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Update on the Affordable Care Act

It has now been five years since the Affordable Care Act (ACA) changes began. While many changes such as exchanges have been visible to the public, the real inner workings of the ACA have been a mystery to many consumers, providers and purchasers as the details escaped most media attention due to the complexity and politically supercharged atmosphere surrounding health care changes.

The economics of why this reform was needed in the first place has not been presented in a manner that is understandable to the public.

A Price Waterhouse Coopers survey in late 2010 conducted an in depth series of interviews with consumers as well as physician and hospital leaders. The research substantiated what most of us have observed – wasteful spending. That is spending that is not connected to care outcome improvement, quality or efficiency improvement. This spending was something that could be found in all levels within the health care system.

In some cases, as attempts to reign in one factor of the health care industry occur, what often happens is that it expands upon another factor of the industry. For example, as many of us fought hard to come up with ethical yet cost conscience guidelines to reign in utilization volume in the 1970s, the effect on pricing of service per unit increased substantially. By the same token, if one were to put a ceiling on prices and fee schedules, it was discovered physicians and hospitals simply increased the volume of services to make up for these fee caps. Our work with capitated IPAs in the early 1970s pointed out that even a capitated primary care medical group might see a reduction in price and volume but as the primary care group networked to other specialists and hospital outside the IPA to fill in for needed specialties the fee for service charges and open ended volume of services used by specialists offset whatever savings the PCP group may have achieved. This gave the entire physician panel a higher than predicted Per Member Per Month Total Cost of Care (TCOC).

One thing is certain; the magnitude of waste is staggering. It is estimated that between $1.2 and $2.2 trillion is on wasteful spending. This represents nearly 50% of all health care spending nationally.

This wasteful spending can be categorized into three broad areas of clinical waste, operational waste and behavioral waste.

Clinical waste is in the defensive medicine area where redundant testing and unnecessary or duplicative services are performed to protect the physician from accusations of shoddy care. This Price Warehouse Coopers (PWC) report has estimated to be $201 billion annually. In terms of operations, the wasted spending is mostly in inefficient claims processing which is another $210 billion. Finally, in terms of behavioral waste, we see preventable conditions such as obesity and being overweight which lead to diseases, such as adult onset diabetes; getting this under control would save $200 billion annually.

The survey concluded that while higher prices were to blame for some of the spending gap rather than just higher resources used, there are now global comparisons proving that there is a substantial opportunity to eliminate a large portion of waste from the system while still enhancing care outcomes for the patient.

As we redefine waste as something more than mere inefficiencies  in the system we now see purchasers including the large (and becoming larger) insurance industry buyers of care and Medicare, the nation’s largest insurer, now focusing on Preventable and Avoidable Costs (PAC) as a means to judge what is effective and therefore a necessary part of the care delivery system. This means that buyers and providers of healthcare have a grand opportunity of using the ACO to construct a better delivery system of the future that is both user friendly (patient as consumers) but substantially more effective and efficient than our current non-system of fragment care sites.

Innovations we see emerging are vast.  As health care now represents 18% of GDP it has become a leading sector of the economy attracting solutions and capital like no other. Part of this attraction has been the move to for-profit intervention bolstering weaker parts of these standalone components, thus allowing for their own maturity and growth. Part of this is the framework laid out by the ACA that, even five years later, is testing the earlier business model of health care management and delivery.

We view these themes and trends as transformative and not cyclical, because once they have occurred and people have led this change or adapted to it in their market there is no going back.

Risk is now the future

There is not a single health care book, magazine or newsletter being published today that does not subscribe to the trend towards Risk in the health care sector. Some call it value based payment and some call it capitation but the reality is that in order to control rising prices and avoid a corresponding rise in utilization, a more predictable pricing model and health outcome are demanded of health care providers.

Purchasers ten years ago were just beginning to use utilization data that HMOs used in the late 1960s to predict price and utilization in order to reset premiums and implement early versions of care management protocols for medical providers and case managers. Today billions are being spent on advanced processing, auto adjudicated claims processing and high end analytics. Soon, as ACOs expand, many hospitals and physician will be investing in access to these same tools either through ownership or outsourcing.  “If you cannot measure it you cannot control it,” goes the old saying and in this post reform environment we have many sources of metrics and tools for clinical decision support we never had before. The exciting introduction of a shared risk approach to provider contracting has brought private employers together with once estranged physicians as physicians have seen the value of becoming a High Performance Network as a private ACO to curry favor with employers or a preferred vendor to earn volume of net new patients in exchange for submitting performance data directly to the employer or employer coalition/network.

For providers the same principle of risk management applies as it does for every decision. You must first understand what the risk is. In other words what does the contract say you are at risk for? Are they bundles of care for a fixed price, fees plus, global all-encompassing by episodes of care, per diems, or are they fee schedules so onerous it seems futile to accept? Most of all, what is the volume of net new patients you expect to obtain from that employer or health plan in exchange for your fee concession? And what if it does not happen?

Then there is the means to manage the risk through reinsurance on the large claims and limiting liability on the front end in terms of being at risk for services you are good at providing and being at no risk for services that can get complicated very quickly.

Heath Insurance and Health Plans

We have made a separation between those health plans that are provider driven and community based versus those larger, for profit insurers that have dominated many markets for decades with little or no competition. For many employers, large and small, the lack of choice has numbed the potential for innovation.  They buy what’s “on the shelf” or listen exclusively to the broker that promised lower rates with a new carrier, only to see costs rise in three years and premiums sucking more from the bottom line.

Our observation of the shift to high deductible and high coinsurance has always been that if one delays access to primary care or sets in motion the fear of financial retribution for using an emergency room when it may be absolutely necessary only plays further into the waste of money in preventable and avoidable costs because many diseases, if caught early, will be manageable and even eliminated. However, if there is a $5,000 out-of–pocket, it is likely the patient will live with the pain until it becomes unbearable and then spend all the money, bury the deductible and be unhappy when the hospital demands monthly payments and unhappy with the employer for having “crummy insurance”. In short the employer pays more than it would have had the patient sought care earlier, the patient is in worse shape with possible loss of work and long term disability because care was not sought early, and the patient resents the fact the employer’s insurance would not “let” the patient go to the doctor until it got so bad.

We have not seen where the large deductible has actually been a good thing in preventing abuse of the care system as was originally thought, and, in fact, we believe many PAC opportunities were lost because of the financial barrier to receive care.

With new ACA rules for employers on the Cadillac tax (employers must pay 40% of an employee’s total health insurance costs  after $10,200 for individual plans and $27, 500 for family plans), a majority of employers in several surveys report they are encouraging employees to use the exchanges. Exchanges have had a large impact on both large insurers as well as smaller health plans in giving smaller plans a level playing field to be considered as an option.

This move from wholesale to retail insurance is something we have been so adamently advocating for both purchasers as well as providers because unlike the business to business approach of top selling insurance to groups, the providers may now have individuals that join or leave and insurers that favor the physicians or hospital as “in network”. This means competition to sell direct to consumers and participating in multiple carrier offerings is a strategic imperative for providers.

According to HHS APE’s Annual Open Enrollment report of March 10, 2015 there are about “11.7 million people enrolled in exchanges through the ACA marketplace. Of the 8.8 million people who signed up on the federal exchange 2.2 million had returned from 2014 to actively shop for this year’s health plan”. So the marketplace option is becoming ingrained in our culture and not just for the poor or uninsured but for the working consumer who has an employer that would rather get out from underneath the regulations.

Primary care: Back to basics.

From our perspective we envision the transformation of the delivery system to be the most essential and breathtaking component of the entire ACA.

Early on we saw private medical homes being constructed by pediatricians for their patients to reach out to specialty referral associates, and centers and other resources for the pediatric patient. This was quickly adopted by the primary care population to have more control over referrals and build small networks of resources upon which they could depend.  The ACA infused $11 billion into federally qualified primary care run health centers in medically underserved areas (MUA) because they saw the value of care coordination and care management for a population with chronic care needs but little assistance in managing through the health care non system.  Another $2 billion was offered to this primary care experiment by a new agency funded by the ACA called the Centers for Medicare and Medicaid Innovation (CMMI).

The call to integration in the 1990s and the early prognostication by us, the advisory board and others that risk was coming in the form of alternative payment mechanisms and that performance and the capacity to manage under strict risk would separate winners from losers, has indeed been reintroduced with the new rules.

This notion of capitation as the trigger point for payment reform came with the Clinton reform movement. Physicians and hospitals were taught what was already known in California, Minnesota and Massachusetts and that is that capitation can be a gold mine if you know how to manage it. As that reform fizzled so did the leadership to try and change the marketplace from the provider perspective. Change came instead from the health plans and employers with a demand for single signature contracts (PHO) clinical integrated delivery systems that were all encompassing. Employers demanded their managed care companies try and glue together the components of a good delivery system based on not just discounts but mostly on outcomes and quality measures.

If this starts to sound like an Accountable Care Organization you are starting to see the framework of what would become the ACA’s pride and joy to not only reform the delivery system structure (that is giving health care delivery a business model instead of a fragmented and redundant series of care outlets) but also change the payment plan with a series of shared savings incentives for quality and efficiency, and you were also seeing organizations get ahead of the ball with integration because they understood its value and its potency in a future marketplace. These clinically integrated systems are truly the early winners in reform.    

Think for a moment that in 2010 there was barely a definition of what an Accountable Care Organization was and now in 2015 we have over 640 ACOs operating with a new crop being added each January. Medicare has saved over $500 million while paying out an additional $400 million in bonuses to successful ACOs.  While some ACOs are still fighting to gain a better understanding of care management and especially the entirely new science of patient engagement, the private sector is now taking hold with the Pacific Business Group on Health and Boeing creating their own private ACOs to act as high performance panels and compete with the broader panels of older networks that continue to practice medicine as usual not understanding they will need to earn the employers’ favor and become part of the high performance network to thrive in a competitive market.

We now see the ACO as a business model to rejuvenate non risk IPAs and PHOs who may already be in violation of antitrust guidelines because they are conducting collective bargaining but taking no risk and are not clinically integrated. For new networks that are watching the large insurers merge into mega meds  who can demand incredibly strict guidelines and limited fee schedules, these ACO networks at least help physicians negotiate as a group for a territory so they have some say in the outcome of these third party negotiations.

There are now 5 types of ACO shared savings arrangements using different levels of risk and reward depending upon the track selected. Add to this the various contracts used by employers in negotiating network agreements and there is a tremendous opportunity for private practice physicians to participate as small practices but have the impact of a Group Practice without Walls.

For many Medicare Shared Savings (MSSP) Accountable Care Organizations there was a savings created for Medicare. However, due to benchmark and threshold variations only 25% of the MSSP ACOs made savings for themselves in addition to Medicare. These savings varied from $6000.00) to $15 million dollars depending on their size of attributed population and geographic location.

For those who have made money and learned to “tame the beast of excess” in their local delivery system the options are becoming clear that eventually they will have wrung out the savings, and each year there are less and less savings, there are less and less contributions to operational and maintenance costs. For many of these ACOs the move to a risk bearing entity is a possibility and building their own licensed health plan for Commercial and Medicare populations gives them stability of the three legged stool of private pay commercial, Medicare Advantage and ACO patient market segments. to support their medical management engine across more and more of their patient population.

New Entrants

While there is a serious attempt to consolidate the physicians, hospitals and insurers in this post reform environment there are some new entrants to the marketplace that can, and should be led by physicians or physicians and employers.

The theoretical model of industry consolidation plays out in health care as it does in banking, airlines and telecommunications, and that is when the bigger players like Aetna, Humana and CIGNA consolidate, it leaves a greater opportunity for new entrants to create a new market for their products and services.

The barriers for market entry are reduced because employers are dissatisfied with the prices or lack of benefits or overall lack of service from the bigger insurers and are willing to seek an alternative such as a physician owned health plan. Because these new community based health plans are owned by providers their pricing can be more favorable than the publicly traded health plans. More importantly, a physician driven plan emphasizes coordination of care, patient engagement and quality outcome indicators as a means to lower costs versus lowering costs through fee discounts or payment and benefit denials and delays which are tools of the big insurers.

We see the first new entrants to be ACOs that have succeeded in managing cost and utilization or those that are forced to extend their ACO after the year three savings have been taken out. We know that ACOs who succeed and learn to manage risk for the senior population have the opportunity to expand this knowledge to manage risk across more populations and this should be part of the growth strategy for providers but also an opportunity for employers including large self-funded employers as well as smaller employer groups .

Medicaid

In many states such as Colorado and Illinois, ACOs are also part of the Medicaid landscape managing large populations of the medically disadvantaged using some of the same coordinated care techniques used for the Medicare population. Probably the most overlooked yet most attractive population of ACOs moving to full risk health plans is the dual eligible population. This offers a substantial per member per month (3 to 4 times that of commercial) and coordinates the Medicare and Medicaid internal  payments so as to give this Special Needs designated Medicare advantage plan a special revenue opportunity to manage Medicare and Medicaid eligibles many of whom do not know they are eligible for both programs .

The next entrants will be integrated care systems and PHOs that have actually succeeded in negotiating with third party insurance companies but now see a market to directly contract with employers ( Books on direct contracting connects here). In many cases these organizations may see the ACO opportunity as a private population opportunity and using their existing framework they can move to a unified signature (single signature) arrangement with employers. Many of these IDNs have done a feasibility study on their ACO Medicare possibilities and found it is just not feasible because even at the fully managed status of their population (that is everyone is meeting or exceeding national guidelines for quality and outcomes), there still may not be enough of a bonus to make the investment of time and energy into a MSSP ACO worthwhile. However, contracting with private employers can be an early step to establishing a product for small and large payers as a provider sponsored health plan.

The third entrants will be those networks and IPAs that, for whatever reason have been a participant in insurance company schemes to provide care for enrollees but are, none the less, not seeing the promised market share or withhold payback in addition to fee for service payment. These IPAs and Networks can form a stronger enterprise but will need data and some staff to assist with measurements and reporting to help employers and payers understand they are able to provide superior care against competing physicians and hospitals in a given area. We have assisted IPAs in forming Management Services Organizations (MSO) to actually manage this function and contract with providers and payers at this level of the high performance network.

Collaborative Model

One of the newer models emerging is the collaborative model that joins together several smaller enterprises into a regional operating company  that takes the responsibility of managing these enterprises as a “back office” but are none the less able to eliminate redundant expense of maintaining an ACO, MSO, or PHO.

These are being created in answer to the reality that a small ACO with 5000 to 7000 members will have a difficult time recover their development costs of $3 to $4 million plus ongoing maintenance costs of $2 million. Much of this cost is in hardware, software, and staffing which, if consolidated, could be a shared expense between three or more enterprises. In broad terms the staffing cost could be cut by two thirds once the new relationship is set up with this back office. IT costs, a continuing and expanding expense for all ACOs and MSOs, could be cut substantially with a data warehouse and centralized technology that could share best practices. In other words three buyers could get more for their money than a single buyer and the sophistication of everything from analytics to billing can be demystified by having highly trained staff and resources purchase across the platform versus trying to hire locally. We have such a model in development in Minnesota and Illinois through our client Gold Star Alliance for Health LLC.

Management Services Organizations

MSOs have actually expanded, offering overhead reduction programs for the network practices in areas of group purchasing, medical malpractice insurance reduction, staff leasing and insurance and property leasing. In short, giving the alignment of independent practices the look and feel of a group practice without walls.

Additional entrants being created by the ACA include single specialty ACOs that contract with larger ACOs for their services on a shared savings bonus plus fees basis, and high performance independent pharmacy networks. Not unlike the physicians, independent pharmacy is being threatened by the big box stores and chain drug stores, so forming a local network and contracting directly with employers as well as collectively bargaining with Insurers is an option to stay in the game.

In addition telehealth companies are being created as standalone enterprises to connect patients and clinicians via technology (Vivre Health and All HealthCare are examples). As health care has become more complicated, consumer literacy is relevant and standalone companies like Zest Health and Azumio are growing to help consumers make good decisions.

Throughout our update we have talked about streamlining process improvement. Companies like Dabo Health and Medisas are addressing this area.

The wellness industry is exploding as well, with industry estimates of $267 billion in potential market share for companies that offer insurance related wellness plans or standalone individual wellness programs for patients.

Summary

The ACA has driven many physicians and employers to rethink how and why they are making decisions to join various insurance schemes and are starting to look for new partners. Many markets have become frozen with many players locked out because they did not take the managed care onslaught seriously or they did not know they could be locked out. With new entrants and consolidation of older players we are seeing a rebirth of new options. While the market unfreezes there are opportunities to get back into contracts with new startups, and there is a need for physicians to sponsor new enterprises that meet the contemporary needs of employers and consumers. 

Pendulum HealthCare Development Corporation's management team has worked with a variety of physicians, hospitals, employers, health plans and provider networks in startup, expansion and turnaround situations. Our goal is to revitalize interest in local delivery system transformation by helping physicians design risk and incentive plans that reimburse doctors based on quality outcomes not just the number of patients seen. Hospitals and health systems are critical to managing inpatient costs through efficient use of clinical standards, chronic care management support and alignment of the delivery system.
We firmly believe employers have options at the local level to improve both quality and access to affordable care through collective action and direct contracting with physicians.

Performance Management System and Incentives

This is accomplished through a sophisticated medical management system tied to a powerful marketing capability that balances growth with care improvement. The system moves away from traditional utilization review and the expectation of cost management through manipulation of price and volume, but instead works toward measuring success of care delivered in terms of actual outcomes.

Both physicians and hospital databanks are used to help physicians to link evidence based care to rewards that benefit the patient and the employer. (With the interest in employers increasing deductibles and coinsurance, patients and employers are interested in making sure they are able to identify the best doctors that offer the most value in terms of efficiency and effective care, not just the cheapest doctors.)

Management Team

Our team comes from a variety of backgrounds and experience. The Shared Vision of the client is viewed by specialists in finance and operations and marketing and management, is seen by clinical analysts, and complemented by medical management staff, organizational development and technology professionals. All have worked in more than a single corporation, have 20 plus years of experience and are required to follow the Consultants Code of Ethical Standards.

Board of Directors and Advisors

Our Board represents physicians, government directors, association executives, academics, entrepreneurs in banking and technology as well as investors.
We also have technical advisors including actuaries, attorneys, infomaticists, software developers and health information exchange professionals.




Health Reform and Your Business

Wednesday, March 19, 2014 • 7:30 a.m. – 9:30 a.m.
University Club of Rockford

The Private Client Group of U.S. Bank cordially invites you to join us for a special presentation about the Affordable Care Act and how its current status relates to impacting small business, consumers, physicians and hospitals. The featured speaker is Mr. DeMarco.


Alexandria Virginia

Accountable Care Organizations
Sponsored by World Congress May 17th and 18th
Hilton Alexandria Mark Center

Mr DeMarco will present a half day workshop on ACO Development


Miami Florida

Complex, Chronic& Costly Medicare Cases
Sponsoredby HealthCare Education Associates and
The Risk Adjustment Initiative April 16- 17th
JW Marriot Marquis

Mr DeMarco and Brian Wolf MD senior Medical Director for Rhode Island Blue Cross & Blue Shield will present on "turning data into and effective actionable care program".


Boston

World Congress’s 9th Annual Health Care Quality Congress on August 1-3, 2011

Dr Bauer and Mr DeMarco will be conducting a 4 hour workshop on Stategy design for performance based contracting.


Chicago Ill

4th Annual Executive Forum & Expo on HealthCare Payment Connectivity Solutions scheduled for July 26-28, 2011 HealthCare Payment Connectivity workshop

Mr DeMarco will address Accountable Care Organization Infrastructure
Chicago Marriot OHare
Rachel Sachs • Conference Coordinator • World Research Group
Phone: (781) 939-2555
Fax: (781) 939-2687
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.


Thursday, July 21, 2011
1:00pm-2:30pm EDT, 10:00am-11:30am PDT
Early Registration Discount Deadline, Friday, June 24, 2011

Add to Your Calendar > Add to Calendar

I am pleased to announce that I will be speaking in an upcoming live phone/web seminar entitled "Physician-Hospital Clinical Integration: Navigating the Complexities" scheduled for Thursday, July 21, 1:00pm-2:30pm EDT.

Effective clinical integration of hospital-physician systems will be a core element of healthcare delivery. Providers must transform current systems into integrated healthcare models to meet the incentive requirements established in the Patient Protection and Affordable Care Act (PPACA).

Healthcare providers must also understand the requirements for clinical integration, which is essential for healthcare providers to participate in accountable care organizations (ACOs) and other new public and private healthcare delivery and payment arrangements in the wake of the new PPACA.

My fellow panelists and I developed this program to prepare attorneys for healthcare providers to structure clinical integrations, including complying with applicable antitrust law, anti-kickback/Stark/CMP law, and the requirements under healthcare reform.

We will offer our perspectives and guidance on these and other critical questions:

  • What are the core elements of a clinically integrated provider network within the meaning of the antitrust laws?
  • What issues do ACOs face under anti-kickback and Stark laws?
  • How do service contract arrangements have to be structured to avoid jeopardizing the hospital's tax exempt status?

May 25th 26th

The World Congress Health Insurance Exchanges conference

Mr DeMarco will address issues of Private and Public Health Exchnages, thier background in the law and current status as health reform transitions to reality. www.worldrg.com


Wyndam Chicago
May 22nd - 24th 2011

Mr DeMarco will Conduct a Workshop on ACO Design and Development

Click to Download PDF


May 9th 10th

World Congress 2nd Annual leadership Conference on

Network Optimization
Boston Massachusetts Bay Hilton
Mr DeMarco will conduct a workshop on ACOs and beyond, thier future in private markets and current proposed Medicare regualtions.


February 17th 2011

Physician Hospital Clinical Integration

Mr DeMarco will be participating with Mc Dermott Will attorneys on the topic of clinical integration and antitrust issues in forming ACOs. Issues will include steering clear of Stark violations, Civil Monetary penalties and general Federal Trade Commission issues with recent decisions. Mr DeMarco will offer practical do's and don’ts in the planning and implementations of ACOs.


September 25th

Lake Geneva, Wisconsin

Keynote Speaker for North American Medical ManagementAnnual leadership retreatPresentation on health reform and its impact on Physician owned enterprises. Clinical Integration, Medical Management and ACOs are discussed


Boston August 2-4

Health Care Quality Congress

Colonnade Hotel
Physician - hospital integration as it relates to organizational and reimbursement changes.
Mr. DeMarco will be participating as a panelist in a discussion on why the organizations who desire to be integrated must be willing to change their reimbursement and compensation programs and create a new organizational and management structure to avoid failures of the past.
Sponsored by World Congress. www.worldcongress.com


Chicago July 26-28

Healthcare Payment Solutions Summit

How to Capitalize on Financial Tools and Innovative Technology to Advance Connectivity & Reduce Administrative Costs Healthcare banking technology is leveraged to deliver value in consumer-driven healthcare benefit design, and assist providers in collecting upfront payments, posting payments electronically, achieving electronic fund transfers, and streamlining electronic remittance advice. This workshop delivers participants with opportunities to capitalize on cost-effective, consumer-centric tools to advance consumer-driven healthcare product design and streamline payment transactions through banking technology. Session learning objectives include:

    • + Add value to CDHP products with card designs linked to tax-advantaged accounts
    • + Recognize the latest in debit card designs and vendor selection
    • + Tie point-of-service information and eligibility screening to card designs to enhance upfront payment
    • + Enhance automation with integrated payment solutions that include Electronic Funds Transfer (EFT), Electronic Remittance Advice (ERA) & Explanation of Payments (EOP)
    • Sponsored by World Research Group

www.worldrg.com


May 11th through 13th 2010

Network Contract Optimization Conference

This annual conference will present on a variety of issues including payment and networking options for new and existing provider and health plan operations. Mr DeMarco will host a half day seminar on ACO formation on May 11th.
Maximizing Business Opportunities with Accountable Care Organizations and the Impact on Health Plan Network Contracting
Topics include
Where states are moving regarding ACOs?
What types of reporting and data transfer may be necessary?
What are the business opportunities?
He will also be participating as a panelist in
Leveraging Data to Optimize Provider Networks &
Strengthen Sales Resources
The panel will discuss
Creative network development
Contracting with employers
Reimbursement options
Sponsored by World Research Group
www.worldrg.com


April 28th, 2010

Webinar

Accountable Care Organizations, A new pathway for Physicians and Hospitals
Presentation will cover several case studies of ACOs emerging and in operation as well as key issues of implementation.
http://healthwebsummit.com/aco042910.htm
Sponsored by MCOL


March 05 2010

Accountable Care Organizations March 2010

Accountable Care Organizations was discussed by William DeMarco and Michael Barrett President of Ascendent Health Celebration Florida Presentation on the background and requirements in forming an Accountable Care Organization under the newly approved health care reconciliation bill. There are many opportunities for providers and health plans to develop the next generation of integration with Accountable Care Organizations as the structure. Different from Medical Homes, ACOs cover a larger breadth of providers and are therefore able to connect with more benefits offered by Medicare or commercial payers. However the requirements, as they stand today, demand providers be organized as a contracted network with proper reporting in place and the ability to alter reimbursement to accept bundled payments.

Webinar Sponsored by


February 18th 2010

Mr DeMarco presented at the annual managed care event sponsored by the Health care Financial Management Association for the local Chicago Chapter of HFMA
He discussed performance based contracting and Accountable Health Organizations as part of his discussion on reform.
Sponsored by HFMA


January 21, 2010

MCOL invited Mr DeMarco to participate in the future oif healthcare workshop. Bill presented on where Accountable Care Organizations and Value Based Purchasing intersect for an audience of administrators and physician executives.
Sponsored by MCOL


October 19 2009

Washington DC

Presentation
Entering the Retiree Market: Feasibility and Execution of the Business Plan

  • Retiree Research and Building a feasibility statement
  • Wellness programs and disease management: Supporting at-risk retirees
  • How the medical homes concept ties into retiree coverage
  • Exploring VEBAs
  • Incorporating consumer-driven methods

Opal Events coordinates leading pharmaceutical and investment management conferences across the United States, Europe and South America. These events provide delegates with the necessary information and networking opportunities to help their business grow in today’s competitive environment. More: www.opalevents.org


March 19th -21st

The Health Ministry of the country of Turkey invited Mr DeMarco to address the 1000 delegates at their conference in Antalya on the topic of American Pay for Performance and health reform.
Delegates from Crete, England, Egypt, Cyprus, World Bank and European Union as well as Israel, Jordan, Russia and the Ukraine met with Mr DeMarco.


October 06 2009

Heath Reform

New York
Presentations on Health Reforms for a private group of investors in health care Reform background and impact will be discussed including Medicare advantage cuts, physicians pay fix, senate and finance committee rules and savings estimates confidential.


September 23rd 2009

Evaluating the Impact of MS-DRGs, POA Indicators & Non-Payment of Never Events for Health Plans

Chicago Ill Presentation and 3 hour workshop on ICD 10 MSDRG and developing reimbursement shifts towards a value based purchasing environment. http://www.worldrg.com


March 19th -21st

International Pay for Performance

Antalya Turkey
August 2008
Boston Mass

In August the Sixth Annual World Leadership Conference on Quality will be held in Boston, Massachusetts. The focus will be topics on quality management and improvement. Mr. DeMarco will conduct a workshop on Quality Measurement and Management of Data to Further Reimbursement and Market Share. He will share the podium with the Director of Medical Management from Physicians United in Michigan. Physicians United is a large IPA of physicians who aggressively market to health plans and employers to obtain patient flow for their several hundred members. Using the Quality Measurement and Management System used by Pendulum Health www.pendulumhealth.com the case study will emphasize real world applications for these data concepts.
www.worldcongress.com


June 2008
The Annual National Institute will be held by Healthcare Financial Management Association in Las Vegas June 23, 24, and 25. This is an annual meeting for health care finance and operations executives to update their skills and certifications in finance, managed care and technology. Mr. DeMarco will speak on Performance Based Contracting and will attend several association meetings as part of this group meeting. www.hfma.org


May 2008

Alexandria Virginia

A session on Medicare Employer Group enrollment will be sponsored by Financial Resource Associates on May 19th and 20th in Virginia during the annual Medicare Advantage meeting. Mr. DeMarco will address the issues and opportunities in enrolling retirees in an employer’s healthcare plan using the Medicare Advantage products. Additional speakers include Gorman Group, CMS department representatives, Milliman and others.
www.frallc.com


April 2008

Honolulu Hawaii

A session on Performance Based Contracting will be presented to the Health Care Financial Management Association Hawaii Chapter on April 24th. The session will cover issues of quality measurement and health plan contracting with providers in an era of performance reporting.
For further information contact the HFMA Hawaii chapter or its President
Keith R. Ridley [ This email address is being protected from spambots. You need JavaScript enabled to view it.]


March 2008

Chicago Illinois

DePaul University Graduate School of Entrepreneurship will host a special lecture by Mr. DeMarco on Consulting and Change Management. Mr. DeMarco has been asked to return to his alma mater to discuss with student entrepreneurs the perils and advantages of starting your own business and dealing with startup issues for new technology and health care companies. Mr. DeMarco will share his experience of starting his own company as well as working with investment banking and venture capital enterprises in conducting market research and business plans to implement creative strategies for new products and services. www.management.depaul.edu


February 2008

Teleconference

A teleconference on Managing Consumer Driven Health Plans will be hosted by the HealthCare Financial Management Association on February 20, 2008 from 1:00 to 2:30 PM CST. This session is part of the national Revenue Cycle Workshop series offered annually on a variety of topics. Mr. DeMarco will discuss consumer driven product formation, banking and insurance consolidation and present solutions for hospitals and medical groups in managing high deductible plans.
Managing Consumer Driven Health Plan Products
February 20, 2008, 1:00-2:30 pm Central


January 2008

Chicago Illinois

Mr. DeMarco will lead the opening workshop on “Discovering the Convergence of Banking and Insurance” on January 28th and 29th at the University of Chicago, Graduate School of Business, Gleecher Hall.
The seminar is sponsored by the Institute for Quality and Productivity New York.
The topics to be covered in his session will include Why Industries Have Joined Forces, or HSA Product Evolution, Market Depth and Financial Opportunity, and Successes and Failures in this New Market. Additional sessions will be presented by USBANK, Exante, Humana, Fifth/Third Bank, Blue Cross Florida, and McDermott, Will and Emory.
The World Congress 2nd Annual Leadership Summit
Sheraton Premiere at Tysons Corner - Vienna, VA
HFMA Chicago Chapter
University Club
Mr DeMarco will give the keynote address on Health Reform
discussing issues affecting hospitals and physicians.


February 10th and 11th 2011 Orlando Florida

Emerging Programs & Models for Medicare Care Management Conference

Mr DeMarco will be sponsor and MC this event for Fiancial Resources LLC.
he will also presnt on ACO formation and management.
www.frallc.com


November 15th -17th 2010

Network Contract Optimization Fall Forum
Wyndam Orlando Resort Orlando Florida
Mr DeMarco will conduct a pre conference workshop on November 15th on
Maximizing Business Opportunities with Accountable Care Organizations and the impact on health plan network Contracting
How health reform proposals are going to have a long term effect on plans and providers, Information technology requirements and business opportunity for providers to establish their own ACO.
Sponsored by World Research Group
www.wrg.org


November 1-2, 2010

San Juan Puerto Rico

Mr DeMarco will address the Accountable Care organization for a gathering of health plan executives and provider organizations as part of the Medicare Advantage Strategic Business Symposium sponsored by Opal Events
La Concha, A Renaissance Resort, San Juan, Puerto Rico
www.opalevents.com April Stearns
Para traducción en español clic aqui


October 20th

Atlantic Information Services Webinar

Joined by RANDALL KRAKAUER, M.D., National medical director at Aetna, Inc and BRUCE FRIED, J.D., partner in Sonnenschein’s national Health Care and Public Law & Policy Strategies groups Mr DeMarco will address topics concerning the national ACO landscape for providers and payers interested in pursuing ACO development and expansion.
www.ais.com
Stephanie Woodrow


October 8th

MCOL Webinar

Inside the ACO
Presentation will address the more detailed topics of governance, bundling and Information technology requirements to create the sustainable platform for providers to move to ACO management


September 9th October 14th Webinar

Sponsored by Strafford Publications www.straffordpub.com Phone: 1800 926 7926

Pendulum HealthCare Development Corporation and DeMarco & Associates play an active role in the managed care industry through presentations, seminars, writing projects, articles published in leading managed care industry publications, committee participation and membership in associations. Follow the links below to learn more about Pendulum HealthCare Development Corporation and DeMarco & Associates' role in the ongoing dialogue and information exchange in managed care.

Author Projects

Authored by William J. DeMarco, president and CEO of Pendulum HealthCare Development Corporation and DeMarco & Associates

"Performance Based Medicine: Creating the High Performance Network to Optimize Managed Care Relationships"

William J. DeMarco MA CMC
Published by CBC Press

Available on Amazon.com. Price: $69.95

Cat. #: K10654
ISBN: 9781439812884
ISBN 10: 1439812888
Publication Date: July 30th, 2011
Number of Pages: 300

"Physician Driven Health Plans: Innovative Strategies for Restoring Physician-Community Integration"

by William J. DeMarco MA CMC and Kenneth M. Hekman
Published by McGraw Hill

Now available from the author or on Amazon.com

"Advanced IPA Management: Direct Contracting"

by William J. DeMarco MA CMC
Published by McGraw Hill

Available on Amazon.com

"Going Prepaid: A Strategic Planning Decision"

by William J. DeMarco MA CMC and Thomas J. Garvey MHA
Published by the Center for Research on Ambulatory Health Administration

Available on Amazon.com

"Advanced IPA Management: Opportunities for IPAs Under the New Medicare"

by Jennifer Marx, Consulting Analyst, DeMarco & Associates
Published by McGraw Hill

Available on Amazon.com

 

Part of the HFMA Healthcare Financial Management Series and endorsed by The IPA Association of America, this book addresses the recent introduction of new Medicare product options, such as PSO, PPO and medical savings account plans, and explores the implications and opportunities now present for IPAs who are currently, or plan to be providing services to Medicare beneficiaries.

Collaborative Projects

DeMarco & Associates and Pendulum HealthCare Development Corporation works with other leading-edge organizations such as InterStudy to collaborate on monographs or contribute chapters to books on relevant and timely managed care topics.

"Capitation: Tools, Trends, Traps and Techniques." Chapter 10. Medicare: Capitation Under Risk, published by Practice Management Information Corporation, 1998.

www.medicalbookstore.com

"Integrating the Practice of Medicine: A Decision Maker's Guide to Organizing and Managing Physician Services." Chapter 19. The Management Services Organization Industry, published by American Hospital Publishing, 1997.

InterStudy, Managed Care Pathways Series: "Medicare Strategy" a monograph authored by William J. DeMarco, President and CEO, DeMarco & Associates with a foreword by Dr. Paul M. Ellwood, President, Jackson Hole Group.

Pendulum HealthCare Development Corporation

Address

2990 North Perryville Road 
Rockford, Illinois 61107

V: 815.387.2001
F: 815.877.8802

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