“The goal would be to produce a better clinical product at a lower cost.”
State law and the rules define an HCC as an entity that:
• Contracts directly with and arranges medical and health care services for insurers, HMOs, and other payers;
• Accepts and distributes payments for medical and health care services;
• Consists of physicians only; or a combination of physicians, hospitals, other health care providers, HMOs, or insurers; and
• Has an HCC license from TDI.
If done right, “these collaboratives can be quite innovative organizations,” said TMA Vice President for Medical Economics Lee Spangler, JD. For example, unlike the federal
payers to collaborate on more coordinat- ed, cost-effective health care delivery. Now that the Texas Department of In- surance (TDI) has adopted rules laying out a path to licensure as a collaborative, Texas physicians have a more flexible op- tion that overcomes many of the barriers preventing doctors from stepping into in- tegrated care models, says Asa C. Lock- hart, MD, chair of the Texas Medical As- sociation’s Ad Hoc Committee on ACOs. “The state-based collaboratives, by far,
offer Texans the best chance for success- ful and meaningful heath system reform because they can be simple and local, allowing for innovation in smaller com- munities,” he said.
While not without some checks and
balances, the rules relieve qualifying HCCs from antitrust pressures that tend to discourage collaboration among phy- sicians and others for fear of being ac- cused of collusion.
As a collaborative, players in the cur-
rent fragmented health care system can more easily “work together to develop new products for health care delivery that increase efficiencies in medicine and root out inefficiencies that don’t add value,” said Dr. Lockhart, an anes- thesiologist in Tyler. Equally significant, the rules preserve TMA-won protections “that recognize the sweat equity physi- cians bring to these organizations, and that can’t be shouted loudly enough. The
26 TEXAS MEDICINE June 2013
A state solution TDI adopted the new regulations in March to implement the HCC provisions authorized by Senate Bill 7. The legisla- tion won support from TMA, the Texas Association of Health Plans, consumer advocacy groups, and others. The Texas Hospital Association was neutral. The rules (
www.tdi.texas.gov/ rules/2012/
parules.html) took effect April 1.
important thing is these [collaboratives] are physician-led.”
TDI’s Jeff Hunt says the statute and
regulatory framework allow room for creativity in how the entities and pay- ments are structured, so physicians, hos- pitals, and other participants “can share costs, share information, and basically provide a better, more well-rounded health product.” He handles company li- censing and registration at TDI and over- sees the HCC application process. But officials also caution that the rules set certain standards that apply across the board to prevent abuse and protect patients. Those include an antitrust review by TDI in conjunction with the state at- torney general’s office. “And we are not really flexible when it comes to our ex- pectations on quality improvement,” said Matthew Tarpley, TDI health plan licens- ing administrator.
“shared savings” ACO models, payers can participate directly in state collabora- tives, which can sell all of their services in one fell swoop to offer patients a one- stop shop for health care. State regulations also provide flex- ibility on how payments can flow within an HCC, whether on a fee-for-service ba- sis or by using alternative mechanisms such as bundled or global payments or capitation models. Because physicians’ pay may be based on performance, an exemption from state antikickback laws permits doctors to refer within an HCC so they can ensure proper care, Mr. Spangler added. The rules also ensure the physicians, with their expertise, have a material voice in governing the collaboratives’ clinical and financial matters, Dr. Lock- hart noted.
If nonphysicians participate in an
HCC, the governing board must have an equal number of physicians and non- physicians, plus a tie-breaking member from the community. Physician board members also have a say in appoint- ing separate compensation and quality committees responsible for the payment methodologies and quality measures used by an HCC. Under federal ACO regulations, on the other hand, board representation is in proportion to the amount of capi- tal a member invests, Dr. Lockhart says. Those rules tend to encourage bigger players with the financial wherewithal
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