WASHINGTON -- In a meeting with national representatives last week, members of the California Association of Physician Groups detailed their patient care coordination efforts and pledged to move forward no matter what the U.S. Supreme Court says about the Affordable Care Act.
The Supreme Court's much-anticipated ruling on the federal health reform law is expected this week.
For last week's meeting, CAPG invited lawmakers for an overview of members' efforts to coordinate care in California.
Don Crane, president and CEO of CAPG, said members of his organization have been delivering coordinated care in California for decades, "and they are going to continue to do that irrespective of what the Supreme Court does."
California physicians have been delivering coordinated care since the Knox Keene Act of 1975 was enacted, Crane said. The act, which provides guidance on coordinating health care for patients, is the main legislative framework regulating managed care plans in California.
Meanwhile, two provisions of the health reform law -- the Medicare Shared Savings Program and the Center for Medicare and Medicaid Innovation -- have stepped up federal efforts to improve health care coordination, he said.
Crane noted that a Supreme Court decision striking down all or part of the ACA likely would affect federal efforts to coordinate care. However, Crane said he does not have the foresight to fully realize the possible implications.
Implications for the Shared Savings Program
The Medicare Shared Savings Program aims to help health care providers who are part of an accountable care organization collaborate to improve health care for Medicare beneficiaries.
CMS in April announced that it selected 27 health care organizations to become accountable care organizations under the Medicare Shared Savings Program that was created by the reform law.
The program aims to improve care delivery and reduce costs by requiring the 27 organizations to meet 33 quality measures, many of which relate to care coordination, according to CMS.
Participating ACOs are rewarded if they reduce the growth in health care costs, while also improving quality.
Two of the participating ACOs are based in California -- AppleCare Medical ACO in Buena Park, Orange County, and Premier ACO Physician Network in Lakewood, near Los Angeles.
Cynthia Guzman, CEO of Coast Healthcare Management, the management organization for Premier ACO, said she expects the program to be "beneficial for our fee-for-service Medicare patients, because their care would be coordinated across the continuum, which is not happening in the current fee-for-service environment."
In the fee-for service model of care, health care providers are reimbursed for the number and type of health care services rendered, not for quality outcomes that keep patients out of hospitals and doctors' offices.
Guzman said, "We don't know if the shared savings program will be dissolved, but we know that the ACO concept -- focusing on preventive coordinated care -- will remain regardless of the court ruling."
Implications for CMMI
The reform law established CMMI to help foster improvements in several areas of health care, including care coordination.
CMMI tests, evaluates and disseminates information on innovations in care coordination. The health reform law allocated $10 billion to the center to identify, develop, support and assess innovative payment and care delivery models for Medicare, Medicaid and Children's Health Insurance Program beneficiaries through an open and competitive process.
An official from CMS' Office of Communications declined to comment on what would happen to the innovation center if the reform law were to be struck down. The agency stands by the idea that the reform law is constitutional.
Some Coordination Efforts Not Tied to Reform Law
At the meeting, several CAPG members pointed to care coordination initiatives they participate in that are unrelated to the federal health reform law and can continue whether or not the law is upheld.
Keith Wilson, a physician with CAPG member HealthCare Partners, said health care coordination is primarily about information exchange.
"It's based on data -- being able to know who your patients are, what kind of disease burden they carry and how you can actively intervene and impact the course of their care, the course of their treatment," Wilson said.
He said many HealthCare Partners affiliates share patient data using electronic health record systems. Those who do not use EHR systems still input patient data that is uploaded to a data warehouse. HealthCare Partners cares for about 800,000 patients in California, Arizona and Florida.
Once data about a patient is uploaded, a provider information report can be sent to a clinician with data on the patient's health conditions, hospitalizations and laboratory tests so that treatment recommendations can be made, Wilson said.
Benny Guzman, medical director at Aveta/Primecare Medical Network, said his physician group also has used health information technology to improve care coordination, launching a health information exchange this year.
The exchange allows hospitals, specialists and primary care physicians to extract data about patients from one central source so providers can avoid ordering unnecessary tests, added Guzman (who is not related to Cynthia Guzman).
Guzman said his physician group also connects patients with "high-touch" care teams that can include a nurse practitioner and a social worker who visits the patient. A team member can call the patient daily.
Market Action May Signal Continuation of Coordinated Care
Crane pointed to market trends in the health care industry that might indicate that health organizations will continue to work toward providing coordinated care even if the Supreme Court ruling undermines the ACA.
He said there have been several high-dollar acquisitions of CAPG members, including renal dialysis company DaVita's $4.42 billion acquisition of HealthCare Partners in May. Crane said the acquisitions are indicators that purchasers "want to buy the know-how that supports coordinated care."
Crane also said that health care organizations rapidly are launching or joining commercial ACOs.
While the federal government launched and supports the 27 ACOs in the shared savings program and 32 Pioneer ACOs -- announced in December 2011 -- through the reform law, a Leavitt Partners report shows that most ACOs are commercial affiliations.
There were a total of 221 ACOs nationwide as of May 2012, according to the report. California had 25 ACOs -- more than any other state, the report found.
Cynthia Guzman from Coast Healthcare Management said her ACO is in discussions with health plans to potentially participate in commercial ACO collaborations, should the reform law that established the Medicare Shared Savings Program be declared unconstitutional.
Crane said the main point is that health reforms that improve coordination of care will continue whether or not the reform law stands.