"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Wednesday, March 30, 2011

Doctors, Free Markets and Healthcare Exchanges

This is a guest post from Lou Galterio, MBA, HIMSS Fellow, CPHIMS
President and CEO
The SunCoast RHIO, Inc.
Sarasota, Florida

Response to the Department of Health and Human Resources
Center for Medicare and Medicaid Services

ACO RFI, 42 CFR Chapter IV

The SunCoast RHIO, Inc. of South West Florida

This document is in response to the request for comments on aspects of the ACO model. We would like to submit our thoughts and ideas for consideration. I represent the SunCoast Regional Health Information Organization (RHIO), Inc and Health Information Exchange (HIE). Our website is www.SunCoastRHIO.org . Our organization appreciates this opportunity to be part of this effort and have our voice heard during this very important point in time as our country takes this very necessary step in the evolution of health care delivery.

The SunCoast RHIO is an organization that both serves and has as its members, doctors, hospitals, and consumers. Doctors have a voice in the RHIO and we listen very closely to what they say. We offer our services to the counties comprising the South West Florida region and we also work closely with the Regional Extension Center here. We are aligned with the efforts of our State Government and the various county Health Departments. Our organization is structured to make the most out of public – private collaborations and collaborations utilizing a non-profit and for profit sustainable business model.

We will address the CMS request for information regarding policies and standards, capital access, attribution, assessment, patient-centeredness, and quality performance standards. We will not address the final point of additional payment models as we are not qualified and this knowledge is beyond our expertise.

Before that, I would like to make four very short observational comments on this topic. The first regards the general resentment and perception of blame as to how we got to the point of high cost healthcare we are at now. Some say it is the high price of doctors, others say the insurers and payers, and most just don’t know. All agree however that the present state is no longer financially tenable.

There is no one to blame. One can look at the history of a healthcare entitlement public perception evolved from practices during World War II, or the high cost of medical education, or the poor cost accounting methods used in the Charge Master recovery models of early hospitals as they evolved from organizations focused only on the poor. The fact is that any system, left unchecked, tends to grow until it reaches a point of instability. This extends over nature and to business. Our friends at the FTC know this well. It is the nature of things as they evolve and it is in the public interest to insure that there are checks and balances in place to avoid this yet do not inhibit free market innovation and self determination. Because of the complexity of this field, we are just getting to that point now. We are all in this together and together is how it will be fixed.

The second statement is an extension of this first point. We live in a country based on free market enterprise system. Here, people can achieve their dreams of wealth and success, as they define it, without fear of being controlled and in partnership, not competition, with the government that serves them and represents them. It is this freedom to innovate that has made us and will continue to make our system the best in the world.

Our next statement is a natural outgrowth of the preceding thoughts. Doctors are intelligent self motivated individuals. They are the cream of the crop of our society. There are many industries where individuals like this could have entered to simply make a good deal of money. But, many have gone beyond that by choosing to dedicate their lives by caring for others and relieving pain and suffering.

From the doctors we speak to every day, most want to practice their profession, not feel commoditized, and be able to make a comfortable living based on reward commiserate - either in dollars determined by the supply and demand for their skills or the satisfaction of helping others. In the vast majority of cases, it is both. Doctors in our RHIO are individuals. They make decisions of life and death. They are often times entrepreneurs and demand a say in how their life evolves and not to have it dictated. They depend on themselves and their colleagues in determining their own destiny.

Finally, we wish to emphasize the benefits of technology and a technology platform as an enabler for an ACO. The landscape is quickly turning from that of brick and mortar offices to one of electronic practices where innovation and business opportunity is encouraged and economies of scale are made available at the speed of electrons. Doctors can be free to practice in this environment without being encumbered by an expectation of becoming technologists themselves unless they choose to. Doctors can choose ACO’s to belong to, build their practices within them, associate as they see fit at the time they wish, and be free to quit and move on to others when the ones they are in fail to serve the purpose. This applies to the consumer as well as the payer and is one of the reasons we feel that a RHIO can be both a service organization supporting an ACO, multiple ACO’s, or an ACO itself, serving far flung doctors and specialists determined not only by geography but by specialty and demographic desired.

Policy and Standards:

We feel an important part of the success criteria of an ACO will be to support a doctor’s will to have choice and control over his or her own destiny. An ACO needs to encourage free enterprise. Doctors do not want things forced upon them. This includes dictating ways to practice or technology tools that they must use without say. We also acknowledge the need to have a basic system in place that serves this drive yet insures a consistent measure of quality, as defined by evidence and patient experience, demanded and deserved by the public and their elected representative government. We believe doctors want this also, not only as providers of care but as patients themselves.

Policies and Standards for ACO’s need to address this. There is numerous guidance within Medicare to guide practice operations and clinic building. There are quality indicators that are being standardized. This should not become an endpoint. Quality demands will change over time as sure as patient preferences and public policy does. However, there are core measures that are permanent.

An organization like a RHIO can package the necessary business and legal requirements to create an ACO model. Policy and standards become the job of the organization challenged to deliver the infrastructure. This gets us away from a payer, hospital, or government lead. Joining a RHIO is a choice that doctors freely make and can leave anytime. A potential set of policies and standards can be attributed to a lead organization sanctioned by CMS for Medicare and Medicaid.

The second aspect of course is compensation. If we have a core set of quality indicators that, when achieved, leads to a core reimbursement, it sounds allot like a base salary – and one that everyone gets regardless of contribution or differentiating practice or ability. It is true that savings can be shared for efficiencies above the standard set but this will not be significant. Secondly, what happens when the savings run out or the chance to create efficiencies is no longer obvious? Do we move to a base compensation that discourages individual effort and achievement?

We need a way to offer reward and self reward. By giving physicians the ability to innovate by choice of affiliation and potential return by being free to build or associate with whomever they wish, we can encourage the benefits only a free enterprise system can afford. By having an overall set of guidance and tools certified by CMS and executed by the organization of choice to the provider, instead of dictating practice, we can look forward to huge rewards, not only determined by how much we can cut and make mechanical but also by unfettered opportunity.

Access to Capital

By encouraging an ACO that is a business organization that follows set basic requirements yet offers the provider choice and innovation, we help foster an organization that can be for profit, not for profit, public, private or any combination.

This approach allows the innovation displayed by members to attract patients, if they are good, charge a partial concierge fee, or work with banks to encourage HSA participation directed at the consumer investment to their doctor of choice, doctor group, and evidenced by their own health care as reported by their peers. Return to the consumer is both personal and financial. Traditional investors could evaluate where to invest based on ROI determined by patient choice which leads to provider returns, practice size, and referral patterns created by good medical practice in line with satisfied and self motivated doctors and basic public policy.


Attribution would be addressed by patient choice and provider choice. Technology encourages, supports, and enables fast movement and the access to the best doctors appropriate to the need. Price works itself out in a free market checked by the awareness that a totally free market tends toward monopoly and a totally controlled market leads to inefficiency.

Beneficiary Experience, Patient-Centeredness and Quality

Patient experience lends itself to patient access tools that are trusted, perceived centralized, and easy to use. By having a co member organization like a RHIO supporting the ACO or being one itself, we can encourage patient experience sharing through Personal Health Records and easy access that is a trusted source. RHIO’s strive to maintain this ease of use and accessibility. This is further supported as we offer portals to HHS Government Databases and as supportive to our State’s efforts in Health Information Exchange. The concept of a Medical home is one that is both an individual and a group experience. People not only care for themselves but for their loved ones. If a way were available to have access to all of these abilities as a family focus, it would be used.

In addition to patient experience, we support provider experience. In one of our new offerings we emphasize provider satisfaction and also recognize that providers trust providers. We support a doctor only blog called Sermo that we can’t get into all our selves. We try to provide a one stop shop access point to providers and patients.

We hope to be a portal for the new insurance clearinghouses by further allowing levels of access to patients and providers to these offerings.

We work closely with quality measurement and analytics through the standards, organizations, payer experience, the best of P4P experience from the past, and a current agreement to utilize DARTNet, an AHRQ funded database, for outcome measurement. We hope to encourage usage of and distribution of Comparative Effectiveness Research and NIH discoveries and studies pertinent to the patient in a language they can understand. By doing this, we can show statistical success or failure by comparing experiences not from a minimum of 5,000 patients but from millions as reported in a consistent manner on behalf of all ACO’s and not just those formed to served a defined region or a concentrated population.

This is not a plug for a RHIO though; it may sound like it, but as a comment to this RFI and something we are passionate about. In that, we strongly believe that a similar organization or a new one never thought of before can act as the engine for an ACO grid that supports provider choice, government guidance, innovation, and public and private capital and interest. This can go beyond Medicare and can enable this experience even in a self pay, private, or even a charity approach.

Thank you for the opportunity to respond.

Lou Galterio, MBA, HIMSS Fellow, CPHIMS
President and CEO
The SunCoast RHIO, Inc.
Sarasota, Florida

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