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Soon they may get their way. Two separate bills in Congress — one in the Senate (SB 146), the other in the House (HR 475) — are gaining strong bipartisan support and could win passage this year.
If passed, the legislation essentially would enable provider groups to pursue Medicare risk contracts without necessarily meeting state licensure requirements that normally apply to bona fide health maintenance organizations (HMOs). The U.S. Department of Health and Human Services (HHS) would create oversight standards that would conform with state licensing criteria.
Meanwhile, the White House has proposed its own measure. The Clinton administration’s budget, which was unveiled in February, carries a provision that gives the HHS the authority to grant waivers to PSOs that wish to operate in a state under a full- or partial-risk contract.
If lawmakers approve any of these measures, some health care organizations say the number of PSOs that rush into the market to win risk contracts will mushroom. "Yes, we would not hesitate to seek a HCFA contract immediately," says Sally A. Arnaud, RN, vice president of administration with Paramount Physician Network, a 900-member independent practice association (IPA) in Denver.
But while hospitals and medical groups are cheering the prospects of direct contracting, some are taking a closer look at the situation. "[Providers] are going to develop a healthy respect for the competencies of insurers," says Frederick B. Abbey, MPA, a partner with Ernst & Young in Washington, DC.
In all likelihood, the HHS isn’t going to depart radically from applying standards it currently uses on insurers, says HCFA official. If so, providers are in for a tough screening process.
HMOs are typically put through a maze of qualifying prerequisites, such as proof of financial solvency, including cash and non-liquid asset reserves. They also have to demonstrate proper levels of patient access, efficient billing and claims processing capabilities, and sufficient commercial risk experience.
The agency sets a minimum 5,000-member commercial enrollment criterion for HMOs before a plan qualifies for Medicare risk (1,500 in rural areas) and prohibits insurers from having more than 50% of their entire membership enrolled in Medicare managed care.
The pending legislation sets even tougher standards for PSOs, including a complex formula for determining net worth (beginning at more than $1.5 million), and implementation of a rigorous internal quality assurance program.
Knowing these facts, providers don’t seem daunted. In the areas of quality and service, large integrated systems are likely to pass muster, says Alan Yordy, CHE, MBA, chief executive officer of Mid-Valley Healthcare, a system of three hospitals and 100 physicians based in Lebanon, OR.
In Yordy’s opinion, the ability of PSOs to directly control quality and utilization automatically raises the organization’s net worth, which should lead HCFA to loosen its solvency requirements.
But even Yordy admits that direct contracting is fraught with pitfalls. "It’s a very difficult business. Unless you can accept full risk for at least 80% of the care that’s delivered, I wouldn’t touch Medicare managed care," Yordy cautions. And there are other perils:
• The enormous amount of working capital required will certainly hamper providers, especially in the initial stages of the contract, Abbey says. Estimates vary, but some providers put the figure at $1.5 million at least. To raise the capital, many will have to affiliate with deep-pocketed partners such as an insurer or regional network, says Abbey.
• The lack of any long-term actuarial experience with Medicare risk patients and the time it takes to grow enrollment to a sufficient size to defuse risk will test a provider’s resolve, Yordy says.
Some estimates call for minimum enrollment volume at between 3,500 to 10,000. But volume alone isn’t an indicator of future success, says Abbey. The more lives you cover, the higher the potential for practice variance — and, therefore, the higher your exposure to risk.
• Cuts are likely to widen in the 95% portion of the annual adjusted per capita cost index, HCFA’s key measure for Medicare HMO reimbursement rates to providers, which is based on geographic averages. The removal of graduate medical education (GME) from the HMO payment formula as proposed in the Clinton budget also is likely to cut incomes.
• Competition, especially from rival health plans, is not going to make it any easier for PSOs, says Michael P. Lance, CPA, chief executive officer of PennMed Member Services Company in Harrisburg, PA.
In fact, a PSO can seriously hurt its commercial business by competing with a contracting HMO. "When you begin taking away their Medicare business, I doubt if they’ll take it mildly," says Lance, whose organization develops integrated networks as a subsidiary of the Pennsylvania Medical Society in Harrisburg.
Ultimately, providers will have to ask themselves whether a risk contract is truly worth the risk and the capital investment, or "whether remaining downstream in the [contracting] process is a wiser course," says Abbey.