Posts Tagged ‘PHO’

Infographic: Critical Factors in Developing ACOs and PHOs

May 14th, 2014 by Jackie Lyons

The number of accountable care organizations (ACOs) led by a physician-hospital organization (PHO) nearly doubled over the last year, according to the third annual ACO survey conducted by the Healthcare Intelligence Network. Properly developing and operating these integrated heath systems is critical for healthcare organizations.

Highly effective leadership, sustained organizational committees and adequate up-front capitalization are just some of the key elements to the success of an integrated heath system, according to a new infographic from Mercury Advisor Group. This infographic identifies five key elements, along with detailed descriptions of each.

Want to know more accountable care trends? 2013 Healthcare Benchmarks: Accountable Care Organizations documents the numerous ways in which accountable care is transforming healthcare delivery, particularly in the area of care coordination, where the ACO model has had the greatest impact for this year’s respondents.

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Predictors of PHO Longevity and Financial Success

April 15th, 2014 by Patricia Donovan

Today, value-based payment models encourage hospitals and physicians to work together and make each more accountable for the other’s actions in a physician-hospital organization (PHO). But what are predictors of PHO longevity and financial success?

Here, Healthcare thought leaders Travis Ansel, MBA, manager of strategic services, Healthcare Strategy Group, and Greg Mertz, MBA, FACMPE, director of consulting operations, Healthcare Strategy Group, debate the question.

Response (Greg Mertz): It’s pretty evident that no one entity is going to be able to meet the needs of the population. If you’ve got a hospital that employs physicians, there’s an excellent chance that the employed physician network isn’t the total answer for caring for the population. They’re going to have to embrace non-employed physicians, other specialties, larger based primary care. Some entity is going to have to be created to make that happen.

But the PHO is an excellent model. Basically, it creates a collaborative entity that can bring in hospitals, employed physicians, non-employed physicians, ancillary providers. The PHO this time is something that is going to be necessary. Value is inevitable. I don’t see any reason that it would not have great longevity.

Response (Travis Ansel): I definitely agree. I think the biggest predictor of long-term success is the culture, but it’s going to be how the governance of the PHO is set up. It’s going to be giving the physicians, both employed and independent, a real voice in the organization and getting their expertise leveraged going forward. That’s going to be the biggest predictor. Beyond that, a willingness to experiment.

We’re in a situation now where organizations can’t really afford to sit on the sidelines for too long with all the different models that CMS and private payors are putting up in order to encourage shared risk between providers and hospitals. A willingness to experiment would be another key to success in my mind because it’s really the only way to learn how to be successful in this new environment, how to get involved in it and not hang on to the current FFS environment until it withers and dies.

Excerpted from Essential Guide to Physician-Hospital Organizations: 7 Key Elements for PHO Success.

Healthcare Business Year in Review: A Look Back at 2013’s Top Stories

January 9th, 2014 by Cheryl Miller

From an early surge in Medicare accountable care collaborations to the rocky introduction of ACA-mandated health insurance exchanges during a government shutdown, healthcare in 2013 was nothing short of unpredictable.

But in this issue, as in “Best of” issues past, we bring you the stories that resonated most with you. Your top story was one that ran nearly a year ago: Post-Hospital Telephonic Outreach Reduces Readmissions by 22 Percent for High Risk Patients. This initiative from Cigna monitored telephonic outreach by health plan case managers within 24 hours of hospital discharge, finding that they reduced future readmissions by 22 percent. Resulting in more physician visits and prescription drug fills, the timing and prioritizing of the calls was critical to its success.

Case managers’ roles in long term care also spiked your interest in our featured white paper: Case Management in 2013: Achieving Results with Cardiovascular Disease; Long-Term Care Next Frontier for Embedded Case Managers. As care coordination by healthcare case managers continues to drive clinical and financial outcomes in population health management, expect to see lots more case managers — not just coordinating care telephonically like Cigna, but co-located in nursing home, long-term care (LTC) and assisted living settings.

Other top stories included CMS’ announcement that Medicare beneficiaries saw significant out-of-pocket savings due to the ACA, including provisions to close the prescription-drug “donut hole” that saved more than 7.1 million seniors and people with disabilities $8.3 billion on their prescription drugs since it took effect.

How the ACO model figures in most hospitals’ futures also topped your reading list, as did a story on how 24 states and the District of Columbia chose a benchmark health insurance plan that met the ACA’s essential health benefit requirement, which is scheduled to begin next month, January 2014. Researchers found that 19 of the states that selected plans chose existing small-group plans, employer-based plans for businesses with fewer than 50 employees. The remaining five states selected HMO or state employee benefit plans.

An infographic on 2013’s Most Significant Healthcare Issues, and our podcast on Physician Hospital Organizations: Developing a Collaborative Structure for Shared Savings Agreements also attracted the most views.

We will continue to provide you with the kind of up-to-the-minute coverage you need to stay informed.

And as with issues past, we send our best wishes to all of you for a happy, healthy, prosperous and peaceful new year.

The PHO in 2013: More Flexibility, Less Risk Than Eighties Model

January 31st, 2013 by Patricia Donovan

Unlike the hospital-dominated physician-hospital organization (PHO) prominent 30 years ago, today’s PHOs are largely physician-centric, notes Travis Ansel, manager of strategic services for the Healthcare Strategy Group. And make no mistake: in the new fee-for-value healthcare universe, payors and employers understand that physicians are the one that control process and control cost, he asserts.

“Hospitals and physicians have a great incentive right now to figure out how they should be working together going forward, and how they need to align legally and what model to use in order to engage those populations,” Ansel notes. Providers unable to provide efficient quality care that’s going to help hospitals survive under value-driven reimbursement will face losses in market share and reimbursement, he continues.

Ansel and Greg Mertz, director of Healthcare Strategy Group, recently explored the key contractual elements to consider when creating a PHO during a webinar on Physician Hospital Organizations: Developing a Collaborative Structure for Shared Savings Agreements.

Today’s PHOs are jointly governed by physicians and hospitals, they explain, with the common goals of quality and cost management and the sharing of savings from any joint contracts or arrangements — elements that weren’t necessarily part of the eighties’ PHO equation.

Compared to other emerging shared savings arrangements — the Medicare Shared Savings Program, commercial accountable care organizations (ACOs) and public and private bundled payments — PHOs offer more flexibility, notes Mertz. For example, a PHO has the option of expanding into an ACO in the future, as well as target multiple populations, something that can be more challenging in an ACO due to its reporting requirements. “Today’s PHO is scalable. It can start with a single client and grow to ACO.”

But flexibility doesn’t preclude serious considerations around forming a PHO, he continues, including its legal structure, number and type of participating physicians, size of the patient population, compensation plans, data support, and most importantly, evidence-based protocols against which to measure PHO performance. And while cost reduction is paramount, patient satisfaction levels are getting equal attention.

“The big difference between today’s programs and the gatekeeper HMO’s back in the eighties is that nobody worried about whether the patient was happy with the HMO,” says Mertz. “Now within public programs, there’s a formal process of monitoring and reporting on patient satisfaction.”

What will the typical PHO look like? Owner physicians and hospitals, plus contracted providers such as imaging, pharmacy and other ancillary services. The PHO team will also rely heavily on nurse case managers, nurse navigators to really interact with the patients as they help to coordinate their care. “It’s cheaper to intervene now than in the emergency room,” Mertz notes.

It is also important to have an accurate picture of the patient population. “Diabetes, pulmonary, cardiac, and depression are the top cost drivers, but dual eligibles (Medicare-Medicaid patients) and patients with behavioral issues are chronically non-compliant and are the biggest cost consumers. It’s important to identify those people up front and develop a patient registry-managed plan for those patients.”

Of course, key to any shared savings model is quantifying the cost of services and then savings gleaned from the PHO’s clinical protocols and quality efforts — then distributing the savings equitably.

The challenge for fledgling PHOs will be changing provider behaviors. “Participants have to believe that the PHO is better than the alternative,” says Mertz. “Creating a culture of collaboration is key; success hinges on provider engagement.”

And not just the physicians that are part of the PHO. “The PHO is really a vehicle to involve all physicians, including community doctors,” concludes Ansel. “Community physicians that aren’t a part of employed networks are just as important and have just as much insight as to how the industry succeeds under this new reality.”

Listen to an expanded interview with Travis Ansel and Greg Mertz about today’s physician-hospital organizations.