Page 11 - SFHN JAN 2022

How an ACO’s Physician-Led Healthcare Reform

Hidden Insides Work Physicians have a unique vantage point on the short com-
ings of the health care delivery system. They witness first-
As a healthcare practice, many have joined or are look- hand the impact of ever-increasing insurance premiums and
ing into joining an ACO (Accountable Care out-of-pocket costs for their patients. Costs which strain
Organization). Here are some insider tips regarding ACO family resources or make insurance coverage unobtainable.
transparency to its members: They bear the brunt of the administrative cost and frustra-
tions of trying to secure medically necessary services for
Five Things to Know – Understanding the their patients through utilization controls enacted by insur-
inner workings of an ACO: ance companies. For physicians in private practice, like
1. Legal Entity – An ACO is a legal entity just like any most businesses, they experience the pain of the annual
other; it can be structured as a corporation, a partnership, Group Health Insurance renewal cycle when they receive
an LLC, under applicable state or federal laws. At first, it annual premium increases with little transparency over BY FRASER COBBE
may appear to be very similar to any other corporation, their utilization of services. And yet, there is constant
but it is really not; many other rules apply. downward pressure on reimbursement rates for physician
2. Mission – An ACO’s mission must be in furtherance BY BEN ASSAD MIRZA, services from governmental and commercial payers.
of providing quality healthcare, increasing patient access ESQ., LLM, MPHA While the DCMA continues to fight for our members, reform of the system through
to healthcare, and with an eye toward sharing in the sav- legislative and regulatory pressure has admittedly been difficult. Success in those venues
ings generated by the plan or the program. is never certain given the influence of other stakeholders.
3. Governing Body – An ACO has to have a separate This reality has led the DCMA to pursue programs that we can control and tools to
and unique governing body, such as a board of directors or managers. The ACO par- help physicians reform care delivery where they can. Just over a year ago, the DCMA
ticipants must be given the opportunity for “meaningful participation” in the ACO’s announced a strategic partnership with FBMC and Physicians Health Benefits to create
governance. If it is to be deemed a physician-owned ACO, at least 75% of the ACO a self-funded health insurance platform for our physician members. The short-term
must be owned or controlled by the physicians. goals of the program were to provide transparency, accountability and premium control
4. Controlling the ACO – The ACO’s have voting powers just like any other corpo- for our physician practices that provide health insurance to their employees.
ration, but they are also required to maintain a “conflict of interest policy” that applies The long-term goal is to encourage more of our members, as well as other organiza-
to the members of the governing body. They are required to be transparent, to disclose tions and businesses in the community, to consider similar platforms that provide claims
conflicts, and to disclose the methodology of how profits or Medicare savings are transparency, lower administrative costs, the ability to keep your excess premium, and
divided among its participants. bring down out-of-pocket costs for employees that utilize services strategically.
5. Healthcare Alignment – The ACO is required to maintain a senior level member Since its launch, there have been many lessons learned and the program has morphed
who is a physician and a medical director of the organization. This position is not considerably. But the success we are having in reaching those goals with our current par-
required to be full time, but it is responsible for clinical oversight and for overseeing ticipants is extremely encouraging.
and establishing the quality assurance and improvement programs of the ACO. It seems like there might be a way after all for physicians to take back a little bit of
control in the health care system. Reach out to the DCMA if you are interested in learn-
ing more.
If you would like to find out more about what the rights, responsibilities and obligations of
Fraser Cobbe, Executive Director, Dade County Medical Association,
an ACO and its participants are, visit www.MirzaHealthLaw.com or call/text Ben Mirza at
can be reached at fcobbe@miamimed.com.
(954)445-5503 or email BAM@MirzaHealthLaw.com.

P.O. Box 19268 Plantation FL 33318
954-964-1660

A message from our President

Dreaming

We are in the throes of change in healthcare. I found an article written many years Telehealth, I will say no more. The COVID-19
ago that was future facing and spoke to some changes that we were supposed to be pandemic has identified the need for us to continue
seeing in healthcare. Things like a vaccine against the common cold (2009), human to refine how healthcare can be delivered virtually.
cloning (2009), genetic therapy (2014), most diseases treated at home (2020) and, All these devices are collecting information and
by 2030, cancer, and heart disease will be wiped out. we are going to learn how to use it to our commu-
I am not sure about most of these predictions, but some almost came true! That nity advantage. How to improve treatment meth-
got me to thinking, “what are futurists saying is the updated vision of the future of ods, how to alert the general community about
healthcare?” Let’s take a few minutes and see. health risks, these benefits are all coming.
The University of California San Francisco sees in the year 2050 game-changing Finally, the ultimate benefit of all this technology Jaime Caldwell
predictions that include universal healthcare for all Americans, a pill to treat obesity, and data analysis is an improvement in health
oral male contraceptives, lab-grown organs, AIDS eradication, and interoperability outcome. With better data and analysis, treatments modalities will be more indi-
solved (yes, in 2050). Unfortunately, pandemics wiping out millions and superbugs vidually prescribed with the additional benefit of making healthcare more cost
proliferating are also in their future. effective (best treatment modalities the first time).
While I hope I am still here in 2050 and enjoying all the benefits of this new med- I saw another article that was “on the edge” but is likely going to be in our
ical reality, let’s look a little closer to home, say, 2030. I am much more comfortable George Jetson future (Google it). It said, “A microscopic robot is implanted
with these predictions as I can see a clear path to them coming true. inside your daughter at birth. Whenever an illness begins, before she feels a
Wearable technology measuring bodily functions becomes more generally avail- symptom, it sends alerts to you and her doctor. Immediately the doctor pre-
able and more affordable. Look at the number of people who already wear wrist- scribes genome-based drug therapies concocted for her biology and sends the
watches (1 in 3) that monitor several body functions. The current number of add- medication to you by drone. Your health is also monitored by sensory equipment
ons to your smart phones that allow you to do more advanced at-home monitoring. connected to remote specialists. Before you can feel a cancer symptom or travel
In the near future, these devices will also routinely monitor body temperature and to a distant hospital for a CT scan or MRI, nanobots collect tissue samples,
blood oxygen levels. replace damaged cells with healthy cells and absorb any toxins in your blood. Even
Genetic testing and genomic profiling will be widely used to identify inherited your elderly father with Parkinson’s no longer needs to be taken to his neurolo-
mutations and the genomic profiling will be looking for things that you picked up gist’s office; internal nanobots discharge dopamine in a specific location in his
along the way that have nothing to do with your heredity. brain.” Say it is so!

South Florida Hospital News southfloridahospitalnews.com January 2022 11