Ophthalmology Adds Value in an ACO-like Setting

The specialty fits well with primary care.

By Jennifer Mcclean, MHA , CMPE

While ophthalmology practices have heard a great deal about the impending formation of numerous multi-specialty accountable care organizations (ACOs) throughout the country, thus far ophthalmology has been largely untouched by the effects of practicing in a highly incentivized ACO environment. Indeed, the ACO and ACO-like healthcare organizations that have been formed to this point have mainly been smaller systems that have fallen under such categories as pilot, demonstration and “Pioneer” programs.

For ophthalmology practices contemplating their future role in an ACO, the following article, by Jennifer McClean, the vice president for Strategic Initiatives at the Mercy Clinic in Springfield, Missouri, provides a positive view of how ophthalmology can be successfully integrated into a real-world, multispecialty, incentivized provider environment.

For independent ophthalmology practices thinking about their potential place in an ACO or ACO-like structure, William L. Rich III, MD, medical director of health policy for the American Academy of Ophthalmology, advises that the unique nature of the services provided by ophthalmologists lends itself best to participating in several ACOs but not being tied exclusively to one such system.

In 2005, before the advent of ACOs and the Shared Savings Program, the Centers for Medicare and Medicaid Services launched the Physician Group Practice (PGP) Demonstration. Like ACOs, the PGP Demonstration offered participants the opportunity to earn incentive payments for improving the quality and cost-efficiency of care delivered to Medicare fee-for-service beneficiaries.

St. John's Health System (now Mercy Clinic), in Springfield, Mo., was a PGP Demonstration participant. The health system had 600 physicians across the region, including five optometrists and 10 ophthalmologists (some of whom practice in corneal, retinal, glaucoma and pediatric subspecialties). As it turned out, the inclusion of ophthalmology in the demonstration proved crucial to helping the health system improve care quality and earn millions of dollars in shared savings and PQRS incentives over the five-year program. Here are some of the reasons why it was so important to involve ophthalmology, as well as some of the lessons we learned along the way:

Integration. During the demonstration, 41 clinical quality measures tracked the management of patients with diabetes, congestive heart failure, hypertension, coronary artery disease and chronic obstructive pulmonary disease. They also traced preventive, frail elderly and transitional care. As noted by ophthalmologist Shachar Tauber, MD, director of Ophthalmology Research for Mercy Clinic Eye Specialists, and director of the Cornea and Refractive Surgery Division, enterprise-wide accounting and management of the status of the eyes — especially for diabetic patients — increased upon participation in the demonstration.

Any provider could pull up a checklist and see, for example, if a diabetic patient was due for an eye exam, foot exam or updated HbA1c score.

According to primary care department chair James Rogers, MD, “We believe our integrated model helped tremendously in data sharing and the ability to speak openly and freely about patient care.” One example: use of wide-field retinal imaging devices in primary care offices, sending digital retinal images taken in the PCP office to the ophthalmologists. In an alarming number of cases, ophthalmologists identified early symptoms of diabetic retinopathy and other disease in otherwise asymptomatic patients that likely would have resulted in permanent vision loss had they gone undetected.

Ownership. Dr. Tauber observes that the demonstration also encouraged ophthalmologists to begin taking more holistic ownership of patient care, with a particularly positive effect on diabetes outcomes. Earlier detection of diabetic retinopathy, glaucoma, macular degeneration and hypertension have not only helped reduce costs but have improved patient care. When illness typically treated by other specialists is suspected at the point of care, physicians now are empowered to order labs, imaging or referrals directly from the ophthalmology office — opening communication channels with primary care physicians and other specialists that were not well established before the PGP Demonstration.

Transparency. Ophthalmologists have access to the same electronic disease registry and laboratory results database used by primary care and other specialty physicians. This allows physicians to view real-time progress toward quality benchmarks. In addition, it improves communication between multidisciplinary teams the health system established to analyze and boost performance on quality benchmarks.

Every practice's and every physician's quality scores are visible. This level of transparency not only motivates competitive spirits, but also helps the health system find top performers who can share best practices with their colleagues.

Incentives. As Mercy predicted, significant upfront investment was necessary for PGP participation. During the first two years of the program, the organization did not reach the savings threshold required to earn CMS payments. Nevertheless, it still hit 100% of its quality measures during those years. Since then, it has achieved millions in shared savings each year and no less than 96% quality. Patient satisfaction scores also increased upon introduction of the demonstration program.

As Dr. Rogers explains, participation in the PGP Demonstration project was initially viewed as an opportunity to better use data and care management to improve patient outcomes.

“Our ability to coordinate services between primary care and ophthalmology helped us address disease management proactively, meet quality markers, improve outcomes and lower costs — especially for diabetic patients,” Dr. Rogers explains. “In the end, this collaborative approach has proven to be right thing to do for all of our patients,” he concludes. OM

Jennifer McClean, MHA, CMPE, is Vice President of Strategic Initiatives, at Mercy Ambulatory Care and Mercy Clinic.