinars each month, members can access the recordings of each webinar.

These are some of the common terms used throughout health care reform. You will see these terms used in the materials as part of the Health Care Reform program.

1) ACO (Accountable Care Organization) - An ACO is a business structure that can incorporate many different business entities.  Virtually every ACO is structured differently, but the important thing to understand is that the ACO is a business entity, not a health care delivery entity. An ACO could be structured to include only providers, or it could be structured to include providers, hospitals, health systems, nursing homes, other health facilities, or any combination of these.

a) There is a saying that when you have seen an ACO, you have seen one ACO. Any other ACO will most likely be structured differently.  It is important that you know the structure of the ACO’s developing in your community as   the business structure is going to drive where and how you negotiate with them to become involved.

2) Medical Home - A medical home is a delivery structure.  The medical home is the usual structure that coordinated care will be delivered through. It is a formal delivery system with a set of guidelines that include the care being patient centered, coordinated, and outcome based. 

3) Coordinated Care- Coordinated care refers to the type of care that results from implementing a Medical Home.  For the purposes of these articles, when ACO’s are referred to, this will be in reference to a business entity, and when a Medical Home is referred to, this will be in reference to a delivery system structure based on the eight Medical Home criteria.  The terms "Medical Home" and "coordinated care" can be used almost interchangeably.  The practical difference is that if a provider group is a Medical Home, it likely means that they have been recognized as a Medicare Medical Home, are doing all of the items included in the eight categories and have been formally recognized as meeting all of the formal criteria for being a Medical Home.  A coordinated care group may or may not be doing all of the things that a formal Medical Home would be doing.

4) Healthcare Effectiveness Data and Information Set (HEDIS) - HEDIS is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA). Although most eye care providers are not familiar with this organization, the commonly used standard of always sending a report to the patient’s primary care physician on every diabetic exam came from this organization. There is another quality measure that directly relates to eye care which is not as well known or complied with by eye care providers. Every patient over the age of 65 that does not have a diagnosis of glaucoma must have a glaucoma test completed yearly and reported to the primary care physician.

5) STARS Rating System - The Five Star Quality Rating System for Medicare Advantage Plans is run by CMS and was put in place as part of an effort to help educate consumers on quality and make quality data more transparent. The ratings consist of over 50 measures taken from 5 different rating systems. This rating system score is applied to every encounter for every patient that is covered under any Medicare Advantage plan. CMS is using these scores to determine which Medicare Advantage plans will have their contracts renewed after January, 2015. 11 of the measures are directly or indirectly affected during an eye examination.

6) Empanelment - Empanelment is the process used by a health system to move patients into coordinated care team delivery. The majority of health care systems and Accountable Care Organizations are using population management to decide which patients to move into coordinated care and in which order. Any patients who are not part of a named population are considered to be part of a global population. This global population is decreasing over time as more populations are identified and moved into coordinated care.

It is almost impossible to understand the changes in the delivery of care under health care reform unless you understand the details of how the Medical Home Model works and how coordinated care teams function. As an eye care practitioner, participation in coordinated care requires you to adopt new ways of practicing and incorporate a new way of thinking about your role in health care.

There are eight categories of training that a primary care physicians undergoes to become a Medical Home. These eight categories represent the core changes that are occurring to the health care delivery system as a result of the move away from fee-for-service based care to a patient-oriented, outcome-based delivery system. Eye care providers are not required to have the same level of training, but must have a general understanding of these categories to be able to be involved.

Resource materials covering each of the categories below are available to OD Excellence members.

Categories of training to become a care provider in a Medical Home:

  1. Engaged Leadership
  2. Empanelment
  3. Enhanced Access
  4. Care Coordination
  5. Team Based Relationship
  6. Patient Centered Interactions
  7. Evidence Based Care 
  8. Quality Improvement Strategy

OD Excellence's Health Care Reform program includes a set of worksheets designed to guide you through a step-by-step, interactive process to be successful under health care reform. Below is a list of example worksheets which members use to guide them through the program.

  1. Understand Healthcare Reform
  2. Connect to the Rest of Healthcare in your Community
  3. Transform the Delivery System in Your Practice
  4. Understand and Improve Quality Measure Scores
  5. Understand and Redefine the Expanded Role of Eye Care Under Health Care Reform
  6. Become Certified in Health Care Reform

Clinical outcome registries are one of the most exciting new tools that health care reform is making available.  Health care providers are rapidly being divided into two groups.  Those who know the clinical outcomes of their patients, and those who do not.

Payers and patients are learning the value of care being provided by practitioners that not only know the outcomes of their own patients, but also have the ability to compare the outcomes of their patients with those of other providers. That process allows each individual provider to make the appropriate decisions to make sure that the care they are providing is resulting in the best possible outcomes for each patient.

PCORI (Patient Centered Outcomes Research Institute) was set up by the Affordable Care Act and funded with over $3.5 billion to study clinical outcomes and educate the public on the importance of patients selecting providers that deliver outcome based care.   Their job is pretty easy.  Think of this question to a patient: “Would you prefer to get care from a provider who purchased testing equipment or is prescribing a medication because a sales person at a conference convinced the provider that it is the best product, OR would you rather receive care from a provider who tracks the results that you and every other patient gets so he or she can compare those outcomes to the results of other providers and ensure your results are the best possible?”

Clinical outcome registries are the tool that lets you as a provider participate in outcome based care delivery.