But one made a complete exit: the Everett (Wash.) Clinic. After six years working with Medicare to make accountable care work, the group practice preferred Medicare managed care, or Medicare Advantage.
Dr. Al Fisk, the chief medical officer for the clinic, said physicians suffered from two disadvantages under Medicare accountable care, a payment model being tested across the nation by Medicare and commercial insurers. Under accountable care, doctors agree to manage medical care and healthcare spending for a group of patients in exchange for the chance to share some of the money they saved—if they save money.
Fisk said Medicare accountable care does not let doctors know upfront which patients they are responsible for, even with rules that give providers a draft list of prospective patients. Under the clinic's six Medicare managed-care contracts, doctors know exactly which patients fall under their management.
Spending targets were the other sticking point. Doctors can keep a share of what they save Medicare under accountable care.
To demonstrate savings, accountable care compares health spending for a group of patients against the spending for other patients outside accountable care, which Fisk said proved to be too complicated.
The Everett Clinic's Medicare managed-care contracts—one of which is full capitation, or a lump-sum payment per patient—more cleanly identify expected spending, he said. If patients' care costs less than doctors are paid, doctors keep the remainder.
The clinic underscored its preference for Medicare Advantage when it announced it would accept only Medicare patients enrolled in managed care starting in 2012.
So doctors know with certainty whose care they must manage and how much that care is expected to cost under managed care, he said. “We like the clarity of that.”
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