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Risk Contracting, v.2.0 Print E-mail
Written by Lawrence Schimmel, M.D., FACS   
Thursday, 26 January 2012 00:00

In the late 80s and through the 90s risk contracting was seen throughout our Florida market. Primary Care physicians or healthcare entrepreneurs working with a physician assumed partial or full risk for providing care to a subset of a health plan’s enrollees. The “risk taker” would then capitate specialty care and other services to minimize their risk. Success or failure depended on the ability of the primary care giver to manage the patient and control outpatient and hospital resources. Success if viewed through the bottom line depended on performing the right services at the right time in the right setting. Unfortunately, some risk takers viewed underutilization as a sure way to enhance the bottom line and quality of care issues would then arise. HEDIS reporting and NCQA accreditation requirements were measured to insure “quality care”. In some instances instead of full risk, “shared risk” arrangements developed between plan and risk taker and we can also remember the financial incentives for primary care physicians that were set in place to assure HEDIS compliance and patient satisfaction.

Does this all sound like something you have been hearing a lot about lately??

Let’s be clear, an ACO is little more than a risk contract with a lot of the bells and whistles now available to us with technology. There is nothing magical and mystical about this entity. The government has recently eliminated the need to take risk for those who choose to create and ACO and allows you as an ACO up to 50% of the savings. Should you choose to take risk you would be entitled to 60% of the savings. Who would want to take risk for an additional 10%?

So what we have is an entity with 5000 Medicare lives that will contract with providers, hospitals, and pharmacy and ancillary services to provide care to a specific set of patients. Should your cost of care over a period of time be less than that a similar group of non-ACO patients you will receive 50% of the savings. Your reporting requirements are tied into quality indicators that the government has identified which also tie into the meaningful use criteria as required in the HITECH Act for EHRs. Risk contracting v2.0 is the development of the ACO. At this time many patients are still cared for in our community under risk contracts from plan to provider. Those patients are part of some type of Medicare Advantage Plan. 

Why are ACOs being talked about so much? Large parts of our Medicare population are free agents, not part of any Medicare Advantage plan. Those are the patients that are targeted for ACOs. To the extent a primary care physician joins an ACO the patient will not really know any difference. The physician will refer to specialists and hospitalize as needed and all ancillary services will still be provided. The patient for all practical purposes will not notice any difference. Internally, all of the physicians, hospitals, ancillary services within a specific ACO will be linked electronically for reporting and financial purposes. Since the primary care doctor is the one who manages the care of his or her Medicare patients, the key component of any ACO is putting them together to meet the minimum criteria (5000 unaffiliated Medicare patients). This is very similar to the old-fashioned risk contracting of the 80s and 90s packaged differently. Since the final rules from CMS a few months ago regarding ACOs, risk is not even a requirement anymore. The battle about who should control the patient is now beginning. All of the stakeholders that are involved are jockeying for control of the patient and management of the ACO. Whether it is the managed care organization, the hospital, the physician, or the healthcare entrepreneur that prevails is yet to be determined. v. 3.0 is not far behind. Stay tuned.

Dr. Schimmel is a Principal at Marcum Healthcare.  You may contact the author at or 305.995.9801.

Last Updated on Monday, 13 February 2012 10:09
Meaningful Use Paying Off Print E-mail
Written by Digital Wire Service   
Thursday, 19 January 2012 00:00

According to the 2009 HITECH Act, physicians are eligible to receive up to $44,000 in total incentives per physician from Medicare for "Meaningful Use" of a certified Electronic Health Record (EHR) starting in 2011. Physicians reimbursed by Medicaid can receive up to $63,750 starting in 2011 based on state-defined guidelines. In July 2010, the Center for Medicare and Medicaid Services (CMS) released their rule for the Stage 1 Meaningful Use requirements that physicians need to meet in order to receive their Meaningful Use incentives.  A growing number of physicians are receiving their initial stimulus payments by demonstrating Meaningful Use.  Click HERE to read more.
Last Updated on Wednesday, 25 January 2012 18:41
FICPA Health Care Industry Conference 2012 Print E-mail
Written by Digital Wire Service   
Tuesday, 03 January 2012 00:00

Orlando, FL

Thursday, April 26, 2012 - Friday, April 27, 2012

Click HERE to learn more. 

The FICPA would like to thank the following sponsors for their support of the 2012 Health Care Industry Conference: 

ADP, AllTrust Insurance, CP Capital Securities, Inc., Crowe Horwath, LLP, Danna-Gracey, Deloitte & Touche, Elavon, Inc., Ernst & Young, FHIcomunications, Fifth Third Bank, Grant Thornton, HFA Partners, iAstros Healthcare Solutions, JPMorgan Chase, Kenneth Michael & Associates, Kerkering, Barberio & Co., KPMG, LarsonAllen, LLP, Mallah Furman & Company, PA, Moore Stephens Lovelace, P.A, Price Waterhouse Coopers.
Last Updated on Saturday, 28 January 2012 11:41
What about Me? Print E-mail
Written by Lawrence Schimmel, M.D., FACS   
Tuesday, 03 January 2012 00:00

As 2012 begins the independent physician practice is under attack from a number of directions and to survive it must be smart enough to understand what is taking place and how to work around it. In the past few years, large single specialty groups have formed with the philosophy that there is strength in numbers. If you are part of this type of organization you have been protected to a degree. Those that are not part of these large single specialty groups have been left to fend for themselves. The independent physician has no strength in numbers, no economy of scale as it relates to purchasing power, and does not control enough market share to demand a higher level of reimbursement from managed care organizations. Understanding the problem is critical for you to make the necessary adjustments in your practice to compete in this environment.
A new threat is just around the corner. It is called the hospital and its physician owned groups. Hospital owned physician groups are a major threat to both independent physicians as well as those in smaller single specialty groups. How did this happen? In the 90s, the emphasis of the new healthcare world was going to be the family practitioner. The primary care doctor was going to be the manager of patient care.  Under the assumption that primary care doctors would provide care, managed care organizations attempted to capitate them to reduce the cost of care. Unfortunately, the result in many instances was that the primary care giver became a triage officer and handed out referral slips rather than caring for their patients.  Additionally, many primary care doctors stopped going to the hospital to admit or coordinate care for their patients. Historically, this shift is important because as primary care physicians went less and less to the hospital the question arose:  Who was going to coordinate the care of there hospitalized patients? A new specialty was born out of the capitation of primary care physicians, the Hospitalist. Initially some entrepreneurial physicians created hosptialist companies, but it was only a matter of time before the hospital saw the benefit of owning their own hospital-based caregivers. Now hospitals are acquiring specialty care physicians and we are faced with the growing reality that it is likely that hospital owned hospitalists will refer consultations to hospital owned specialists. 
The hospital has closed the loop on the delivery of care with its approach to owning and managing the urgent care center, the outpatient center, the hospital, the primary care physician, the hospitalist, and now the specialist. There are those who will say that this integrated delivery system is the best way to provide care to the patients surrounding hospital campuses.  However, this creates a dilemma for the independent physician in our community. Whether a planned strategy or something that just happened, many feel that the hospital is just a license away from being a managed care organization or under the new health care reform act very close to forming an ACO.
This is the new reality in many locations throughout Florida, so what is the majority of physicians who remain independent going to do about it to survive? Perhaps this will be the impetus for multi-specialty groups to organize? Perhaps this will force more specialists into larger single specialty groups? Perhaps the small independent needs to adjust their practice to the new realities and make more out of less?  Every business needs to adjust to market conditions and a medical practice is no exception. This is a very fluid environment and the decisions that are made by independent physician groups in the next year will have long-term consequences on their specific practice.
Dr. Schimmel is a Principal at Marcum Healthcare.  You may contact the author at or 305.995.9801.
Last Updated on Friday, 27 January 2012 13:19
Baptist Medical Group Adds 3 New Docs Print E-mail
Written by Jeffrey Herschler   
Wednesday, 07 December 2011 13:06

Baptist Health Medical Group, an organization of more than 80 physicians in multiple specialties closely aligned with Baptist Health South Florida, welcomes three new physicians:
  • Ronald Tolchin, D.O
  • Dionne Casthely, D.O
  • Francisco Borja, M.D 

Dr. Tolchin is medical director of the Baptist Center for Spine Care, part of Baptist Hospital's Neuroscience Center. He specializes in physical medicine & rehabilitation, low back pain and spine disorders. Dr. Casthely specializes in spine disorders and musculoskeletal rehabilitation and fluoroscopic guided injections. Dr. Borja specializes in adult orthopedic hip and knee joint replacement and arthroscopic knee surgery.

Last Updated on Wednesday, 07 December 2011 13:13
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