Here comes EmergeOrtho.
All across the United States, thoughtful and entrepreneurial orthopedists are taking the initiative to improve the healthcare delivery models for both care givers and their patients. These doctors are not satisfied with the current system and are using their skills to come up with better solutions. The latest example is EmergeOrtho in North Carolina. Here is that inspiring story.
Thomas Dimmig, M.D. is an orthopedic doctor and surgeon on a mission to help independent orthopedic physicians across the state of North Carolina remain independent and improve patient care.
He’s been the driving force behind a two-year project to initially merge four orthopedic physician groups serving 49 office locations in 21 counties.
The project dubbed “Ortho I-40” is on the final leg of its journey to pull together 126 physicians from locations accessible to Interstate 40 across North Carolina, making it one of the largest physician-owned orthopedic practices in the country.
Dimmig and the planning team logged thousands of miles as they completed each milestone that led to the August 1 launch and grand opening of EmergeOrtho—the new company that provides streamlined, patient-centered care for the following four physician groups: Blue Ridge Bone and Joint of Asheville, Hendersonville and Arden; Carolina Orthopaedic Specialists with offices in Alexander, Burke, Caldwell and Catawba counties; OrthoWilmington with offices in New Hanover, Brunswick and Onslow counties; and Triangle Orthopaedic Associates of the greater Raleigh-Durham area with 23 locations covering 12 counties.
EmergeOrtho Improves Quality Through Independent Model
The combined practices that make up EmergeOrtho include 126 physicians and 237 physician assistants, nurse practitioners and therapists. Additional practices are poised to join the company in early 2017, bringing the total number of physicians to 170. Patients of each individual group practice should see no interruption in their care and services, said Dimmig, president of Triangle Orthopaedic Associates, who also serves as president of the new group.
“We are very fortunate to be creating an alliance of four well-established physician practices with excellent reputations, ” said Dimmig. “We united in order to preserve the private practice model, a standard of care that puts the patient first. The integrated group will allow these physicians to remain independent and provide their own higher quality, lower cost care.”
“We chose the name EmergeOrtho because it describes the group’s mission, ” added Dimmig. Steve DiBiasi, CEO of Ortho Wilmington, helped coordinate the creation and naming process for the entire group. “The goal of orthopedics is for patients to emerge from treatment, their illness or injury healed. Through excellent care, patients can emerge stronger and healthier, better able to lead an active life, ” said DiBiasi.
Integrating their network across North Carolina, all EmergeOrtho offices will use the same electronic health records system. Patients treated for injury while on vacation, for example, can follow up with an EmergeOrtho provider in their hometown who has seamless access to their medical chart.
Dimmig emphasized that the new organization will continue to build on proven strategies and implement programs that improve outcomes and lower costs for patients. Ancillary services such as diagnostic imaging and physical therapy are available in most EmergeOrtho locations, and 12 offices provide MRI. Orthopedic urgent care centers in 14 locations address emergent orthopedic needs as a prompt, less expensive alternative to the ER. Additionally, each group is committed to the present and future alternative payment concepts, such as risk-sharing bundled payments, and all accept a broad range of insurance options.
The Urge to Merge and the Necessity
Dimmig has been practicing orthopedics for more than 30 years. During his time at the helm of Triangle Orthopaedic Associates he has experienced first-hand the changes in healthcare industry rules and regulations that threaten the private-practice model.
“I think merging clearly is the future of where orthopedics is headed, ” said Dimmig. “I don’t see how you are going to be able to function as a small office and remain independent.” He cites changes in regulations and patient tracking, alternative payment programs and the need to meet quality care guidelines as examples of industry pressures put on practitioners. It’s becoming more difficult for groups to survive without having a big back office to help them.”
Dimmig has practice building back-office operations and leading a culture that is not frightened to change. “In order to provide better service to our patients, we had to grow. To provide the kind of care we wanted, we needed to always be bigger, ” he said.
Triangle Orthopedics is located in the Raleigh Durham area, which Dimmig says is very competitive with a couple of large university health systems. “We felt in order to compete we had to grow. Over many years, we grew to about 70 physicians in the entire group. Even though that’s pretty large, I didn’t think that was ever large enough to do what we needed to do to be successful as independent practitioners, ” he said.
Dimmig said he understands the appeal to physicians who join hospital systems or university systems and become employed physicians, but it’s never been what he has wanted. So, he set out to develop a model that helps patients and allows for independence. “Small groups of five, six or ten doctors are struggling; whereas, with a group of our size we were able to realize that we could do a lot of things for economies of scale, such as purchasing, providing better service to our patients, electronic records, starting a bundling program with our partner Blue Cross, for example. We are attracting like-minded, successful physician groups with an eye on creating the future of independent medical practices.”
Dimmig points to new rules and penalties outlined by the Centers for Medicare and Medicaid Services (CMS) as adding more fuel to the fire to merge. Medicare Access & Chip Reauthorization Act of 2015 (MACRA) specifically encourages physicians to report quality measures through electronic health records (EHRs) or Qualified Clinical Data Registries (QCDR). Practices would move away from claims-based reporting, move towards QCDR reporting, increase public reporting of performance data and incentives clearly in place to encourage physician participation in alternative payment models.
The Merit-Based Incentive Payment System (MIPS) states each provider will receive a composite score between 0-100 based on performance in the following categories:
- Quality 30%
- Resource Use/Cost 30%
- Meaningful Use 25%
- Clinical Practice Improvement Activities 15%.
Practices are required to meet the scoring requirement or face penalties. According to the CMS website, in 2015, the program began applying a negative payment adjustment to individual Eligible Professionals (Eps) and Physician Quality Reporting System (PQRS) group practices who did not satisfactorily report data on quality measures for Medicare Part B Physician Fee Schedule (MPFS) covered professional services in 2013.
“This kind of reporting requires physician oversight and a system like athenahealth that can help with reporting, ” Dimmig said. According to the Ingenious Mind research group, projected penalty rates based on CMS estimates for the 2017 participation period are high for small practice groups. It’s estimated that 70% and 59% of practices with 2-9 physicians and 10-24 physicians will incur penalties, respectively.
“It’s a sad state for medicine, if you can’t be successful with a 5 or 15-doctor practice, ” Dimmig said. “This [merger] is all about quality for the patient. Obviously, we want to be independent and successful. But, for us, the end game is to provide a product that is accessible to the patient that has high quality and good outcomes for a cost that is understandable to them. Bringing consumerism back to medicine is important to us.”
The Making of a Merger: Steps to Success
According to Dimmig, several key qualities and steps were important for the success of the merger between the four groups:
- A culture of change. “At Triangle, we had a culture of not being frightened to change. We knew we had to grow.
- Find similar sized partners. The four practice groups that came together are “pretty much similar sized. There are many doctors in each group, they have great culture, are well run with good administrators, they also have a vision for the future, and they are not afraid of the change that is necessary for us to survive.”
- A vision of how things could be better—what a merger might look like. “We started initial conversations with Ortho Wilmington about two years ago, when we explored a concept of putting together a statewide organization with one tax ID, one medical record, one billing We thought the same branded product across the state would be very powerful and very good for our patients.”
- A commitment to patient quality, cost containment and transparency. “We were trying to find value, which you can look at as quality divided by cost, but you can only ratchet down costs so much. In order to do that [provide quality], you have to have outcome studies, data, invest in uniform treatment, and bundle programs, and that takes a lot of time, personnel and IT infrastructure to do that.”
- Decide on a governance structure. “We decided to follow a divisional model, ” Dimmig said. “We all are under the same contracts. Everyone is under one tax ID. Everybody’s employment contracts are the same, and then we govern it to a divisional model with a board of directors that includes representatives from each division.”
Dimmig’s practice and the three other practice groups were able to begin doing that until they had a statewide footprint in place. The merged group is able to provide a statewide network that offers insurance groups one site to come to and negotiate fees across the state, for example. In addition, two of the practice groups were using the athenahealth electronic records system, so the other two practices agreed to switch too. Dimmig said, “Athenahealth is a flexible practice management system that we believe will help us through the transition.”
“The independent physicians in our system provide care at a lesser cost than hospitals or health systems are able to provide. We do not bill facility fees or HOPD (Hospital Outpatient Department). Therefore, costs of care in the independent world are often lower than if you are going to see a hospital employed physician in general.”
“In that regard, we are able to control the costs to the patients, especially now since many patients have high-deductible programs and out-of-pocket expenses. We are all wedded to the fact that alternative payments are here and will be a way we have to practice.”
Dimmig cites successful bundling programs that allow patients to know exactly what their care costs. “They have one bill and they aren’t exposed to six or seven other bills that they don’t understand. In our bundle program, the patient knows exactly how much it’s going to cost when they walk in the door. They know the services they are going to be receiving, and they are not going to have extra charges.”
The physicians remain independent. They are all owners and are all part of the governance of the entity. “We are physician owned, led and driven, ” he said. “Each division keeps their doctors and their flavor of how they provide medicine in their communities. Each community will continue to see the same doctors and services they know and trust, at the same locations. We anticipate that each community will see a higher level of quality, as we build on our common mission to deliver value-based, transparent, patient-centered care.”
