Perspectives

A new report finds that 49% of surveyed primary care physicians expect to participate in an accountable care organization in the next year. Twenty percent already are in ACOs, and most of them are contracting with commercial payers and Medicaid.

Why this dramatic jump? At the end of the day, it is all about the shift from volume-based reimbursement (fee for service) to value-based reimbursement. ACOs are a means to an end, not the end itself. If we will get paid for squeezing waste out of our current system and look at the best way to do it, the elements of an ACO logically fall into place.²

We attribute the big jump in primary care participation to three main factors:

1. Primary care will drive value.

The highest-impact targets for ACOs are:

• Prevention and wellness.

• Chronic disease management.

• Care transitions and navigation.

• Reduced hospitalizations.

• Multispecialty care coordination of complex patients.

While not a monopoly of primary care, all of these opportunities are in your wheelhouse. That is why the Medicare Shared Savings Program ACO regulations correctly require every ACO to include primary care providers. Consequently, primary care providers are being heavily recruited by ACOs.

2. Primary care will derive benefits.

Most ACOs are compensated by receiving some percentage, usually 50%, of savings for a patient population if quality and patient satisfaction metrics are also met. For an ACO to be successful, distribution of savings should be in proportion to their contribution. Primary care physicians should contract only with ACOs that recognize this fundamental connection.

The distribution must be an incentive for every participant to contribute as much value as possible. That will not happen unless the savings distribution is based on merit. As noted, primary care stands to contribute more value, and thus merit more distributions, than any other ACO participant.

The dysfunctions of the fee-for-service system have left primary care underpaid. Now, with the compensation model shifting leverage from costs to savings, primary care physicians are stepping up to close this gap.

3. Primary care is realizing that ACOs are for real.

The move to value-based reimbursement is being driven by unsustainable health care costs, not "Obamacare" or the U.S. Supreme Court. The "fiscal cliff" will have more impact on the growth of ACOs than the Affordable Care Act, as it is forcing us to look at the main drivers of the deficit – entitlements such as Social Security, Medicaid, and Medicare. Notwithstanding, many physicians were waiting until after the election to get serious about ACOs.

3a. This column

(Just kidding!)

So, for these reasons, it is not surprising that primary care physicians are now jumping into ACOs. That said, it is still pretty startling to see a 250% increase in 1 year, which was probably a 250% jump from the year before. Thank you for stepping up to help save American health care.

References

1. Accountable Care Organizations: How Will Payer and Provider Adoption of This Model Impact Prescribing Trends in Cardiometabolic Diseases? Decision Resources, October 2012.

2. As covered in prior articles, besides value-based reimbursement, there are seven other essential elements for a successful ACO: primary care, culture, administration, information technology, patient engagement, scale, and best practices.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians to form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or 919-821-6612.

A new report finds that 49% of surveyed primary care physicians expect to participate in an accountable care organization in the next year. Twenty percent already are in ACOs, and most of them are contracting with commercial payers and Medicaid.

Why this dramatic jump? At the end of the day, it is all about the shift from volume-based reimbursement (fee for service) to value-based reimbursement. ACOs are a means to an end, not the end itself. If we will get paid for squeezing waste out of our current system and look at the best way to do it, the elements of an ACO logically fall into place.²

We attribute the big jump in primary care participation to three main factors:

1. Primary care will drive value.

The highest-impact targets for ACOs are:

• Prevention and wellness.

• Chronic disease management.

• Care transitions and navigation.

• Reduced hospitalizations.

• Multispecialty care coordination of complex patients.

While not a monopoly of primary care, all of these opportunities are in your wheelhouse. That is why the Medicare Shared Savings Program ACO regulations correctly require every ACO to include primary care providers. Consequently, primary care providers are being heavily recruited by ACOs.

2. Primary care will derive benefits.

Most ACOs are compensated by receiving some percentage, usually 50%, of savings for a patient population if quality and patient satisfaction metrics are also met. For an ACO to be successful, distribution of savings should be in proportion to their contribution. Primary care physicians should contract only with ACOs that recognize this fundamental connection.

The distribution must be an incentive for every participant to contribute as much value as possible. That will not happen unless the savings distribution is based on merit. As noted, primary care stands to contribute more value, and thus merit more distributions, than any other ACO participant.

The dysfunctions of the fee-for-service system have left primary care underpaid. Now, with the compensation model shifting leverage from costs to savings, primary care physicians are stepping up to close this gap.

3. Primary care is realizing that ACOs are for real.

The move to value-based reimbursement is being driven by unsustainable health care costs, not "Obamacare" or the U.S. Supreme Court. The "fiscal cliff" will have more impact on the growth of ACOs than the Affordable Care Act, as it is forcing us to look at the main drivers of the deficit – entitlements such as Social Security, Medicaid, and Medicare. Notwithstanding, many physicians were waiting until after the election to get serious about ACOs.

3a. This column

(Just kidding!)

So, for these reasons, it is not surprising that primary care physicians are now jumping into ACOs. That said, it is still pretty startling to see a 250% increase in 1 year, which was probably a 250% jump from the year before. Thank you for stepping up to help save American health care.

References

1. Accountable Care Organizations: How Will Payer and Provider Adoption of This Model Impact Prescribing Trends in Cardiometabolic Diseases? Decision Resources, October 2012.

2. As covered in prior articles, besides value-based reimbursement, there are seven other essential elements for a successful ACO: primary care, culture, administration, information technology, patient engagement, scale, and best practices.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians to form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or 919-821-6612.

A new report finds that 49% of surveyed primary care physicians expect to participate in an accountable care organization in the next year. Twenty percent already are in ACOs, and most of them are contracting with commercial payers and Medicaid.

Why this dramatic jump? At the end of the day, it is all about the shift from volume-based reimbursement (fee for service) to value-based reimbursement. ACOs are a means to an end, not the end itself. If we will get paid for squeezing waste out of our current system and look at the best way to do it, the elements of an ACO logically fall into place.²

We attribute the big jump in primary care participation to three main factors:

1. Primary care will drive value.

The highest-impact targets for ACOs are:

• Prevention and wellness.

• Chronic disease management.

• Care transitions and navigation.

• Reduced hospitalizations.

• Multispecialty care coordination of complex patients.

While not a monopoly of primary care, all of these opportunities are in your wheelhouse. That is why the Medicare Shared Savings Program ACO regulations correctly require every ACO to include primary care providers. Consequently, primary care providers are being heavily recruited by ACOs.

2. Primary care will derive benefits.

Most ACOs are compensated by receiving some percentage, usually 50%, of savings for a patient population if quality and patient satisfaction metrics are also met. For an ACO to be successful, distribution of savings should be in proportion to their contribution. Primary care physicians should contract only with ACOs that recognize this fundamental connection.

The distribution must be an incentive for every participant to contribute as much value as possible. That will not happen unless the savings distribution is based on merit. As noted, primary care stands to contribute more value, and thus merit more distributions, than any other ACO participant.

The dysfunctions of the fee-for-service system have left primary care underpaid. Now, with the compensation model shifting leverage from costs to savings, primary care physicians are stepping up to close this gap.

3. Primary care is realizing that ACOs are for real.

The move to value-based reimbursement is being driven by unsustainable health care costs, not "Obamacare" or the U.S. Supreme Court. The "fiscal cliff" will have more impact on the growth of ACOs than the Affordable Care Act, as it is forcing us to look at the main drivers of the deficit – entitlements such as Social Security, Medicaid, and Medicare. Notwithstanding, many physicians were waiting until after the election to get serious about ACOs.

3a. This column

(Just kidding!)

So, for these reasons, it is not surprising that primary care physicians are now jumping into ACOs. That said, it is still pretty startling to see a 250% increase in 1 year, which was probably a 250% jump from the year before. Thank you for stepping up to help save American health care.

References

1. Accountable Care Organizations: How Will Payer and Provider Adoption of This Model Impact Prescribing Trends in Cardiometabolic Diseases? Decision Resources, October 2012.

2. As covered in prior articles, besides value-based reimbursement, there are seven other essential elements for a successful ACO: primary care, culture, administration, information technology, patient engagement, scale, and best practices.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians to form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or 919-821-6612.

There seems to be a cruel irony at work: It is generally recognized that a primary care physician–based accountable care organization stands the greatest chance of successfully squeezing the waste out of our health care system – yet that same system has historically deprived primary care of the means to finance an ACO.

Worse, most of the payments that are necessary to fund and sustain ACOs are deferred for more than a year, because they come from savings created during the prior year. It is the proverbial "you can’t get there from here" problem.

How do we avoid this "Catch-22," in which the primary care–driven ACO model is best suited to meet the goals of ACOs but often is least able to afford the costs of creating ACOs?

The answer may be the federal government. There are several viable options available to have the government effectively fund 100% of your ACO start-up costs.

Consider the following:

• Meaningful use incentives. Why not have the government pay for your ACO technology platform? If you think ahead, the health information exchange you will want for your ACO will likely qualify you for stage 2 and stage 3 meaningful use incentives. You can earn up to $44,000 over 5 years from Medicare, or up to $63,750 over 6 years from Medicaid. Instead of data being a burden under fee for service, access to and exchange capability of data will be a huge asset.

You will need to make these investments anyway. If you have your ACO game plan in place, much of what you and your colleagues do to meet the meaningful use criteria can be used to fund your ACO.

• Advance payment model program. The Centers for Medicare and Medicaid Services apparently recognized the "you can’t get there from here" dilemma by creating the advance payment model program. Physician-run ACOs in rural areas have been singled out to receive enough up-front funding to completely pay for the development and implementation of the Medicare Shared Savings Program (MSSP) ACO until shared savings payments kick in.

In addition to the MSSP application, ACOs that wish to receive advance funding from the CMS Innovation Center must also complete the advance payment model application. The advance payment model is open to only two types of ACOs: ACOs that do not include any inpatient facilities and have less than $50 million in total annual revenue; and ACOs in which the only inpatient facilities are critical access hospitals and/or Medicare low-volume rural hospitals, and that have less than $80 million in total annual revenue. ACOs that are co-owned with a health plan will be ineligible, regardless of whether they also fall into one of the above categories.

The advance payment model application consists of two primary sections: the ACO’s financial characteristics; and the ACO’s investment plan.

With respect to the financial characteristics, the ACO will need to list the total annual revenue and total Medicaid revenue for each ACO participant during the preceding 3 years. The information submitted by the ACO will need to be based on either federal tax returns or audited financial statements.

The second key section of the advance payment model application is the ACO investment plan. The ACO must explain how it intends to use the advance payment funds awarded from CMS.

Specifically, the investment plan must include:

• A description of the types of staffing and infrastructure that the ACO will acquire and/or expand using the funding available through the advance payment model.

• The timing of such acquisitions or expansions, and the estimated unit costs.

• A description of how such investments build on staff and infrastructure the ACO already has or plans to acquire through its own upcoming investments.

• An explanation of how each investment will support the ACO in achieving the three-part aim of better health, better health care, and lower per capita costs for Medicare beneficiaries.

The advance payment model money may not be renewed once the initial $1 billion budgeted amount is exhausted. But if the results and return on investment are as powerful as predicted for the targeted ACOs, this could be viewed as a sound investment by CMS.

At current levels, an ACO will receive an up-front fixed amount of $250,000, a variable $36/member, and then $8/member per month. This will be repaid if there are ACO shared savings later on.

Beyond the dollars and cents impact, the APM program is vivid evidence for primary care physicians of just how promising CMS believes physician-directed ACOs are.

Primary care physicians are starting to understand the professional and financial rewards behind ACOs. They should not be dismayed by lack of funding. The payers know that funding these ACOs is a smart "investment" in reforming our inefficient and wasteful current system.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians forming integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or 919-821-6612.

There seems to be a cruel irony at work: It is generally recognized that a primary care physician–based accountable care organization stands the greatest chance of successfully squeezing the waste out of our health care system – yet that same system has historically deprived primary care of the means to finance an ACO.

Worse, most of the payments that are necessary to fund and sustain ACOs are deferred for more than a year, because they come from savings created during the prior year. It is the proverbial "you can’t get there from here" problem.

How do we avoid this "Catch-22," in which the primary care–driven ACO model is best suited to meet the goals of ACOs but often is least able to afford the costs of creating ACOs?

The answer may be the federal government. There are several viable options available to have the government effectively fund 100% of your ACO start-up costs.

Consider the following:

• Meaningful use incentives. Why not have the government pay for your ACO technology platform? If you think ahead, the health information exchange you will want for your ACO will likely qualify you for stage 2 and stage 3 meaningful use incentives. You can earn up to $44,000 over 5 years from Medicare, or up to $63,750 over 6 years from Medicaid. Instead of data being a burden under fee for service, access to and exchange capability of data will be a huge asset.

You will need to make these investments anyway. If you have your ACO game plan in place, much of what you and your colleagues do to meet the meaningful use criteria can be used to fund your ACO.

• Advance payment model program. The Centers for Medicare and Medicaid Services apparently recognized the "you can’t get there from here" dilemma by creating the advance payment model program. Physician-run ACOs in rural areas have been singled out to receive enough up-front funding to completely pay for the development and implementation of the Medicare Shared Savings Program (MSSP) ACO until shared savings payments kick in.

In addition to the MSSP application, ACOs that wish to receive advance funding from the CMS Innovation Center must also complete the advance payment model application. The advance payment model is open to only two types of ACOs: ACOs that do not include any inpatient facilities and have less than $50 million in total annual revenue; and ACOs in which the only inpatient facilities are critical access hospitals and/or Medicare low-volume rural hospitals, and that have less than $80 million in total annual revenue. ACOs that are co-owned with a health plan will be ineligible, regardless of whether they also fall into one of the above categories.

The advance payment model application consists of two primary sections: the ACO’s financial characteristics; and the ACO’s investment plan.

With respect to the financial characteristics, the ACO will need to list the total annual revenue and total Medicaid revenue for each ACO participant during the preceding 3 years. The information submitted by the ACO will need to be based on either federal tax returns or audited financial statements.

The second key section of the advance payment model application is the ACO investment plan. The ACO must explain how it intends to use the advance payment funds awarded from CMS.

Specifically, the investment plan must include:

• A description of the types of staffing and infrastructure that the ACO will acquire and/or expand using the funding available through the advance payment model.

• The timing of such acquisitions or expansions, and the estimated unit costs.

• A description of how such investments build on staff and infrastructure the ACO already has or plans to acquire through its own upcoming investments.

• An explanation of how each investment will support the ACO in achieving the three-part aim of better health, better health care, and lower per capita costs for Medicare beneficiaries.

The advance payment model money may not be renewed once the initial $1 billion budgeted amount is exhausted. But if the results and return on investment are as powerful as predicted for the targeted ACOs, this could be viewed as a sound investment by CMS.

At current levels, an ACO will receive an up-front fixed amount of $250,000, a variable $36/member, and then $8/member per month. This will be repaid if there are ACO shared savings later on.

Beyond the dollars and cents impact, the APM program is vivid evidence for primary care physicians of just how promising CMS believes physician-directed ACOs are.

Primary care physicians are starting to understand the professional and financial rewards behind ACOs. They should not be dismayed by lack of funding. The payers know that funding these ACOs is a smart "investment" in reforming our inefficient and wasteful current system.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians forming integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or 919-821-6612.

There seems to be a cruel irony at work: It is generally recognized that a primary care physician–based accountable care organization stands the greatest chance of successfully squeezing the waste out of our health care system – yet that same system has historically deprived primary care of the means to finance an ACO.

Worse, most of the payments that are necessary to fund and sustain ACOs are deferred for more than a year, because they come from savings created during the prior year. It is the proverbial "you can’t get there from here" problem.

How do we avoid this "Catch-22," in which the primary care–driven ACO model is best suited to meet the goals of ACOs but often is least able to afford the costs of creating ACOs?

The answer may be the federal government. There are several viable options available to have the government effectively fund 100% of your ACO start-up costs.

Consider the following:

• Meaningful use incentives. Why not have the government pay for your ACO technology platform? If you think ahead, the health information exchange you will want for your ACO will likely qualify you for stage 2 and stage 3 meaningful use incentives. You can earn up to $44,000 over 5 years from Medicare, or up to $63,750 over 6 years from Medicaid. Instead of data being a burden under fee for service, access to and exchange capability of data will be a huge asset.

You will need to make these investments anyway. If you have your ACO game plan in place, much of what you and your colleagues do to meet the meaningful use criteria can be used to fund your ACO.

• Advance payment model program. The Centers for Medicare and Medicaid Services apparently recognized the "you can’t get there from here" dilemma by creating the advance payment model program. Physician-run ACOs in rural areas have been singled out to receive enough up-front funding to completely pay for the development and implementation of the Medicare Shared Savings Program (MSSP) ACO until shared savings payments kick in.

In addition to the MSSP application, ACOs that wish to receive advance funding from the CMS Innovation Center must also complete the advance payment model application. The advance payment model is open to only two types of ACOs: ACOs that do not include any inpatient facilities and have less than $50 million in total annual revenue; and ACOs in which the only inpatient facilities are critical access hospitals and/or Medicare low-volume rural hospitals, and that have less than $80 million in total annual revenue. ACOs that are co-owned with a health plan will be ineligible, regardless of whether they also fall into one of the above categories.

The advance payment model application consists of two primary sections: the ACO’s financial characteristics; and the ACO’s investment plan.

With respect to the financial characteristics, the ACO will need to list the total annual revenue and total Medicaid revenue for each ACO participant during the preceding 3 years. The information submitted by the ACO will need to be based on either federal tax returns or audited financial statements.

The second key section of the advance payment model application is the ACO investment plan. The ACO must explain how it intends to use the advance payment funds awarded from CMS.

Specifically, the investment plan must include:

• A description of the types of staffing and infrastructure that the ACO will acquire and/or expand using the funding available through the advance payment model.

• The timing of such acquisitions or expansions, and the estimated unit costs.

• A description of how such investments build on staff and infrastructure the ACO already has or plans to acquire through its own upcoming investments.

• An explanation of how each investment will support the ACO in achieving the three-part aim of better health, better health care, and lower per capita costs for Medicare beneficiaries.

The advance payment model money may not be renewed once the initial $1 billion budgeted amount is exhausted. But if the results and return on investment are as powerful as predicted for the targeted ACOs, this could be viewed as a sound investment by CMS.

At current levels, an ACO will receive an up-front fixed amount of $250,000, a variable $36/member, and then $8/member per month. This will be repaid if there are ACO shared savings later on.

Beyond the dollars and cents impact, the APM program is vivid evidence for primary care physicians of just how promising CMS believes physician-directed ACOs are.

Primary care physicians are starting to understand the professional and financial rewards behind ACOs. They should not be dismayed by lack of funding. The payers know that funding these ACOs is a smart "investment" in reforming our inefficient and wasteful current system.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians forming integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or 919-821-6612.

"Clinical transformation has less to do with technical capabilities and more with the ability to effect cultural change." –Gary Edmiston and David Wofford

As we’ve demonstrated in previous columns, there’s plenty of potential for primary care physicians who embrace the concept of the accountable care organization. But what characteristics and capabilities are critical to ensuring that the promise of ACOs is realized in real – and sustainable – organizations?

There are at least eight elements that are fundamental to the success of an ACO – and they should be part of every physician’s decision-making checklist when you consider forming or joining an ACO:

• A culture of teamwork. The most important element, yet the one most difficult for physicians to attain, is a team-oriented culture with a deeply held, shared commitment to reorganize care to achieve higher quality at lower cost.

Physician attitudes favor autonomy and individualism over collaboration. These attitudes are inculcated in clinical training and reinforced daily in care delivery. Physicians need to understand that the level of involvement needed to effect changes in quality and cost is much different than just banding together for contracting purposes.

Furthermore, physicians tend to be cynical about prior "next best things," such as HMOs, gatekeeping, and capitation, and they have little experience with, or time for, organizational-level strategic planning.

• Primary care physicians. As Harold Miller of the Center for Healthcare Quality and Payment Reform asserts, "It seems clear that in order to be accountable for the health and health care of a broad population of patients, an accountable care organization must have one or more primary care practices playing a central role." This need is logical when you examine the highest-impact targets identified for ACOs: prevention and wellness; chronic disease management; reduced hospitalizations; improved care transitions across the current fragmented system; and multispecialty comanagement of complex patients.

• Adequate administrative capabilities. There are three essential infrastructure functional capabilities: performance measurement; financial administration; and clinical direction.

For example, ACOs qualifying under the Medicare Shared Savings Program must have a leadership and management structure that includes clinical and administrative systems that align with the aims of the Shared Savings Program. The ACO must have an infrastructure capable of promoting evidence-based medicine and beneficiary engagement, reporting on quality and cost metrics, and coordinating care.

• Adequate financial incentives. Three tiers of financial income models are available to ACOs: upside-bonus-only shared savings; a hybrid of limited-upside and limited-downside shared savings and penalty; and full-upside and full-downside capitation.

Shared savings is emerging as the common initial preference of start-up ACOs. If quality and patient satisfaction are enhanced or maintained, and if there are savings relative to the predicted costs for the assigned patient population, then a portion (commonly 50%) of those savings is shared with the ACO.

To maximize incentives, the savings pool should be divided in proportion to the level of contribution of each ACO participant. If primary care has especially high medical home management responsibility, this responsibility may be accompanied by the addition of a flat per member/per month payment.

• Health information technology and data. ACO data are usually a combination of quality, efficiency, and patient-satisfaction measures. These data will usually have outcomes and process measures. Nationally accepted benchmarks are emerging. Three categories of data needs exist for an ACO: baseline data; performance measurement data; and data as a clinical tool. The ACO will need the capability to move data across the continuum of care in a meaningful way, often termed "health information exchange" capability.

• Best practices across the continuum of care. Another essential element of a successful ACO is the ability to translate evidence-based medical principles into best practices in actual clinical care.

According to the Advisory Board Company’s "Moving Toward Accountable Care" project, "The best bet for achieving returns from integration is to prioritize initiatives specifically targeting waste and inefficiency caused by fragmentation in today’s delivery system, unnecessary spending relating to substandard clinical coordination, aggravated with the complexity of navigating episodes of care, and unwanted variations in clinical outcomes driven by lack of adherence to best clinical practice."

• Patient engagement. Patient engagement is another essential element. Unfortunately, many of today’s health care consumers erroneously believe that more is better – especially when they are not "paying" for it, insurance is. It is difficult to accept a compensation model based on improved patient population health when that is dramatically affected by a variable outside of your control: patient adherence.

• Scale-sufficient patient population. It is okay, even desirable, to start small or "walk before you run." However, potential ACOs often overlook the requirement that there needs to be a minimal critical mass of patients to justify the time and infrastructure investment for the ACO. The Medicare Shared Savings Program, for example, requires that an ACO have a minimum of 5,000 beneficiaries assigned to the ACO.

Investing the time now to assess an organization’s ability to deliver on these eight elements will pay off later for primary care physicians who are ready to build or join an ACO.

For more information on the topics covered here, visit www.smithlaw.com/publications/ACOG.pdf.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience helping physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact Mr. Bobbitt at bbobbitt@smithlaw.com or at 919-821-6612.

"Clinical transformation has less to do with technical capabilities and more with the ability to effect cultural change." –Gary Edmiston and David Wofford

As we’ve demonstrated in previous columns, there’s plenty of potential for primary care physicians who embrace the concept of the accountable care organization. But what characteristics and capabilities are critical to ensuring that the promise of ACOs is realized in real – and sustainable – organizations?

There are at least eight elements that are fundamental to the success of an ACO – and they should be part of every physician’s decision-making checklist when you consider forming or joining an ACO:

• A culture of teamwork. The most important element, yet the one most difficult for physicians to attain, is a team-oriented culture with a deeply held, shared commitment to reorganize care to achieve higher quality at lower cost.

Physician attitudes favor autonomy and individualism over collaboration. These attitudes are inculcated in clinical training and reinforced daily in care delivery. Physicians need to understand that the level of involvement needed to effect changes in quality and cost is much different than just banding together for contracting purposes.

Furthermore, physicians tend to be cynical about prior "next best things," such as HMOs, gatekeeping, and capitation, and they have little experience with, or time for, organizational-level strategic planning.

• Primary care physicians. As Harold Miller of the Center for Healthcare Quality and Payment Reform asserts, "It seems clear that in order to be accountable for the health and health care of a broad population of patients, an accountable care organization must have one or more primary care practices playing a central role." This need is logical when you examine the highest-impact targets identified for ACOs: prevention and wellness; chronic disease management; reduced hospitalizations; improved care transitions across the current fragmented system; and multispecialty comanagement of complex patients.

• Adequate administrative capabilities. There are three essential infrastructure functional capabilities: performance measurement; financial administration; and clinical direction.

For example, ACOs qualifying under the Medicare Shared Savings Program must have a leadership and management structure that includes clinical and administrative systems that align with the aims of the Shared Savings Program. The ACO must have an infrastructure capable of promoting evidence-based medicine and beneficiary engagement, reporting on quality and cost metrics, and coordinating care.

• Adequate financial incentives. Three tiers of financial income models are available to ACOs: upside-bonus-only shared savings; a hybrid of limited-upside and limited-downside shared savings and penalty; and full-upside and full-downside capitation.

Shared savings is emerging as the common initial preference of start-up ACOs. If quality and patient satisfaction are enhanced or maintained, and if there are savings relative to the predicted costs for the assigned patient population, then a portion (commonly 50%) of those savings is shared with the ACO.

To maximize incentives, the savings pool should be divided in proportion to the level of contribution of each ACO participant. If primary care has especially high medical home management responsibility, this responsibility may be accompanied by the addition of a flat per member/per month payment.

• Health information technology and data. ACO data are usually a combination of quality, efficiency, and patient-satisfaction measures. These data will usually have outcomes and process measures. Nationally accepted benchmarks are emerging. Three categories of data needs exist for an ACO: baseline data; performance measurement data; and data as a clinical tool. The ACO will need the capability to move data across the continuum of care in a meaningful way, often termed "health information exchange" capability.

• Best practices across the continuum of care. Another essential element of a successful ACO is the ability to translate evidence-based medical principles into best practices in actual clinical care.

According to the Advisory Board Company’s "Moving Toward Accountable Care" project, "The best bet for achieving returns from integration is to prioritize initiatives specifically targeting waste and inefficiency caused by fragmentation in today’s delivery system, unnecessary spending relating to substandard clinical coordination, aggravated with the complexity of navigating episodes of care, and unwanted variations in clinical outcomes driven by lack of adherence to best clinical practice."

• Patient engagement. Patient engagement is another essential element. Unfortunately, many of today’s health care consumers erroneously believe that more is better – especially when they are not "paying" for it, insurance is. It is difficult to accept a compensation model based on improved patient population health when that is dramatically affected by a variable outside of your control: patient adherence.

• Scale-sufficient patient population. It is okay, even desirable, to start small or "walk before you run." However, potential ACOs often overlook the requirement that there needs to be a minimal critical mass of patients to justify the time and infrastructure investment for the ACO. The Medicare Shared Savings Program, for example, requires that an ACO have a minimum of 5,000 beneficiaries assigned to the ACO.

Investing the time now to assess an organization’s ability to deliver on these eight elements will pay off later for primary care physicians who are ready to build or join an ACO.

For more information on the topics covered here, visit www.smithlaw.com/publications/ACOG.pdf.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience helping physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact Mr. Bobbitt at bbobbitt@smithlaw.com or at 919-821-6612.

"Clinical transformation has less to do with technical capabilities and more with the ability to effect cultural change." –Gary Edmiston and David Wofford

As we’ve demonstrated in previous columns, there’s plenty of potential for primary care physicians who embrace the concept of the accountable care organization. But what characteristics and capabilities are critical to ensuring that the promise of ACOs is realized in real – and sustainable – organizations?

There are at least eight elements that are fundamental to the success of an ACO – and they should be part of every physician’s decision-making checklist when you consider forming or joining an ACO:

• A culture of teamwork. The most important element, yet the one most difficult for physicians to attain, is a team-oriented culture with a deeply held, shared commitment to reorganize care to achieve higher quality at lower cost.

Physician attitudes favor autonomy and individualism over collaboration. These attitudes are inculcated in clinical training and reinforced daily in care delivery. Physicians need to understand that the level of involvement needed to effect changes in quality and cost is much different than just banding together for contracting purposes.

Furthermore, physicians tend to be cynical about prior "next best things," such as HMOs, gatekeeping, and capitation, and they have little experience with, or time for, organizational-level strategic planning.

• Primary care physicians. As Harold Miller of the Center for Healthcare Quality and Payment Reform asserts, "It seems clear that in order to be accountable for the health and health care of a broad population of patients, an accountable care organization must have one or more primary care practices playing a central role." This need is logical when you examine the highest-impact targets identified for ACOs: prevention and wellness; chronic disease management; reduced hospitalizations; improved care transitions across the current fragmented system; and multispecialty comanagement of complex patients.

• Adequate administrative capabilities. There are three essential infrastructure functional capabilities: performance measurement; financial administration; and clinical direction.

For example, ACOs qualifying under the Medicare Shared Savings Program must have a leadership and management structure that includes clinical and administrative systems that align with the aims of the Shared Savings Program. The ACO must have an infrastructure capable of promoting evidence-based medicine and beneficiary engagement, reporting on quality and cost metrics, and coordinating care.

• Adequate financial incentives. Three tiers of financial income models are available to ACOs: upside-bonus-only shared savings; a hybrid of limited-upside and limited-downside shared savings and penalty; and full-upside and full-downside capitation.

Shared savings is emerging as the common initial preference of start-up ACOs. If quality and patient satisfaction are enhanced or maintained, and if there are savings relative to the predicted costs for the assigned patient population, then a portion (commonly 50%) of those savings is shared with the ACO.

To maximize incentives, the savings pool should be divided in proportion to the level of contribution of each ACO participant. If primary care has especially high medical home management responsibility, this responsibility may be accompanied by the addition of a flat per member/per month payment.

• Health information technology and data. ACO data are usually a combination of quality, efficiency, and patient-satisfaction measures. These data will usually have outcomes and process measures. Nationally accepted benchmarks are emerging. Three categories of data needs exist for an ACO: baseline data; performance measurement data; and data as a clinical tool. The ACO will need the capability to move data across the continuum of care in a meaningful way, often termed "health information exchange" capability.

• Best practices across the continuum of care. Another essential element of a successful ACO is the ability to translate evidence-based medical principles into best practices in actual clinical care.

According to the Advisory Board Company’s "Moving Toward Accountable Care" project, "The best bet for achieving returns from integration is to prioritize initiatives specifically targeting waste and inefficiency caused by fragmentation in today’s delivery system, unnecessary spending relating to substandard clinical coordination, aggravated with the complexity of navigating episodes of care, and unwanted variations in clinical outcomes driven by lack of adherence to best clinical practice."

• Patient engagement. Patient engagement is another essential element. Unfortunately, many of today’s health care consumers erroneously believe that more is better – especially when they are not "paying" for it, insurance is. It is difficult to accept a compensation model based on improved patient population health when that is dramatically affected by a variable outside of your control: patient adherence.

• Scale-sufficient patient population. It is okay, even desirable, to start small or "walk before you run." However, potential ACOs often overlook the requirement that there needs to be a minimal critical mass of patients to justify the time and infrastructure investment for the ACO. The Medicare Shared Savings Program, for example, requires that an ACO have a minimum of 5,000 beneficiaries assigned to the ACO.

Investing the time now to assess an organization’s ability to deliver on these eight elements will pay off later for primary care physicians who are ready to build or join an ACO.

For more information on the topics covered here, visit www.smithlaw.com/publications/ACOG.pdf.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience helping physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact Mr. Bobbitt at bbobbitt@smithlaw.com or at 919-821-6612.

Many thanks for the thoughtful e-mails from many of you readers. Some express cautious hope, some skepticism, and all the curiosity and caring that reminds me of how fortunate I am to have been a physician advocate for my legal career.

Here is one reader’s concerns about patient engagement – or lack thereof – in accountable care organizations.

– Reader: "ACOs will never work because, once again, the patient has been left out of the equation."

We hear this quite often, and it is surely true in some cases – but not all. In fact, we are convinced that patient engagement is such an essential element necessary for every successful ACO, that an ACO should not be called an ACO without it.

Patient noncompliance is a problem, especially regarding chronic diseases and lifestyle management. It is difficult to accept a compensation model based on input on improved patient population health when that is dramatically affected by a variable outside of your control: patient adherence. But patient engagement is part of patient-centeredness, which is required by the Affordable Care Act for an ACO to qualify for CMS’ Shared Savings Program.

So, what can an ACO do to engage patients?

Consider the following approaches:

– The patient compact. Some ACOs, such as the Geisinger Clinic, engage the patient through a compact, or agreement. It may involve a written commitment by the patient to be responsible for his or her own wellness or chronic care management, coupled with rewards for so doing, education, tools, self-care modules, and shared decision-making empowerment. The providers will need to embrace the importance of patient involvement and hold up their end of the engagement bargain.

– Benefit differentials for lifestyle choices. The financial impact of many volitional patient lifestyle choices is actuarially measurable. A logical consequence of the patient choice could be a benefit or financial differential reflecting at least partially these avoidable health care costs.

– Stay in contact. A Kaiser Permanente study of more than 35,000 hypertensive and diabetic patients found that the blood pressure and cholesterol levels for those who engaged in secure messaging were better than for those who did not.

– More time with your patients. Develop personal relationships. One ACO saw its results jump when its primary care physicians started using Biosignia’s "Know Your Number," a computer-generated graphic depiction of a patient’s health risks based on lab results and the Framingham Study. It is used by the treating physician at the point of care.

– Patient remote access to test results. This can be achieved with tools such as a web portal with multiple functions.

– Care navigators. We predict that the demands for care navigators, or coordinators, will skyrocket as ACOs take hold. Their use will include home visits. This may be the best patient engagement method.

– Empathetic listening. In curriculum and residency programs of medical schools, the paternalistic model is yielding to empathetic listening and communication skills in physician training.

– Educational materials. This consists of patient-friendly educational material that explains the benefits of being linked to a medical home.

I agree so much with this reader’s assertion that an ACO without patient engagement will fail, that I consider it an essential, almost definitional, element of every successful ACO. It is crucial that we emphasize the role of the patient. It is truly the "other shoe" that must fall for the new outcomes-based health care to succeed.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact Mr. Bobbit at bbobbitt@smithlaw.com, or at 919-821-6612.

Many thanks for the thoughtful e-mails from many of you readers. Some express cautious hope, some skepticism, and all the curiosity and caring that reminds me of how fortunate I am to have been a physician advocate for my legal career.

Here is one reader’s concerns about patient engagement – or lack thereof – in accountable care organizations.

– Reader: "ACOs will never work because, once again, the patient has been left out of the equation."

We hear this quite often, and it is surely true in some cases – but not all. In fact, we are convinced that patient engagement is such an essential element necessary for every successful ACO, that an ACO should not be called an ACO without it.

Patient noncompliance is a problem, especially regarding chronic diseases and lifestyle management. It is difficult to accept a compensation model based on input on improved patient population health when that is dramatically affected by a variable outside of your control: patient adherence. But patient engagement is part of patient-centeredness, which is required by the Affordable Care Act for an ACO to qualify for CMS’ Shared Savings Program.

So, what can an ACO do to engage patients?

Consider the following approaches:

– The patient compact. Some ACOs, such as the Geisinger Clinic, engage the patient through a compact, or agreement. It may involve a written commitment by the patient to be responsible for his or her own wellness or chronic care management, coupled with rewards for so doing, education, tools, self-care modules, and shared decision-making empowerment. The providers will need to embrace the importance of patient involvement and hold up their end of the engagement bargain.

– Benefit differentials for lifestyle choices. The financial impact of many volitional patient lifestyle choices is actuarially measurable. A logical consequence of the patient choice could be a benefit or financial differential reflecting at least partially these avoidable health care costs.

– Stay in contact. A Kaiser Permanente study of more than 35,000 hypertensive and diabetic patients found that the blood pressure and cholesterol levels for those who engaged in secure messaging were better than for those who did not.

– More time with your patients. Develop personal relationships. One ACO saw its results jump when its primary care physicians started using Biosignia’s "Know Your Number," a computer-generated graphic depiction of a patient’s health risks based on lab results and the Framingham Study. It is used by the treating physician at the point of care.

– Patient remote access to test results. This can be achieved with tools such as a web portal with multiple functions.

– Care navigators. We predict that the demands for care navigators, or coordinators, will skyrocket as ACOs take hold. Their use will include home visits. This may be the best patient engagement method.

– Empathetic listening. In curriculum and residency programs of medical schools, the paternalistic model is yielding to empathetic listening and communication skills in physician training.

– Educational materials. This consists of patient-friendly educational material that explains the benefits of being linked to a medical home.

I agree so much with this reader’s assertion that an ACO without patient engagement will fail, that I consider it an essential, almost definitional, element of every successful ACO. It is crucial that we emphasize the role of the patient. It is truly the "other shoe" that must fall for the new outcomes-based health care to succeed.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact Mr. Bobbit at bbobbitt@smithlaw.com, or at 919-821-6612.

Many thanks for the thoughtful e-mails from many of you readers. Some express cautious hope, some skepticism, and all the curiosity and caring that reminds me of how fortunate I am to have been a physician advocate for my legal career.

Here is one reader’s concerns about patient engagement – or lack thereof – in accountable care organizations.

– Reader: "ACOs will never work because, once again, the patient has been left out of the equation."

We hear this quite often, and it is surely true in some cases – but not all. In fact, we are convinced that patient engagement is such an essential element necessary for every successful ACO, that an ACO should not be called an ACO without it.

Patient noncompliance is a problem, especially regarding chronic diseases and lifestyle management. It is difficult to accept a compensation model based on input on improved patient population health when that is dramatically affected by a variable outside of your control: patient adherence. But patient engagement is part of patient-centeredness, which is required by the Affordable Care Act for an ACO to qualify for CMS’ Shared Savings Program.

So, what can an ACO do to engage patients?

Consider the following approaches:

– The patient compact. Some ACOs, such as the Geisinger Clinic, engage the patient through a compact, or agreement. It may involve a written commitment by the patient to be responsible for his or her own wellness or chronic care management, coupled with rewards for so doing, education, tools, self-care modules, and shared decision-making empowerment. The providers will need to embrace the importance of patient involvement and hold up their end of the engagement bargain.

– Benefit differentials for lifestyle choices. The financial impact of many volitional patient lifestyle choices is actuarially measurable. A logical consequence of the patient choice could be a benefit or financial differential reflecting at least partially these avoidable health care costs.

– Stay in contact. A Kaiser Permanente study of more than 35,000 hypertensive and diabetic patients found that the blood pressure and cholesterol levels for those who engaged in secure messaging were better than for those who did not.

– More time with your patients. Develop personal relationships. One ACO saw its results jump when its primary care physicians started using Biosignia’s "Know Your Number," a computer-generated graphic depiction of a patient’s health risks based on lab results and the Framingham Study. It is used by the treating physician at the point of care.

– Patient remote access to test results. This can be achieved with tools such as a web portal with multiple functions.

– Care navigators. We predict that the demands for care navigators, or coordinators, will skyrocket as ACOs take hold. Their use will include home visits. This may be the best patient engagement method.

– Empathetic listening. In curriculum and residency programs of medical schools, the paternalistic model is yielding to empathetic listening and communication skills in physician training.

– Educational materials. This consists of patient-friendly educational material that explains the benefits of being linked to a medical home.

I agree so much with this reader’s assertion that an ACO without patient engagement will fail, that I consider it an essential, almost definitional, element of every successful ACO. It is crucial that we emphasize the role of the patient. It is truly the "other shoe" that must fall for the new outcomes-based health care to succeed.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact Mr. Bobbit at bbobbitt@smithlaw.com, or at 919-821-6612.

Even by conservative predictions, patient quality of care will improve significantly under Accountable Care Organizations, while saving Medicare millions of dollars. And, by some estimates, primary care incomes will double.

Why is that the case?

ACOs are designed to motivate providers to follow evidence-based practices in the management of patient populations. Total expenditures for that population are tracked and, if there are savings relative to an unmanaged population, providers typically will receive about half of the savings.

Of all the possible ACO initiatives that could deliver value, five represent the highest-impact targets that are expected to deliver the biggest and earliest bang for the buck. Primary care will likely thrive under ACOs because all five targets are in the specialty’s "sweet spot."

• Prevention and Wellness – This is the clearest example of health care’s shift from payment for volume under fee for service, to payment for value under accountable care. Of course, you’ve always seen the cost-saving impact of making and keeping people healthy; the sicker a patient becomes, the more money providers make treating sometimes quite avoidable issues. Now, with a shift toward managing the total costs for a patient population, successful prevention and wellness will be tied to powerful economic rewards. Primary care physicians will now be paid to spend that extra time with patients, to do more follow-up, to build a medical home, and to influence healthy lifestyles.

• Chronic Disease Management – Chronic disease now represents some 75% of all health care spending, and much of it is preventable. For Medicare, it is an even greater percentage. According to a recent report by Forbes Insights, in 2005, an average patient with one chronic disease cost $7,000 annually $15,000 with two diseases, and $32,000 with three. Chronic diseases are complex, harder to reverse, and involve more specialists, but primary care-driven care coordination is still key.

• Reduced Hospitalizations (ER Avoidance) – It is important to make clear that this refers only to avoidable hospitalizations. Lifestyle-related chronic diseases drive many avoidable admissions; lack of prevention or coordination of care drives others. Primary care can reduce hospitalizations through a sound emergency department diversion policy for non-emergencies. Establishing a physician-patient relationship will help the patient avoid using the ED as a default primary care office.

• Care Transitions –A fundamental premise behind the medical home concept is that it helps coordinate care by helping patients navigate through the system that heretofore consisted of fragmented segments. Care transitioning is not the sole province of primary care medicine, but the medical home’s ability to help transition patients and coordinate their care will be a significant factor in ACO success.

• Multispecialty Care Coordination of Complex Patients – These are the patients who consume a hugely disproportionate share of health care dollars. Early ACO activity suggests that if the ACO has a medical home component, it serves as the organizational hub for care coordination for complex patients, with enhanced administrative support by the ACO’s informatics center and an increased role of select specialists. The patient is assigned to a coordinating physician who ensures that there is an appropriate care plan. Pharmacy, specialists, home health, physical therapy, and case management services are all coordinated for the complex patient pursuant to the plan.

These five targets are the proverbial "low-hanging fruit" for ACOs. Primary care has the opportunity, and oftentimes the necessity, for significant involvement in all of them. It is no wonder that primary care physicians are essential for ACO success. ACO compensation, say through shared savings, is designed to incentivize and reward those who follow best practices and who generate the savings. Thus, primary care should experience not only deep professional rewards from having the tools and teammates to positively impact so many patients, but also significant financial rewards. A physician approached by an ACO can evaluate its likelihood of sustainability and its appreciation of the role of primary care, by comparing its initiatives against the top five ACO targets described above.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. Contact him at bbobbitt@smithlaw.com.

Even by conservative predictions, patient quality of care will improve significantly under Accountable Care Organizations, while saving Medicare millions of dollars. And, by some estimates, primary care incomes will double.

Why is that the case?

ACOs are designed to motivate providers to follow evidence-based practices in the management of patient populations. Total expenditures for that population are tracked and, if there are savings relative to an unmanaged population, providers typically will receive about half of the savings.

Of all the possible ACO initiatives that could deliver value, five represent the highest-impact targets that are expected to deliver the biggest and earliest bang for the buck. Primary care will likely thrive under ACOs because all five targets are in the specialty’s "sweet spot."

• Prevention and Wellness – This is the clearest example of health care’s shift from payment for volume under fee for service, to payment for value under accountable care. Of course, you’ve always seen the cost-saving impact of making and keeping people healthy; the sicker a patient becomes, the more money providers make treating sometimes quite avoidable issues. Now, with a shift toward managing the total costs for a patient population, successful prevention and wellness will be tied to powerful economic rewards. Primary care physicians will now be paid to spend that extra time with patients, to do more follow-up, to build a medical home, and to influence healthy lifestyles.

• Chronic Disease Management – Chronic disease now represents some 75% of all health care spending, and much of it is preventable. For Medicare, it is an even greater percentage. According to a recent report by Forbes Insights, in 2005, an average patient with one chronic disease cost $7,000 annually $15,000 with two diseases, and $32,000 with three. Chronic diseases are complex, harder to reverse, and involve more specialists, but primary care-driven care coordination is still key.

• Reduced Hospitalizations (ER Avoidance) – It is important to make clear that this refers only to avoidable hospitalizations. Lifestyle-related chronic diseases drive many avoidable admissions; lack of prevention or coordination of care drives others. Primary care can reduce hospitalizations through a sound emergency department diversion policy for non-emergencies. Establishing a physician-patient relationship will help the patient avoid using the ED as a default primary care office.

• Care Transitions –A fundamental premise behind the medical home concept is that it helps coordinate care by helping patients navigate through the system that heretofore consisted of fragmented segments. Care transitioning is not the sole province of primary care medicine, but the medical home’s ability to help transition patients and coordinate their care will be a significant factor in ACO success.

• Multispecialty Care Coordination of Complex Patients – These are the patients who consume a hugely disproportionate share of health care dollars. Early ACO activity suggests that if the ACO has a medical home component, it serves as the organizational hub for care coordination for complex patients, with enhanced administrative support by the ACO’s informatics center and an increased role of select specialists. The patient is assigned to a coordinating physician who ensures that there is an appropriate care plan. Pharmacy, specialists, home health, physical therapy, and case management services are all coordinated for the complex patient pursuant to the plan.

These five targets are the proverbial "low-hanging fruit" for ACOs. Primary care has the opportunity, and oftentimes the necessity, for significant involvement in all of them. It is no wonder that primary care physicians are essential for ACO success. ACO compensation, say through shared savings, is designed to incentivize and reward those who follow best practices and who generate the savings. Thus, primary care should experience not only deep professional rewards from having the tools and teammates to positively impact so many patients, but also significant financial rewards. A physician approached by an ACO can evaluate its likelihood of sustainability and its appreciation of the role of primary care, by comparing its initiatives against the top five ACO targets described above.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. Contact him at bbobbitt@smithlaw.com.

Even by conservative predictions, patient quality of care will improve significantly under Accountable Care Organizations, while saving Medicare millions of dollars. And, by some estimates, primary care incomes will double.

Why is that the case?

ACOs are designed to motivate providers to follow evidence-based practices in the management of patient populations. Total expenditures for that population are tracked and, if there are savings relative to an unmanaged population, providers typically will receive about half of the savings.

Of all the possible ACO initiatives that could deliver value, five represent the highest-impact targets that are expected to deliver the biggest and earliest bang for the buck. Primary care will likely thrive under ACOs because all five targets are in the specialty’s "sweet spot."

• Prevention and Wellness – This is the clearest example of health care’s shift from payment for volume under fee for service, to payment for value under accountable care. Of course, you’ve always seen the cost-saving impact of making and keeping people healthy; the sicker a patient becomes, the more money providers make treating sometimes quite avoidable issues. Now, with a shift toward managing the total costs for a patient population, successful prevention and wellness will be tied to powerful economic rewards. Primary care physicians will now be paid to spend that extra time with patients, to do more follow-up, to build a medical home, and to influence healthy lifestyles.

• Chronic Disease Management – Chronic disease now represents some 75% of all health care spending, and much of it is preventable. For Medicare, it is an even greater percentage. According to a recent report by Forbes Insights, in 2005, an average patient with one chronic disease cost $7,000 annually $15,000 with two diseases, and $32,000 with three. Chronic diseases are complex, harder to reverse, and involve more specialists, but primary care-driven care coordination is still key.

• Reduced Hospitalizations (ER Avoidance) – It is important to make clear that this refers only to avoidable hospitalizations. Lifestyle-related chronic diseases drive many avoidable admissions; lack of prevention or coordination of care drives others. Primary care can reduce hospitalizations through a sound emergency department diversion policy for non-emergencies. Establishing a physician-patient relationship will help the patient avoid using the ED as a default primary care office.

• Care Transitions –A fundamental premise behind the medical home concept is that it helps coordinate care by helping patients navigate through the system that heretofore consisted of fragmented segments. Care transitioning is not the sole province of primary care medicine, but the medical home’s ability to help transition patients and coordinate their care will be a significant factor in ACO success.

• Multispecialty Care Coordination of Complex Patients – These are the patients who consume a hugely disproportionate share of health care dollars. Early ACO activity suggests that if the ACO has a medical home component, it serves as the organizational hub for care coordination for complex patients, with enhanced administrative support by the ACO’s informatics center and an increased role of select specialists. The patient is assigned to a coordinating physician who ensures that there is an appropriate care plan. Pharmacy, specialists, home health, physical therapy, and case management services are all coordinated for the complex patient pursuant to the plan.

These five targets are the proverbial "low-hanging fruit" for ACOs. Primary care has the opportunity, and oftentimes the necessity, for significant involvement in all of them. It is no wonder that primary care physicians are essential for ACO success. ACO compensation, say through shared savings, is designed to incentivize and reward those who follow best practices and who generate the savings. Thus, primary care should experience not only deep professional rewards from having the tools and teammates to positively impact so many patients, but also significant financial rewards. A physician approached by an ACO can evaluate its likelihood of sustainability and its appreciation of the role of primary care, by comparing its initiatives against the top five ACO targets described above.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. Contact him at bbobbitt@smithlaw.com.

Regardless of the fate of federal health reform, accountable care organizations will continue to develop because the current system is completely unsustainable.

These organizations are emerging because of the necessity to shift the unsustainable payment for volume in today’s fee-for-service health care delivery system to one that rewards value. ACOs will be judged on the delivery of quality health care while controlling overall costs. In general, ACOs will usually receive about half of the savings if quality standards are met.

This will necessitate a transformative shift from fragmented, episodic care to care that is delivered by teams following best practices across the continuum. Providers will thus be "accountable" to each other to achieve value (defined as the highest quality at the lowest cost), because they must work together to generate a sizable savings pool and to improve a patient population’s health status.

Why are ACOs empowering to primary care physicians?

ACOs will target the following key drivers of value:

• Prevention and wellness.

• Chronic disease management.

• Reduced hospitalizations.

• Improved care transitions.

• Multispecialty comanagement of complex patients.

Primary care physicians play a central role in each of these categories.

As Harold Miller of the Center for Healthcare Quality and Payment Reform once said: "In order to be accountable for the health and health care of a broad population of patients, an accountable care organization must have one or more primary care practices playing a central role."

In fact, primary care providers are the only type of provider mandated for inclusion in the ACO Shared Savings Program under the Affordable Care Act.

But are ACOs likely to be favorable situations for primary care physicians?

First, let’s consider the pros. Many physicians find that the ACO movement’s emphasis on primary care to be a validation of the reasons they went to medical school. Being asked to guide the health care delivery system and being given the tools to do so is empowering. Leading change that will save lives and improve patient access to care would be deeply fulfilling. There also is, of course, the potential for financial gain. Unlike physicians in other specialties, primary care physicians have many opportunities in ACOs.

On the con side, you are not alone if you feel overworked or burned out, or that you simply do not have the time, resources, or remaining intellectual bandwidth to get involved.

Many have already weathered promises from the "next big thing" that in the end did not work out as advertised. And equal numbers have little capital and no business or legal consultants on retainer, as do other health care stakeholders. Time is stretched tight in many areas of the country that are already feeling the effects of a primary care workforce shortage – and now the ACO model is asking that you take on more responsibility?

But here’s the thing: If primary care physicians do not recognize the magnitude of their role in time, the opportunity for ACO success will pass them by and be replaced by dismal alternatives.

And there are already success stories. Starting with several simple Medicaid initiatives, North Carolina primary care physicians created a statewide confederation of 14 medical home ACO networks. Although the work involved is plentiful, so have been the rewards.

Among them is a renewed empowerment and leverage for their interests when they contract with payers and facilities. In interviews with the networks’ physicians, the consensus is that although much is uncertain, the primary care physicians feel much more prepared to face the changes in health care, having first created the medical home networks that lead to medical home–centric ACOs.

For those primary care physicians who choose to join a hospital, the same pros and cons generally apply. By being on the "inside," employed physicians may actually have more influence to shape a successful ACO that fairly values the role of primary care. However, they may have more difficulty freely associating with an ACO outside of the hospital’s ACO.

Whether you are inside or outside the hospital setting, there is tremendous financial opportunity for primary care providers. Shared savings is based on all costs, including those for hospitalization and drugs. The distribution of the shared savings will be proportional to the relative contribution to the savings. Thus, the percentage going to primary care stands to be considerable.

America cannot afford its current health care system. It is asking physicians to run a new health care system, with primary care at its core. There is a dramatic change of focus, from cost centers in health care to savings centers in health care.

Empowerment is being offered, but primary care must step up in order to enjoy it.

Regardless of the fate of federal health reform, accountable care organizations will continue to develop because the current system is completely unsustainable.

These organizations are emerging because of the necessity to shift the unsustainable payment for volume in today’s fee-for-service health care delivery system to one that rewards value. ACOs will be judged on the delivery of quality health care while controlling overall costs. In general, ACOs will usually receive about half of the savings if quality standards are met.

This will necessitate a transformative shift from fragmented, episodic care to care that is delivered by teams following best practices across the continuum. Providers will thus be "accountable" to each other to achieve value (defined as the highest quality at the lowest cost), because they must work together to generate a sizable savings pool and to improve a patient population’s health status.

Why are ACOs empowering to primary care physicians?

ACOs will target the following key drivers of value:

• Prevention and wellness.

• Chronic disease management.

• Reduced hospitalizations.

• Improved care transitions.

• Multispecialty comanagement of complex patients.

Primary care physicians play a central role in each of these categories.

As Harold Miller of the Center for Healthcare Quality and Payment Reform once said: "In order to be accountable for the health and health care of a broad population of patients, an accountable care organization must have one or more primary care practices playing a central role."

In fact, primary care providers are the only type of provider mandated for inclusion in the ACO Shared Savings Program under the Affordable Care Act.

But are ACOs likely to be favorable situations for primary care physicians?

First, let’s consider the pros. Many physicians find that the ACO movement’s emphasis on primary care to be a validation of the reasons they went to medical school. Being asked to guide the health care delivery system and being given the tools to do so is empowering. Leading change that will save lives and improve patient access to care would be deeply fulfilling. There also is, of course, the potential for financial gain. Unlike physicians in other specialties, primary care physicians have many opportunities in ACOs.

On the con side, you are not alone if you feel overworked or burned out, or that you simply do not have the time, resources, or remaining intellectual bandwidth to get involved.

Many have already weathered promises from the "next big thing" that in the end did not work out as advertised. And equal numbers have little capital and no business or legal consultants on retainer, as do other health care stakeholders. Time is stretched tight in many areas of the country that are already feeling the effects of a primary care workforce shortage – and now the ACO model is asking that you take on more responsibility?

But here’s the thing: If primary care physicians do not recognize the magnitude of their role in time, the opportunity for ACO success will pass them by and be replaced by dismal alternatives.

And there are already success stories. Starting with several simple Medicaid initiatives, North Carolina primary care physicians created a statewide confederation of 14 medical home ACO networks. Although the work involved is plentiful, so have been the rewards.

Among them is a renewed empowerment and leverage for their interests when they contract with payers and facilities. In interviews with the networks’ physicians, the consensus is that although much is uncertain, the primary care physicians feel much more prepared to face the changes in health care, having first created the medical home networks that lead to medical home–centric ACOs.

For those primary care physicians who choose to join a hospital, the same pros and cons generally apply. By being on the "inside," employed physicians may actually have more influence to shape a successful ACO that fairly values the role of primary care. However, they may have more difficulty freely associating with an ACO outside of the hospital’s ACO.

Whether you are inside or outside the hospital setting, there is tremendous financial opportunity for primary care providers. Shared savings is based on all costs, including those for hospitalization and drugs. The distribution of the shared savings will be proportional to the relative contribution to the savings. Thus, the percentage going to primary care stands to be considerable.

America cannot afford its current health care system. It is asking physicians to run a new health care system, with primary care at its core. There is a dramatic change of focus, from cost centers in health care to savings centers in health care.

Empowerment is being offered, but primary care must step up in order to enjoy it.

Regardless of the fate of federal health reform, accountable care organizations will continue to develop because the current system is completely unsustainable.

These organizations are emerging because of the necessity to shift the unsustainable payment for volume in today’s fee-for-service health care delivery system to one that rewards value. ACOs will be judged on the delivery of quality health care while controlling overall costs. In general, ACOs will usually receive about half of the savings if quality standards are met.

This will necessitate a transformative shift from fragmented, episodic care to care that is delivered by teams following best practices across the continuum. Providers will thus be "accountable" to each other to achieve value (defined as the highest quality at the lowest cost), because they must work together to generate a sizable savings pool and to improve a patient population’s health status.

Why are ACOs empowering to primary care physicians?

ACOs will target the following key drivers of value:

• Prevention and wellness.

• Chronic disease management.

• Reduced hospitalizations.

• Improved care transitions.

• Multispecialty comanagement of complex patients.

Primary care physicians play a central role in each of these categories.

As Harold Miller of the Center for Healthcare Quality and Payment Reform once said: "In order to be accountable for the health and health care of a broad population of patients, an accountable care organization must have one or more primary care practices playing a central role."

In fact, primary care providers are the only type of provider mandated for inclusion in the ACO Shared Savings Program under the Affordable Care Act.

But are ACOs likely to be favorable situations for primary care physicians?

First, let’s consider the pros. Many physicians find that the ACO movement’s emphasis on primary care to be a validation of the reasons they went to medical school. Being asked to guide the health care delivery system and being given the tools to do so is empowering. Leading change that will save lives and improve patient access to care would be deeply fulfilling. There also is, of course, the potential for financial gain. Unlike physicians in other specialties, primary care physicians have many opportunities in ACOs.

On the con side, you are not alone if you feel overworked or burned out, or that you simply do not have the time, resources, or remaining intellectual bandwidth to get involved.

Many have already weathered promises from the "next big thing" that in the end did not work out as advertised. And equal numbers have little capital and no business or legal consultants on retainer, as do other health care stakeholders. Time is stretched tight in many areas of the country that are already feeling the effects of a primary care workforce shortage – and now the ACO model is asking that you take on more responsibility?

But here’s the thing: If primary care physicians do not recognize the magnitude of their role in time, the opportunity for ACO success will pass them by and be replaced by dismal alternatives.

And there are already success stories. Starting with several simple Medicaid initiatives, North Carolina primary care physicians created a statewide confederation of 14 medical home ACO networks. Although the work involved is plentiful, so have been the rewards.

Among them is a renewed empowerment and leverage for their interests when they contract with payers and facilities. In interviews with the networks’ physicians, the consensus is that although much is uncertain, the primary care physicians feel much more prepared to face the changes in health care, having first created the medical home networks that lead to medical home–centric ACOs.

For those primary care physicians who choose to join a hospital, the same pros and cons generally apply. By being on the "inside," employed physicians may actually have more influence to shape a successful ACO that fairly values the role of primary care. However, they may have more difficulty freely associating with an ACO outside of the hospital’s ACO.

Whether you are inside or outside the hospital setting, there is tremendous financial opportunity for primary care providers. Shared savings is based on all costs, including those for hospitalization and drugs. The distribution of the shared savings will be proportional to the relative contribution to the savings. Thus, the percentage going to primary care stands to be considerable.

America cannot afford its current health care system. It is asking physicians to run a new health care system, with primary care at its core. There is a dramatic change of focus, from cost centers in health care to savings centers in health care.

Empowerment is being offered, but primary care must step up in order to enjoy it.

Dear Dr. Mossman:

I practice in a region with few psychiatrists and very little public transportation. For many patients, coming to my office is inconvenient, expensive, or time-consuming. Sometimes, their emotional problems make it hard for them to travel, and sometimes, bad weather makes travel difficult. I am considering providing remote treatment via Skype. Is this a reasonable idea? What are the risks of using this technology in my practice? — Submitted by “Dr. A”

Diagnosing and treating patients without a face-to-face encounter is not new. Doctors have provided “remote treatment” since shortly after telephones were invented.¹ Until recently, however, forensic psychiatrists advised colleagues not to diagnose patients or start treatment based on phone contact alone.²

The Internet has revolutionized our attitudes about many things. Communication technologies that seemed miraculous a generation ago have become commonplace and have transformed standards for ordinary and “acceptable” human contact. A quick Internet search of “telephone psychotherapy” turns up hundreds of mental health professionals who offer remote treatment services to patients via computers and Web cams.

Physicians in many specialties practice telemedicine, often with the support and encouragement of state governments and third-party payers. To decide whether to include telepsychiatry in your psychiatric practice, you should know:

• what “telemedicine” means and includes
• the possible advantages of offering remote health care
• potential risks and ambiguity about legal matters.

Defining telemedicine

Studies of remote, closed-circuit “telediagnosis” extend back more than 4 decades, closely following mid-20^th century advancements in audio and video relay technologies that made space broadcasts possible.³ Then as now, “telemedicine” simply means conveying health-related information from 1 site to another for diagnostic or treatment purposes.⁴ It’s an adaptation of available technology to deliver care more easily, with the goal of improving patients’ access to care and health status.

Telemedicine usage accelerated as the Internet and related technologies developed. Telemedicine programs in the United States increased by 1,500% from 1993 to 1998.⁴ Telemedicine use has grown 10% annually in recent years and has become a $4 billion per year industry in the United States.⁵ Recently enacted federal legislation is likely to extend health care coverage to 36 million Americans and require coverage of pre-existing conditions. To make these changes affordable, health care delivery will need to exploit new, efficiency-enhancing technologies.⁶

Advantages of telemedicine

State governments and some third-party payers have recognized that telemedicine can overcome geographic and cost barriers to health services and patient education.^5,7-9 Although closed-circuit video transmission has served this purpose for some time, Skype—free software that allows individuals to make video phone calls over the Internet using their computers—is an option that doctors are using to treat patients.^10-12

Research suggests that telepsychiatry may provide huge benefits to medically underserved areas while reducing health care costs.⁴ Telepsychiatry can reduce travel time and expenses for professionals and patients, and it also may lower wait times and “no-show” rates (Table 1).⁴ Telepsychiatry lets patients see caregivers when winter weather makes roads unsafe. It may allow geriatric patients who can no longer drive to access psychiatric care and it lowers health care’s “carbon footprint,” making it “eco-friendly.”¹³

Social media strategies are playing an expanding role in medical education,^14,15 and this probably will help practitioners feel more at ease about incorporating the underlying technologies into work with patients. Increased use of laptops and mobile phones lends itself well to telepsychiatry applications,¹³ and studies have examined the feasibility of psychotherapies delivered via remote communication devices.¹⁶ Smartphone apps are being designed to assist mental health professionals¹⁷ and consumers.¹⁸

Table 1

Potential benefits of telemedicine

Potential pitfalls and drawbacks

Although convenience, access, cost, and fossil fuel savings may favor video-chat doctor visits, telemedicine has downsides, some of which apply specifically to psychiatry. First, no current technology provides psychiatrists with “the rich multidimensional aspects of a person-to-person encounter,”¹⁹ and remote communication may change what patients tell us, how they feel when they tell us things, and how they feel when we respond. Often, an inherent awkwardness affects many forms of Internet communication.²⁰

Also uncertain is whether Skype is compliant with the Health Insurance Portability and Accountability Act and protects doctor-patient privacy well enough to satisfy ethical standards—although it probably is far better than e-mail in this regard. Third-party payers often will not reimburse for telephone calls and may balk at paying for Skype-based therapy, even in states that require insurers to reimburse for telemedicine.

Psychiatrists typically have limited physical contact with patients, but we often check weight and vital signs when we prescribe certain psychotropic medications. Results from home- and drugstore-based blood pressure monitors may not be accurate enough for treatment purposes. Remote communication also reduces the quality of visual information,²⁰ which can be crucial—for example, when good lighting and visual resolution is needed to decide whether a skin rash might be drug-induced.

Telemedicine raises concerns about licensure and meeting adequate standards of care. Medical care usually is deemed to have occurred in the state where the patient is located. For example, only physicians licensed to practice medicine in California are legally permitted to treat patients in California. As is the case with any treatment, care delivered via telemedicine must include appropriate patient examination and diagnosis.²¹

Help and guidance

Despite these potential drawbacks, many state agencies recognize the promise of telemedicine, and have developed networks to promote it (Table 2).^7-9,22,23 These networks have various goals but share a common pattern of establishing infrastructure, policies, and organized results. In the future, states may adopt laws or regulations that address conflicts in malpractice standards and liability coverage, licensing, accreditation, reimbursement, privacy, and data protection policies that now may impede or inhibit use of telepsychiatric services across jurisdictional boundaries. Last year, Ohio produced regulations to guide psychiatrists in prescribing medication remotely without an in-person examination. The University of Hawaii suggested steps that its state legislature might take to help providers predict the potential legal ramifications of telemedicine.⁶

Further help for telepsychiatry practitioners may be found in practice standards and guidelines developed by the American Telemedicine Association.^24,25 These documents gave guidance and support for the practice of telemedicine and for providing appropriate telepsychiatry health services.

Table 2

Telemedicine services available in different states

What should Dr. A do?

In answer to Dr. A’s question, many factors favor including telepsychiatry in her practice. Yet we know little about the accuracy and reliability of psychiatric assessments made solely via Skype or other remote video technology in ordinary practice. Legislation and legal rules about acceptable practices are ambiguous, although in the absence of clear guidance, psychiatrists should assume that all usual professional standards and expectations about adequate care apply to treatment via Skype or other remote communication methods.

Related Resources

• Skype. www.skype.com.
• American Telemedicine Association. www.americantelemed.org.

Dear Dr. Mossman:

I practice in a region with few psychiatrists and very little public transportation. For many patients, coming to my office is inconvenient, expensive, or time-consuming. Sometimes, their emotional problems make it hard for them to travel, and sometimes, bad weather makes travel difficult. I am considering providing remote treatment via Skype. Is this a reasonable idea? What are the risks of using this technology in my practice? — Submitted by “Dr. A”

Diagnosing and treating patients without a face-to-face encounter is not new. Doctors have provided “remote treatment” since shortly after telephones were invented.¹ Until recently, however, forensic psychiatrists advised colleagues not to diagnose patients or start treatment based on phone contact alone.²

The Internet has revolutionized our attitudes about many things. Communication technologies that seemed miraculous a generation ago have become commonplace and have transformed standards for ordinary and “acceptable” human contact. A quick Internet search of “telephone psychotherapy” turns up hundreds of mental health professionals who offer remote treatment services to patients via computers and Web cams.

Physicians in many specialties practice telemedicine, often with the support and encouragement of state governments and third-party payers. To decide whether to include telepsychiatry in your psychiatric practice, you should know:

• what “telemedicine” means and includes
• the possible advantages of offering remote health care
• potential risks and ambiguity about legal matters.

Defining telemedicine

Studies of remote, closed-circuit “telediagnosis” extend back more than 4 decades, closely following mid-20^th century advancements in audio and video relay technologies that made space broadcasts possible.³ Then as now, “telemedicine” simply means conveying health-related information from 1 site to another for diagnostic or treatment purposes.⁴ It’s an adaptation of available technology to deliver care more easily, with the goal of improving patients’ access to care and health status.

Telemedicine usage accelerated as the Internet and related technologies developed. Telemedicine programs in the United States increased by 1,500% from 1993 to 1998.⁴ Telemedicine use has grown 10% annually in recent years and has become a $4 billion per year industry in the United States.⁵ Recently enacted federal legislation is likely to extend health care coverage to 36 million Americans and require coverage of pre-existing conditions. To make these changes affordable, health care delivery will need to exploit new, efficiency-enhancing technologies.⁶

Advantages of telemedicine

State governments and some third-party payers have recognized that telemedicine can overcome geographic and cost barriers to health services and patient education.^5,7-9 Although closed-circuit video transmission has served this purpose for some time, Skype—free software that allows individuals to make video phone calls over the Internet using their computers—is an option that doctors are using to treat patients.^10-12

Research suggests that telepsychiatry may provide huge benefits to medically underserved areas while reducing health care costs.⁴ Telepsychiatry can reduce travel time and expenses for professionals and patients, and it also may lower wait times and “no-show” rates (Table 1).⁴ Telepsychiatry lets patients see caregivers when winter weather makes roads unsafe. It may allow geriatric patients who can no longer drive to access psychiatric care and it lowers health care’s “carbon footprint,” making it “eco-friendly.”¹³

Social media strategies are playing an expanding role in medical education,^14,15 and this probably will help practitioners feel more at ease about incorporating the underlying technologies into work with patients. Increased use of laptops and mobile phones lends itself well to telepsychiatry applications,¹³ and studies have examined the feasibility of psychotherapies delivered via remote communication devices.¹⁶ Smartphone apps are being designed to assist mental health professionals¹⁷ and consumers.¹⁸

Table 1

Potential benefits of telemedicine

Potential pitfalls and drawbacks

Although convenience, access, cost, and fossil fuel savings may favor video-chat doctor visits, telemedicine has downsides, some of which apply specifically to psychiatry. First, no current technology provides psychiatrists with “the rich multidimensional aspects of a person-to-person encounter,”¹⁹ and remote communication may change what patients tell us, how they feel when they tell us things, and how they feel when we respond. Often, an inherent awkwardness affects many forms of Internet communication.²⁰

Also uncertain is whether Skype is compliant with the Health Insurance Portability and Accountability Act and protects doctor-patient privacy well enough to satisfy ethical standards—although it probably is far better than e-mail in this regard. Third-party payers often will not reimburse for telephone calls and may balk at paying for Skype-based therapy, even in states that require insurers to reimburse for telemedicine.

Psychiatrists typically have limited physical contact with patients, but we often check weight and vital signs when we prescribe certain psychotropic medications. Results from home- and drugstore-based blood pressure monitors may not be accurate enough for treatment purposes. Remote communication also reduces the quality of visual information,²⁰ which can be crucial—for example, when good lighting and visual resolution is needed to decide whether a skin rash might be drug-induced.

Telemedicine raises concerns about licensure and meeting adequate standards of care. Medical care usually is deemed to have occurred in the state where the patient is located. For example, only physicians licensed to practice medicine in California are legally permitted to treat patients in California. As is the case with any treatment, care delivered via telemedicine must include appropriate patient examination and diagnosis.²¹

Help and guidance

Despite these potential drawbacks, many state agencies recognize the promise of telemedicine, and have developed networks to promote it (Table 2).^7-9,22,23 These networks have various goals but share a common pattern of establishing infrastructure, policies, and organized results. In the future, states may adopt laws or regulations that address conflicts in malpractice standards and liability coverage, licensing, accreditation, reimbursement, privacy, and data protection policies that now may impede or inhibit use of telepsychiatric services across jurisdictional boundaries. Last year, Ohio produced regulations to guide psychiatrists in prescribing medication remotely without an in-person examination. The University of Hawaii suggested steps that its state legislature might take to help providers predict the potential legal ramifications of telemedicine.⁶

Further help for telepsychiatry practitioners may be found in practice standards and guidelines developed by the American Telemedicine Association.^24,25 These documents gave guidance and support for the practice of telemedicine and for providing appropriate telepsychiatry health services.

Table 2

Telemedicine services available in different states

What should Dr. A do?

In answer to Dr. A’s question, many factors favor including telepsychiatry in her practice. Yet we know little about the accuracy and reliability of psychiatric assessments made solely via Skype or other remote video technology in ordinary practice. Legislation and legal rules about acceptable practices are ambiguous, although in the absence of clear guidance, psychiatrists should assume that all usual professional standards and expectations about adequate care apply to treatment via Skype or other remote communication methods.

Related Resources

• Skype. www.skype.com.
• American Telemedicine Association. www.americantelemed.org.

Dear Dr. Mossman:

I practice in a region with few psychiatrists and very little public transportation. For many patients, coming to my office is inconvenient, expensive, or time-consuming. Sometimes, their emotional problems make it hard for them to travel, and sometimes, bad weather makes travel difficult. I am considering providing remote treatment via Skype. Is this a reasonable idea? What are the risks of using this technology in my practice? — Submitted by “Dr. A”

Diagnosing and treating patients without a face-to-face encounter is not new. Doctors have provided “remote treatment” since shortly after telephones were invented.¹ Until recently, however, forensic psychiatrists advised colleagues not to diagnose patients or start treatment based on phone contact alone.²

The Internet has revolutionized our attitudes about many things. Communication technologies that seemed miraculous a generation ago have become commonplace and have transformed standards for ordinary and “acceptable” human contact. A quick Internet search of “telephone psychotherapy” turns up hundreds of mental health professionals who offer remote treatment services to patients via computers and Web cams.

Physicians in many specialties practice telemedicine, often with the support and encouragement of state governments and third-party payers. To decide whether to include telepsychiatry in your psychiatric practice, you should know:

• what “telemedicine” means and includes
• the possible advantages of offering remote health care
• potential risks and ambiguity about legal matters.

Defining telemedicine

Studies of remote, closed-circuit “telediagnosis” extend back more than 4 decades, closely following mid-20^th century advancements in audio and video relay technologies that made space broadcasts possible.³ Then as now, “telemedicine” simply means conveying health-related information from 1 site to another for diagnostic or treatment purposes.⁴ It’s an adaptation of available technology to deliver care more easily, with the goal of improving patients’ access to care and health status.

Telemedicine usage accelerated as the Internet and related technologies developed. Telemedicine programs in the United States increased by 1,500% from 1993 to 1998.⁴ Telemedicine use has grown 10% annually in recent years and has become a $4 billion per year industry in the United States.⁵ Recently enacted federal legislation is likely to extend health care coverage to 36 million Americans and require coverage of pre-existing conditions. To make these changes affordable, health care delivery will need to exploit new, efficiency-enhancing technologies.⁶

Advantages of telemedicine

State governments and some third-party payers have recognized that telemedicine can overcome geographic and cost barriers to health services and patient education.^5,7-9 Although closed-circuit video transmission has served this purpose for some time, Skype—free software that allows individuals to make video phone calls over the Internet using their computers—is an option that doctors are using to treat patients.^10-12

Research suggests that telepsychiatry may provide huge benefits to medically underserved areas while reducing health care costs.⁴ Telepsychiatry can reduce travel time and expenses for professionals and patients, and it also may lower wait times and “no-show” rates (Table 1).⁴ Telepsychiatry lets patients see caregivers when winter weather makes roads unsafe. It may allow geriatric patients who can no longer drive to access psychiatric care and it lowers health care’s “carbon footprint,” making it “eco-friendly.”¹³

Social media strategies are playing an expanding role in medical education,^14,15 and this probably will help practitioners feel more at ease about incorporating the underlying technologies into work with patients. Increased use of laptops and mobile phones lends itself well to telepsychiatry applications,¹³ and studies have examined the feasibility of psychotherapies delivered via remote communication devices.¹⁶ Smartphone apps are being designed to assist mental health professionals¹⁷ and consumers.¹⁸

Table 1

Potential benefits of telemedicine

Potential pitfalls and drawbacks

Although convenience, access, cost, and fossil fuel savings may favor video-chat doctor visits, telemedicine has downsides, some of which apply specifically to psychiatry. First, no current technology provides psychiatrists with “the rich multidimensional aspects of a person-to-person encounter,”¹⁹ and remote communication may change what patients tell us, how they feel when they tell us things, and how they feel when we respond. Often, an inherent awkwardness affects many forms of Internet communication.²⁰

Also uncertain is whether Skype is compliant with the Health Insurance Portability and Accountability Act and protects doctor-patient privacy well enough to satisfy ethical standards—although it probably is far better than e-mail in this regard. Third-party payers often will not reimburse for telephone calls and may balk at paying for Skype-based therapy, even in states that require insurers to reimburse for telemedicine.

Psychiatrists typically have limited physical contact with patients, but we often check weight and vital signs when we prescribe certain psychotropic medications. Results from home- and drugstore-based blood pressure monitors may not be accurate enough for treatment purposes. Remote communication also reduces the quality of visual information,²⁰ which can be crucial—for example, when good lighting and visual resolution is needed to decide whether a skin rash might be drug-induced.

Telemedicine raises concerns about licensure and meeting adequate standards of care. Medical care usually is deemed to have occurred in the state where the patient is located. For example, only physicians licensed to practice medicine in California are legally permitted to treat patients in California. As is the case with any treatment, care delivered via telemedicine must include appropriate patient examination and diagnosis.²¹

Help and guidance

Despite these potential drawbacks, many state agencies recognize the promise of telemedicine, and have developed networks to promote it (Table 2).^7-9,22,23 These networks have various goals but share a common pattern of establishing infrastructure, policies, and organized results. In the future, states may adopt laws or regulations that address conflicts in malpractice standards and liability coverage, licensing, accreditation, reimbursement, privacy, and data protection policies that now may impede or inhibit use of telepsychiatric services across jurisdictional boundaries. Last year, Ohio produced regulations to guide psychiatrists in prescribing medication remotely without an in-person examination. The University of Hawaii suggested steps that its state legislature might take to help providers predict the potential legal ramifications of telemedicine.⁶

Further help for telepsychiatry practitioners may be found in practice standards and guidelines developed by the American Telemedicine Association.^24,25 These documents gave guidance and support for the practice of telemedicine and for providing appropriate telepsychiatry health services.

Table 2

Telemedicine services available in different states

What should Dr. A do?

In answer to Dr. A’s question, many factors favor including telepsychiatry in her practice. Yet we know little about the accuracy and reliability of psychiatric assessments made solely via Skype or other remote video technology in ordinary practice. Legislation and legal rules about acceptable practices are ambiguous, although in the absence of clear guidance, psychiatrists should assume that all usual professional standards and expectations about adequate care apply to treatment via Skype or other remote communication methods.

Related Resources

• Skype. www.skype.com.
• American Telemedicine Association. www.americantelemed.org.

Formerly called multiple personality disorder, dissociative identity disorder (DID) is a controversial diagnosis that challenges forensic psychiatrists, other mental health clinicians, legal professionals, the media, and the public. DID cases often present in the criminal justice system rather than in the mental health system, and the illness perplexes experts in both professions.

Individuals may commit criminal acts while in a dissociated state. A study that tracked 21 reported DID cases found that 47% of men and 35% of women reported engaging in criminal activity, including 19% of men and 7% of women who committed homicide.¹ Defendants occasionally use DID as a basis for pleading not guilty by reason of insanity (NGRI). Controversy over the DID diagnosis has contributed to debates about the disorder’s role in criminal responsibility.

The DID diagnosis

An American Psychiatric Association Work Group has proposed new diagnostic criteria for DID for DSM-5, which is scheduled to be published in May 2013.² Presently, DID is listed in DSM-IV-TR as an axis I disorder.³ Criteria for DID include the presence of ≥2 distinctive identities or personality states that recurrently take control of an individual’s behavior (Table 1).³ This is accompanied by an inability to recall important personal information to an extent that cannot be explained by ordinary forgetfulness. Patients with DID typically have a primary identity that is passive, dependent, guilty, and depressed, and alternate identities with characteristics that differ from the primary identity, commonly in reported age and gender, vocabulary, general knowledge, or predominant affect.³

Dissociative pathology may result from trauma, comorbid mental illness, or other medical issues, including complex partial seizures. Developmental theorists have proposed that severe sexual, physical, or psychological trauma in childhood predisposes an individual to develop DID.⁴ Theoretically, harm by a trusted caregiver forces a child to split off awareness and memory of the trauma to survive in the relationship. Later these memories and feelings are experienced as a separate personality. Because this process happens repeatedly, the patient develops multiple personalities; each has different memories and performs different functions, which may be helpful or destructive. Later, dissociation becomes a coping mechanism when individuals face stressful situations.⁵

Personality traits that may predispose patients to develop a dissociative disorder include mental absorption, suggestibility, ability to be easily hypnotized, and tendency to fantasize.⁶ Patients with dissociation also may meet criteria for posttraumatic stress disorder, borderline personality disorder, somatoform disorder, eating disorder, or substance use disorders.⁷

Table 1

DSM-IV-TR criteria for dissociative identity disorder

DID and NGRI

An insanity defense is raised in <1% of felony cases, and is successful in only a fraction of those.⁸ A criminal defendant who claims NGRI asserts that he committed the offense and asks the court to find him not culpable because of his mental state when the offense occurred.

The legal approach used by the defense in cases of NGRI due to DID will be determined by the jurisdiction in which the case is tried. The “Alter-in-control” approach considers the key issue as which “alter” (personality) was in control at the time of the offense and whether he or she met the insanity standard, the “Each-alter” approach considers whether each personality met the insanity standard, and the “Host-alter” approach considers whether the dominant or primary personality met the insanity standard.⁹

Legal and mental health professionals are divided on whether DID warrants an acquittal for insanity. The first time DID was recognized as a mental disorder that could excuse criminal responsibility occurred in State v Milligan (1978).¹⁰ The court declared serial rapist Billy Milligan insane due to lack of one integrated personality and therefore not culpable of the crimes he committed. Public outrage was extraordinary. Since this case, most DID defenses have not been successful (Table 2).^10-16

In a 1980 court case,¹¹ a defendant charged with murder pleaded NGRI due to having multiple personalities. The court found that having alter personalities was not necessarily a mental disease that would preclude responsibility for the murder.

In State v Grimsley (1982),¹² the defense used NGRI due to multiple personalities in a drunk driving case. The court ruled that it is immaterial what state of consciousness or personality the defendant was in as long as the personality controlling the behavior was conscious and aware of his or her actions.

In Kirkland v State (1983),¹³ attorneys for a woman who committed a bank robbery asserted an insanity defense based on a psychogenic fugue, which is sudden, unexpected travel away from home accompanied by inability to recall one’s past and confusion about identity or assumption of a new identity.³ The court found that the law adjudges criminal liability according to the person’s state of mind at the time of the act and will not inquire whether an individual possesses other personalities, fugues, or even moods in which he would not have performed the crime.

In State v Jones (1988),¹⁴ the court found the defendant guilty of murdering a woman he met at a bar despite expert testimony that his multiple personalities “paralyzed” him from knowing right from wrong.

More recently, courts have rejected the admissibility of DID evidence, including expert testimony, because the scientific evidence failed to meet reliability standards, and therefore is not ultimately useful to the judge or jury. In State v Greene (1998),¹⁵ the defendant claimed that 1 of his 24 alters was responsible for killing his therapist. The Supreme Court of Washington affirmed that evidence of Mr. Greene’s DID, including expert testimony, was not reliable and not admissible.

Similarly, in State v Lockhart (2000),¹⁶ Mr. Lockhart contested his conviction of first degree sexual assault on the basis that he was not permitted to present evidence of DID to support his insanity defense. The West Virginia Court held that the diagnosis of DID was speculative and therefore did not meet reliability standards for evidence.

Table 2

Using dissociative identity disorder* as a basis for not guilty by reason of insanity

Evaluating DID

Because the courts may ask psychiatrists to provide expert opinion on DID to assist with legal rulings, clinicians must remain vigilant to the possibility of DID as well as to defendants who may malinger multiple personalities to evade punishment. In such situations, factors to consider include the mental status examination, data and history collection, collateral information, criminal background, mental health history, history of abuse, and objective assessment tools.

Extensive field testing has shown that the Structured Clinical Interview for Dissociative Disorders (SCID-D) has good reliability and excellent validity.¹⁷ The SCID-D allows a trained interviewer to assess the severity of 5 dissociative symptoms: amnesia, depersonalization, derealization, identity confusion, and identity alteration.¹⁷ Other tools that may help assess a patient with suspected DID are listed in Table 3.

Patients who commit criminal acts while in a dissociated state may assert a defense of NGRI due to DID, but rarely has this defense been successful. Although a patient may have distinct personalities that control his or her behavior, this condition does not preclude criminal responsibility.

The role of hypnosis in evaluating DID is controversial. The introduction of pseudo-memories and potential for iatrogenic DID may complicate the clinical presentation and subsequent diagnosis.¹⁸

Table 3

Tools for diagnosing dissociative identity disorder

Related Resource

• West S, Noffsinger S. Is this patient not guilty by reason of insanity? Current Psychiatry. 2006;5(8):54-62.

Disclosure

Dr. Farrell reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Formerly called multiple personality disorder, dissociative identity disorder (DID) is a controversial diagnosis that challenges forensic psychiatrists, other mental health clinicians, legal professionals, the media, and the public. DID cases often present in the criminal justice system rather than in the mental health system, and the illness perplexes experts in both professions.

Individuals may commit criminal acts while in a dissociated state. A study that tracked 21 reported DID cases found that 47% of men and 35% of women reported engaging in criminal activity, including 19% of men and 7% of women who committed homicide.¹ Defendants occasionally use DID as a basis for pleading not guilty by reason of insanity (NGRI). Controversy over the DID diagnosis has contributed to debates about the disorder’s role in criminal responsibility.

The DID diagnosis

An American Psychiatric Association Work Group has proposed new diagnostic criteria for DID for DSM-5, which is scheduled to be published in May 2013.² Presently, DID is listed in DSM-IV-TR as an axis I disorder.³ Criteria for DID include the presence of ≥2 distinctive identities or personality states that recurrently take control of an individual’s behavior (Table 1).³ This is accompanied by an inability to recall important personal information to an extent that cannot be explained by ordinary forgetfulness. Patients with DID typically have a primary identity that is passive, dependent, guilty, and depressed, and alternate identities with characteristics that differ from the primary identity, commonly in reported age and gender, vocabulary, general knowledge, or predominant affect.³

Dissociative pathology may result from trauma, comorbid mental illness, or other medical issues, including complex partial seizures. Developmental theorists have proposed that severe sexual, physical, or psychological trauma in childhood predisposes an individual to develop DID.⁴ Theoretically, harm by a trusted caregiver forces a child to split off awareness and memory of the trauma to survive in the relationship. Later these memories and feelings are experienced as a separate personality. Because this process happens repeatedly, the patient develops multiple personalities; each has different memories and performs different functions, which may be helpful or destructive. Later, dissociation becomes a coping mechanism when individuals face stressful situations.⁵

Personality traits that may predispose patients to develop a dissociative disorder include mental absorption, suggestibility, ability to be easily hypnotized, and tendency to fantasize.⁶ Patients with dissociation also may meet criteria for posttraumatic stress disorder, borderline personality disorder, somatoform disorder, eating disorder, or substance use disorders.⁷

Table 1

DSM-IV-TR criteria for dissociative identity disorder

DID and NGRI

An insanity defense is raised in <1% of felony cases, and is successful in only a fraction of those.⁸ A criminal defendant who claims NGRI asserts that he committed the offense and asks the court to find him not culpable because of his mental state when the offense occurred.

The legal approach used by the defense in cases of NGRI due to DID will be determined by the jurisdiction in which the case is tried. The “Alter-in-control” approach considers the key issue as which “alter” (personality) was in control at the time of the offense and whether he or she met the insanity standard, the “Each-alter” approach considers whether each personality met the insanity standard, and the “Host-alter” approach considers whether the dominant or primary personality met the insanity standard.⁹

Legal and mental health professionals are divided on whether DID warrants an acquittal for insanity. The first time DID was recognized as a mental disorder that could excuse criminal responsibility occurred in State v Milligan (1978).¹⁰ The court declared serial rapist Billy Milligan insane due to lack of one integrated personality and therefore not culpable of the crimes he committed. Public outrage was extraordinary. Since this case, most DID defenses have not been successful (Table 2).^10-16

In a 1980 court case,¹¹ a defendant charged with murder pleaded NGRI due to having multiple personalities. The court found that having alter personalities was not necessarily a mental disease that would preclude responsibility for the murder.

In State v Grimsley (1982),¹² the defense used NGRI due to multiple personalities in a drunk driving case. The court ruled that it is immaterial what state of consciousness or personality the defendant was in as long as the personality controlling the behavior was conscious and aware of his or her actions.

In Kirkland v State (1983),¹³ attorneys for a woman who committed a bank robbery asserted an insanity defense based on a psychogenic fugue, which is sudden, unexpected travel away from home accompanied by inability to recall one’s past and confusion about identity or assumption of a new identity.³ The court found that the law adjudges criminal liability according to the person’s state of mind at the time of the act and will not inquire whether an individual possesses other personalities, fugues, or even moods in which he would not have performed the crime.

In State v Jones (1988),¹⁴ the court found the defendant guilty of murdering a woman he met at a bar despite expert testimony that his multiple personalities “paralyzed” him from knowing right from wrong.

More recently, courts have rejected the admissibility of DID evidence, including expert testimony, because the scientific evidence failed to meet reliability standards, and therefore is not ultimately useful to the judge or jury. In State v Greene (1998),¹⁵ the defendant claimed that 1 of his 24 alters was responsible for killing his therapist. The Supreme Court of Washington affirmed that evidence of Mr. Greene’s DID, including expert testimony, was not reliable and not admissible.

Similarly, in State v Lockhart (2000),¹⁶ Mr. Lockhart contested his conviction of first degree sexual assault on the basis that he was not permitted to present evidence of DID to support his insanity defense. The West Virginia Court held that the diagnosis of DID was speculative and therefore did not meet reliability standards for evidence.

Table 2

Using dissociative identity disorder* as a basis for not guilty by reason of insanity

Evaluating DID

Because the courts may ask psychiatrists to provide expert opinion on DID to assist with legal rulings, clinicians must remain vigilant to the possibility of DID as well as to defendants who may malinger multiple personalities to evade punishment. In such situations, factors to consider include the mental status examination, data and history collection, collateral information, criminal background, mental health history, history of abuse, and objective assessment tools.

Extensive field testing has shown that the Structured Clinical Interview for Dissociative Disorders (SCID-D) has good reliability and excellent validity.¹⁷ The SCID-D allows a trained interviewer to assess the severity of 5 dissociative symptoms: amnesia, depersonalization, derealization, identity confusion, and identity alteration.¹⁷ Other tools that may help assess a patient with suspected DID are listed in Table 3.

Patients who commit criminal acts while in a dissociated state may assert a defense of NGRI due to DID, but rarely has this defense been successful. Although a patient may have distinct personalities that control his or her behavior, this condition does not preclude criminal responsibility.

The role of hypnosis in evaluating DID is controversial. The introduction of pseudo-memories and potential for iatrogenic DID may complicate the clinical presentation and subsequent diagnosis.¹⁸

Table 3

Tools for diagnosing dissociative identity disorder

Related Resource

• West S, Noffsinger S. Is this patient not guilty by reason of insanity? Current Psychiatry. 2006;5(8):54-62.

Disclosure

Dr. Farrell reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Formerly called multiple personality disorder, dissociative identity disorder (DID) is a controversial diagnosis that challenges forensic psychiatrists, other mental health clinicians, legal professionals, the media, and the public. DID cases often present in the criminal justice system rather than in the mental health system, and the illness perplexes experts in both professions.

Individuals may commit criminal acts while in a dissociated state. A study that tracked 21 reported DID cases found that 47% of men and 35% of women reported engaging in criminal activity, including 19% of men and 7% of women who committed homicide.¹ Defendants occasionally use DID as a basis for pleading not guilty by reason of insanity (NGRI). Controversy over the DID diagnosis has contributed to debates about the disorder’s role in criminal responsibility.

The DID diagnosis

An American Psychiatric Association Work Group has proposed new diagnostic criteria for DID for DSM-5, which is scheduled to be published in May 2013.² Presently, DID is listed in DSM-IV-TR as an axis I disorder.³ Criteria for DID include the presence of ≥2 distinctive identities or personality states that recurrently take control of an individual’s behavior (Table 1).³ This is accompanied by an inability to recall important personal information to an extent that cannot be explained by ordinary forgetfulness. Patients with DID typically have a primary identity that is passive, dependent, guilty, and depressed, and alternate identities with characteristics that differ from the primary identity, commonly in reported age and gender, vocabulary, general knowledge, or predominant affect.³

Dissociative pathology may result from trauma, comorbid mental illness, or other medical issues, including complex partial seizures. Developmental theorists have proposed that severe sexual, physical, or psychological trauma in childhood predisposes an individual to develop DID.⁴ Theoretically, harm by a trusted caregiver forces a child to split off awareness and memory of the trauma to survive in the relationship. Later these memories and feelings are experienced as a separate personality. Because this process happens repeatedly, the patient develops multiple personalities; each has different memories and performs different functions, which may be helpful or destructive. Later, dissociation becomes a coping mechanism when individuals face stressful situations.⁵

Personality traits that may predispose patients to develop a dissociative disorder include mental absorption, suggestibility, ability to be easily hypnotized, and tendency to fantasize.⁶ Patients with dissociation also may meet criteria for posttraumatic stress disorder, borderline personality disorder, somatoform disorder, eating disorder, or substance use disorders.⁷

Table 1

DSM-IV-TR criteria for dissociative identity disorder

DID and NGRI

An insanity defense is raised in <1% of felony cases, and is successful in only a fraction of those.⁸ A criminal defendant who claims NGRI asserts that he committed the offense and asks the court to find him not culpable because of his mental state when the offense occurred.

The legal approach used by the defense in cases of NGRI due to DID will be determined by the jurisdiction in which the case is tried. The “Alter-in-control” approach considers the key issue as which “alter” (personality) was in control at the time of the offense and whether he or she met the insanity standard, the “Each-alter” approach considers whether each personality met the insanity standard, and the “Host-alter” approach considers whether the dominant or primary personality met the insanity standard.⁹

Legal and mental health professionals are divided on whether DID warrants an acquittal for insanity. The first time DID was recognized as a mental disorder that could excuse criminal responsibility occurred in State v Milligan (1978).¹⁰ The court declared serial rapist Billy Milligan insane due to lack of one integrated personality and therefore not culpable of the crimes he committed. Public outrage was extraordinary. Since this case, most DID defenses have not been successful (Table 2).^10-16

In a 1980 court case,¹¹ a defendant charged with murder pleaded NGRI due to having multiple personalities. The court found that having alter personalities was not necessarily a mental disease that would preclude responsibility for the murder.

In State v Grimsley (1982),¹² the defense used NGRI due to multiple personalities in a drunk driving case. The court ruled that it is immaterial what state of consciousness or personality the defendant was in as long as the personality controlling the behavior was conscious and aware of his or her actions.

In Kirkland v State (1983),¹³ attorneys for a woman who committed a bank robbery asserted an insanity defense based on a psychogenic fugue, which is sudden, unexpected travel away from home accompanied by inability to recall one’s past and confusion about identity or assumption of a new identity.³ The court found that the law adjudges criminal liability according to the person’s state of mind at the time of the act and will not inquire whether an individual possesses other personalities, fugues, or even moods in which he would not have performed the crime.

In State v Jones (1988),¹⁴ the court found the defendant guilty of murdering a woman he met at a bar despite expert testimony that his multiple personalities “paralyzed” him from knowing right from wrong.

More recently, courts have rejected the admissibility of DID evidence, including expert testimony, because the scientific evidence failed to meet reliability standards, and therefore is not ultimately useful to the judge or jury. In State v Greene (1998),¹⁵ the defendant claimed that 1 of his 24 alters was responsible for killing his therapist. The Supreme Court of Washington affirmed that evidence of Mr. Greene’s DID, including expert testimony, was not reliable and not admissible.

Similarly, in State v Lockhart (2000),¹⁶ Mr. Lockhart contested his conviction of first degree sexual assault on the basis that he was not permitted to present evidence of DID to support his insanity defense. The West Virginia Court held that the diagnosis of DID was speculative and therefore did not meet reliability standards for evidence.

Table 2

Using dissociative identity disorder* as a basis for not guilty by reason of insanity

Evaluating DID

Because the courts may ask psychiatrists to provide expert opinion on DID to assist with legal rulings, clinicians must remain vigilant to the possibility of DID as well as to defendants who may malinger multiple personalities to evade punishment. In such situations, factors to consider include the mental status examination, data and history collection, collateral information, criminal background, mental health history, history of abuse, and objective assessment tools.

Extensive field testing has shown that the Structured Clinical Interview for Dissociative Disorders (SCID-D) has good reliability and excellent validity.¹⁷ The SCID-D allows a trained interviewer to assess the severity of 5 dissociative symptoms: amnesia, depersonalization, derealization, identity confusion, and identity alteration.¹⁷ Other tools that may help assess a patient with suspected DID are listed in Table 3.

Patients who commit criminal acts while in a dissociated state may assert a defense of NGRI due to DID, but rarely has this defense been successful. Although a patient may have distinct personalities that control his or her behavior, this condition does not preclude criminal responsibility.

The role of hypnosis in evaluating DID is controversial. The introduction of pseudo-memories and potential for iatrogenic DID may complicate the clinical presentation and subsequent diagnosis.¹⁸

Table 3

Tools for diagnosing dissociative identity disorder

Related Resource

• West S, Noffsinger S. Is this patient not guilty by reason of insanity? Current Psychiatry. 2006;5(8):54-62.

Disclosure

Dr. Farrell reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Each year, the World Federation of Mental Health chooses a theme for World Mental Health Day, which is Oct. 10. This year’s theme is “Mental Health Promotion and Suicide Prevention.”

Vstock LLC/ThinkStock

About 800,000 people die by suicide every year, according to the World Health Organization. Suicide is the second-leading cause of death among people aged 15-29 years.¹

Most suicide occurs in low- and middle-income countries, the WHO reports. In addition, almost two-thirds of those deaths around the world occur in males, a recent study shows.² The study, conducted by Danah Alothman and Andrew Fogarty, MBBS, of the NIHR Biomedical Research Center at the University of Nottingham (England), looked at sex-specific suicide rates for 182 countries in 2015.

They found that the highest difference between male:female suicide rates were in the Americas (median, 4:1/100,000), and the lowest were in Africa and Asia (median for both continents, 2.7:1/100,000).

“The implication is that as societies become richer and more educated, males have a higher risk of dying as a consequence of suicide relative to females,” they wrote in the Journal of Affective Disorders.

For clinicians who treat patients with mental illness, particularly those of us who practice in the Americas, this sex differential is concerning. We know that women are more likely to be diagnosed the depression.³ But perhaps this has something to do with the way men are socialized around the world. In other words, as John S. Ogrodniczuk, PhD, and John L. Oliffe, PhD, wrote,4 depression in men “often manifests as irritability; anger; hostile, aggressive, abusive behavior; risk taking, substance abuse; and escaping behavior.” They argue that the outward behavior shown by some men with depression might, in fact, “serve as a cover-up mechanism to hide the internal turmoil” they are experiencing. We certainly know that some men adhere to masculine norms such as stoicism, which in turn, heightens self-stigma. Unfortunately, men seek help for depression less often than do women.⁵ So one key question becomes: What can we as mental health professionals do to better meet the treatment needs of our male patients?

I would like to see more clinical interventions that are tailored to increase the engagement of men in mental health services. One example of a program that could hold promise in this area is one called Men at Risk. That program, developed by the nonprofit Centre for Suicide Prevention, in Grande Prairie, Alta., helps men who work in the oil, forestry, and agriculture sectors talk about their challenges and encourages them to let go of stigma.⁶

Factors other than male gender also might increase the likelihood of suicide. It has rightly been said that genetics and environment play a big role on the psyche of the individuals, and the act of suicide is no different when we discuss the etiologic factors that lead to perpetration of such an act. Genetic vulnerability is a factor that cannot be modified or altered in an easy way, hence, control of environmental factors is more pertinent.

Poverty and violence are two major detrimental factors that have reached alarming proportions and can lead people end their lives.

The developing countries, and now to a significant extent, developed countries, face terrorism that affect the human psyche and can lead to depression, psychosis, and substance abuse, and hence, increase the vulnerability toward the act of suicide. In our offices, we psychiatrists come across patients with borderline personality disorder, for example, who present to emergency departments with multiple and repeated suicidal attempts. There is a big role of genetics here – and role of specific interventions, such as dialectical behavior therapy. Pharmacologic treatment can play a vital role.

In order to make the world a safe place, joint global efforts are required. Enhanced security steps, improved immigration screening, and political will are essential to curb this heartbreaking act. Responsible reporting on the part of the media is needed to make suicide contagion less likely.⁷

Among other important measures are reducing access to guns and other firearms, and increasing health education about consumption of alcohol and other substances. We also need early identification and prompt treatment of mental illnesses; alleviation of poverty; mobilization of community supports; activation of multiple crisis lines; increased availability and affordability of psychotropic medications; reduction of waiting times for seeking treatment of mental illness; enhanced training of crisis workers; and refresher courses for psychiatrists, family physicians, and other allied mental health workers. Above all, strategies are needed to address the stigma associated with seeking help for mental health issues.

Suicide is a global public health issue, and it is of the utmost importance that a collaborative effort be placed in perspective by individual countries within their own health-related policies and parameters.

Good-quality data on suicide prevalence rates would be of the utmost help in understanding the magnitude of this grave problem. The WHO Mental Health Action Plan 2013-2020 indicates the commitment of member states to work toward the global target of reducing the suicide rate in countries by 10% by 2020.

Individual and collective efforts should become the priority to achieve this target going forward.
 

References

1. World Health Organization. Suicide. 2019 Sep 2.

2. Alothman D and A Fogarty. J Affect Disord. 2020 Jan 1. doi: 10.1016/j.jad.2019.08.093.

3. Albert PR. J Psychiatry Neurosci. 2015 Jul;40(4):219-21.

4. Ogrodniczuk JS and JL Oliffe. Can Fam Physician. 2011;57(2):153-5.

5. Seidler ZE et al. Clin Psychology Rev. 2016;49:106-18.

6. Ellwand O. Men at risk program helping men in Alberta trades, industry, agriculture struggling with mental health issues. Edmonton Sun. 2016 Mar 27.

7. American Association of Suicidology, et al. Recommendations for reporting on suicide.
 

Dr. Muhammad is clinical professor of psychiatry and consultant psychiatrist at Niagara Health Service, St. Catharines, Ont.

Each year, the World Federation of Mental Health chooses a theme for World Mental Health Day, which is Oct. 10. This year’s theme is “Mental Health Promotion and Suicide Prevention.”

Vstock LLC/ThinkStock

About 800,000 people die by suicide every year, according to the World Health Organization. Suicide is the second-leading cause of death among people aged 15-29 years.¹

Most suicide occurs in low- and middle-income countries, the WHO reports. In addition, almost two-thirds of those deaths around the world occur in males, a recent study shows.² The study, conducted by Danah Alothman and Andrew Fogarty, MBBS, of the NIHR Biomedical Research Center at the University of Nottingham (England), looked at sex-specific suicide rates for 182 countries in 2015.

They found that the highest difference between male:female suicide rates were in the Americas (median, 4:1/100,000), and the lowest were in Africa and Asia (median for both continents, 2.7:1/100,000).

“The implication is that as societies become richer and more educated, males have a higher risk of dying as a consequence of suicide relative to females,” they wrote in the Journal of Affective Disorders.

For clinicians who treat patients with mental illness, particularly those of us who practice in the Americas, this sex differential is concerning. We know that women are more likely to be diagnosed the depression.³ But perhaps this has something to do with the way men are socialized around the world. In other words, as John S. Ogrodniczuk, PhD, and John L. Oliffe, PhD, wrote,4 depression in men “often manifests as irritability; anger; hostile, aggressive, abusive behavior; risk taking, substance abuse; and escaping behavior.” They argue that the outward behavior shown by some men with depression might, in fact, “serve as a cover-up mechanism to hide the internal turmoil” they are experiencing. We certainly know that some men adhere to masculine norms such as stoicism, which in turn, heightens self-stigma. Unfortunately, men seek help for depression less often than do women.⁵ So one key question becomes: What can we as mental health professionals do to better meet the treatment needs of our male patients?

I would like to see more clinical interventions that are tailored to increase the engagement of men in mental health services. One example of a program that could hold promise in this area is one called Men at Risk. That program, developed by the nonprofit Centre for Suicide Prevention, in Grande Prairie, Alta., helps men who work in the oil, forestry, and agriculture sectors talk about their challenges and encourages them to let go of stigma.⁶

Factors other than male gender also might increase the likelihood of suicide. It has rightly been said that genetics and environment play a big role on the psyche of the individuals, and the act of suicide is no different when we discuss the etiologic factors that lead to perpetration of such an act. Genetic vulnerability is a factor that cannot be modified or altered in an easy way, hence, control of environmental factors is more pertinent.

Poverty and violence are two major detrimental factors that have reached alarming proportions and can lead people end their lives.

The developing countries, and now to a significant extent, developed countries, face terrorism that affect the human psyche and can lead to depression, psychosis, and substance abuse, and hence, increase the vulnerability toward the act of suicide. In our offices, we psychiatrists come across patients with borderline personality disorder, for example, who present to emergency departments with multiple and repeated suicidal attempts. There is a big role of genetics here – and role of specific interventions, such as dialectical behavior therapy. Pharmacologic treatment can play a vital role.

In order to make the world a safe place, joint global efforts are required. Enhanced security steps, improved immigration screening, and political will are essential to curb this heartbreaking act. Responsible reporting on the part of the media is needed to make suicide contagion less likely.⁷

Among other important measures are reducing access to guns and other firearms, and increasing health education about consumption of alcohol and other substances. We also need early identification and prompt treatment of mental illnesses; alleviation of poverty; mobilization of community supports; activation of multiple crisis lines; increased availability and affordability of psychotropic medications; reduction of waiting times for seeking treatment of mental illness; enhanced training of crisis workers; and refresher courses for psychiatrists, family physicians, and other allied mental health workers. Above all, strategies are needed to address the stigma associated with seeking help for mental health issues.

Suicide is a global public health issue, and it is of the utmost importance that a collaborative effort be placed in perspective by individual countries within their own health-related policies and parameters.

Good-quality data on suicide prevalence rates would be of the utmost help in understanding the magnitude of this grave problem. The WHO Mental Health Action Plan 2013-2020 indicates the commitment of member states to work toward the global target of reducing the suicide rate in countries by 10% by 2020.

Individual and collective efforts should become the priority to achieve this target going forward.
 

References

1. World Health Organization. Suicide. 2019 Sep 2.

2. Alothman D and A Fogarty. J Affect Disord. 2020 Jan 1. doi: 10.1016/j.jad.2019.08.093.

3. Albert PR. J Psychiatry Neurosci. 2015 Jul;40(4):219-21.

4. Ogrodniczuk JS and JL Oliffe. Can Fam Physician. 2011;57(2):153-5.

5. Seidler ZE et al. Clin Psychology Rev. 2016;49:106-18.

6. Ellwand O. Men at risk program helping men in Alberta trades, industry, agriculture struggling with mental health issues. Edmonton Sun. 2016 Mar 27.

7. American Association of Suicidology, et al. Recommendations for reporting on suicide.
 

Dr. Muhammad is clinical professor of psychiatry and consultant psychiatrist at Niagara Health Service, St. Catharines, Ont.

Each year, the World Federation of Mental Health chooses a theme for World Mental Health Day, which is Oct. 10. This year’s theme is “Mental Health Promotion and Suicide Prevention.”

Vstock LLC/ThinkStock

About 800,000 people die by suicide every year, according to the World Health Organization. Suicide is the second-leading cause of death among people aged 15-29 years.¹

Most suicide occurs in low- and middle-income countries, the WHO reports. In addition, almost two-thirds of those deaths around the world occur in males, a recent study shows.² The study, conducted by Danah Alothman and Andrew Fogarty, MBBS, of the NIHR Biomedical Research Center at the University of Nottingham (England), looked at sex-specific suicide rates for 182 countries in 2015.

They found that the highest difference between male:female suicide rates were in the Americas (median, 4:1/100,000), and the lowest were in Africa and Asia (median for both continents, 2.7:1/100,000).

“The implication is that as societies become richer and more educated, males have a higher risk of dying as a consequence of suicide relative to females,” they wrote in the Journal of Affective Disorders.

For clinicians who treat patients with mental illness, particularly those of us who practice in the Americas, this sex differential is concerning. We know that women are more likely to be diagnosed the depression.³ But perhaps this has something to do with the way men are socialized around the world. In other words, as John S. Ogrodniczuk, PhD, and John L. Oliffe, PhD, wrote,4 depression in men “often manifests as irritability; anger; hostile, aggressive, abusive behavior; risk taking, substance abuse; and escaping behavior.” They argue that the outward behavior shown by some men with depression might, in fact, “serve as a cover-up mechanism to hide the internal turmoil” they are experiencing. We certainly know that some men adhere to masculine norms such as stoicism, which in turn, heightens self-stigma. Unfortunately, men seek help for depression less often than do women.⁵ So one key question becomes: What can we as mental health professionals do to better meet the treatment needs of our male patients?

I would like to see more clinical interventions that are tailored to increase the engagement of men in mental health services. One example of a program that could hold promise in this area is one called Men at Risk. That program, developed by the nonprofit Centre for Suicide Prevention, in Grande Prairie, Alta., helps men who work in the oil, forestry, and agriculture sectors talk about their challenges and encourages them to let go of stigma.⁶

Factors other than male gender also might increase the likelihood of suicide. It has rightly been said that genetics and environment play a big role on the psyche of the individuals, and the act of suicide is no different when we discuss the etiologic factors that lead to perpetration of such an act. Genetic vulnerability is a factor that cannot be modified or altered in an easy way, hence, control of environmental factors is more pertinent.

Poverty and violence are two major detrimental factors that have reached alarming proportions and can lead people end their lives.

The developing countries, and now to a significant extent, developed countries, face terrorism that affect the human psyche and can lead to depression, psychosis, and substance abuse, and hence, increase the vulnerability toward the act of suicide. In our offices, we psychiatrists come across patients with borderline personality disorder, for example, who present to emergency departments with multiple and repeated suicidal attempts. There is a big role of genetics here – and role of specific interventions, such as dialectical behavior therapy. Pharmacologic treatment can play a vital role.

In order to make the world a safe place, joint global efforts are required. Enhanced security steps, improved immigration screening, and political will are essential to curb this heartbreaking act. Responsible reporting on the part of the media is needed to make suicide contagion less likely.⁷

Among other important measures are reducing access to guns and other firearms, and increasing health education about consumption of alcohol and other substances. We also need early identification and prompt treatment of mental illnesses; alleviation of poverty; mobilization of community supports; activation of multiple crisis lines; increased availability and affordability of psychotropic medications; reduction of waiting times for seeking treatment of mental illness; enhanced training of crisis workers; and refresher courses for psychiatrists, family physicians, and other allied mental health workers. Above all, strategies are needed to address the stigma associated with seeking help for mental health issues.

Suicide is a global public health issue, and it is of the utmost importance that a collaborative effort be placed in perspective by individual countries within their own health-related policies and parameters.

Good-quality data on suicide prevalence rates would be of the utmost help in understanding the magnitude of this grave problem. The WHO Mental Health Action Plan 2013-2020 indicates the commitment of member states to work toward the global target of reducing the suicide rate in countries by 10% by 2020.

Individual and collective efforts should become the priority to achieve this target going forward.
 

References

1. World Health Organization. Suicide. 2019 Sep 2.

2. Alothman D and A Fogarty. J Affect Disord. 2020 Jan 1. doi: 10.1016/j.jad.2019.08.093.

3. Albert PR. J Psychiatry Neurosci. 2015 Jul;40(4):219-21.

4. Ogrodniczuk JS and JL Oliffe. Can Fam Physician. 2011;57(2):153-5.

5. Seidler ZE et al. Clin Psychology Rev. 2016;49:106-18.

6. Ellwand O. Men at risk program helping men in Alberta trades, industry, agriculture struggling with mental health issues. Edmonton Sun. 2016 Mar 27.

7. American Association of Suicidology, et al. Recommendations for reporting on suicide.
 

Dr. Muhammad is clinical professor of psychiatry and consultant psychiatrist at Niagara Health Service, St. Catharines, Ont.