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Providers align, quality matters in health care reform
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LAS VEGAS – “All providers are now on the same side of the table: doctors, hospitals, other ancillary providers. If they do well taking care of patients, they get to share in the wealth,” Charles Posternack, MD, FACP, FRCPC, said here at Vision Expo West.
With accountable care organizations, “this is the first time providers are on the same side of the table,” he said. “Patients have a say in all of this; you have to keep them happy. That’s the paradigm shift.”
Posternack, who is chairman of the board of PFO Global and chief medical officer at Boca Raton Regional Hospital, explained that accountable care organizations (ACOs) are integrated delivery systems led by hospitals, doctors or insurers that take care of populations on a prepaid basis. There are 120 in the U.S., he said, with a third led by doctors, a third by insurers and a third by hospitals.
“The goal is to have a prepaid group of patients that you assume control over,” he said. “You can be part of an ACO if the doctor in that ACO takes care of most of the health care for that patient.”
Posternack noted that payors are now capped at making between 15% and 20% profit.
“We are seeing a shift away from fee for service into prepaid plans where providers are being paid a fixed amount of money to care for patients,” Posternack said. “Reporting is important; quality has to be high. They want you to accept risk, and if you do, you’ll be ahead of the curve.”
He said that Medicare has 37 million enrollees today, and that number is expected to grow at a rate of 10,000 per day.
“Sixth-five percent of Medicare Advantage programs have a vision benefit, and it’s anticipated that all of them will within the next 2 years,” Posternack said.
“It has also been predicted that Medicaid, Medicare and health care exchanges will require vision care benefits for all patients in health care exchanges – not just children,” he continued.
Posternack said that an eye exam and finished eye wear is a benefit in most Medicaid plans today.
“We anticipate most school boards will require their children to get vision exams,” he added.
“The bottom line is that the most rapid growth in our industry will take place in the entitlement programs,” Posternack said. “Utilization will increase. Older patients all have vision problems and the younger ones are going to start earlier. We’ll have to control utilization and keep quality high.”
Posternack said the optical industry has historically been the only part of health care not under risk. “Dentistry joined a few years ago,” he said. “You guys are the last ones to go.”
He predicted that fee for service will disappear, and in anticipation of this insurers are looking for people who are effective utilizers with high quality.
“You’ll have to pay more attention to HEDIS measures,” he said. “You will be more involved in primary care of patients. The shift to risk will occur overnight. This gives you freedom to take care of patients how you want to. We can shift this paradigm in a very positive way.”
Posternack noted that 5 million Americans were in ACOs between 2013 and 2014, and 29 of the ACOs saved $380 million.
“The largest ACO gave each primary care physician a check for $1 million because they saved money in the system,” he added. – by Nancy Hemphill, ELS