Healthcare Attorney, Siroky Law
As an attorney who also holds a degree in health administration, Todd Siroky has a unique insight to the challenges that face healthcare providers in West Tennessee. He has witnessed the effects various legislative measures have had on healthcare providers. As a healthcare attorney, Siroky knows that the ever-changing healthcare environment is one that holds uncertainty and opportunities for clinics, hospitals, providers, and suppliers.
Originally a native of Chicago, Siroky moved to West Tennessee at an early age where he graduated from the University School of Jackson. He earned an undergraduate degree in healthcare administration with a minor in economics from the University of Kentucky in 2002. Throughout college, he worked as a runner and a clerk for a law firm, but it was actually his health law class that sparked his interest to pursue law school after graduation.
“My health law professor at UK, Julia Costich, JD, PhD, initially got me interested in the law,” said Siroky. “Dr. Costich setup a semester-long practicum working in the legal department of a managed care organization in Lexington, called CHA Health. I worked in the legal department and focused on government relations. I attended meetings and legislative committee sessions at the state capital regarding healthcare reform and got an up close view of the politics behind healthcare policy.”
When Siroky enrolled at Cecil C. Humphreys School of Law at the University of Memphis, he said he went in with an open mind on the area of law he would practice.” Besides clerking in both a private practice and government legal department, I did a semester judicial externship for Chief Judge James D. Todd in the United States District Court for the Western District of Tennessee. It was an invaluable experience and something I would recommend for any law student,” he said. “But it wasn’t until my first job after graduating in 2005 when I realized my healthcare administration studies would translate into my private law practice.”
In 2014, Siroky founded Siroky Law, PLC. “I saw an opportunity to open a boutique firm and cater to small businesses, which is what most of my healthcare clients are,” said Siroky. “In addition to healthcare law, I counsel individuals, business owners, and institutional clients in the areas of business law, commercial litigation and estate planning.”
Over his 16 years of watching the healthcare industry, Siroky has seen many changes. For providers in Tennessee, 2015 will see more changes with the Tennessee Healthcare Innovation Initiative which is designed to transition the state healthcare payment system to better reward patient-centered, high-quality, high-value healthcare outcomes for all Tennesseans. Ultimately it will change how the state pays for healthcare services and reflects a shift from fee-for-service payments to value-based models of care.
“The initiative came as a proposal funded, in part, by a grant from the federal government to help control the unsustainable cost of healthcare in the state while improving quality and outcomes. The state estimates savings in the neighborhood of $1.1 billion on healthcare spending over the next five years,” said Siroky.” The initiative is modeled after the reforms adopted and implemented by the State of Arkansas in 2013 and includes the same major components.”
The initiative has three basic outcomes-based strategies: improve primary care services to focus on the delivery of preventive care and the management of chronic illnesses; retrospective episode-based payment adjustments to providers for selected conditions and procedures; and a long-term care component. Two of the plan’s two major components include retrospective episode-based payments and population health management through patient-centered medical homes. The goal of the program is that within three to five years, episodes and population-based payment models account for the majority of healthcare spending.
Episodes of care focus on the healthcare delivered in association with an acute healthcare event such as a surgical procedure or an inpatient hospitalization. Episodes encompass care delivered by multiple providers in relation to a specific healthcare event over a specified period during which patients may receive care from multiple providers.
With input from clinicians, insurers, and other stakeholders, the three initial episodes selected for the first wave of the initiative are total joint replacement, acute asthma events and perinatal care. In May 2014, select providers began to receive their first reports for Wave 1 episodes from Amerigroup, Blue Cross Blue Shield of Tennessee and UnitedHealthcare, but the actual performance period does not begin until January 2015. Wave 2 initiatives are being developed with Tennessee clinicians and stakeholders and will focus on acute and non-acute PCI, cholecystectomy, colonoscopy and COPD. It is anticipated that the state will roll out new waves of episodes every six months, with the goal of designing and implementing 75 episodes over the next five years.
Under this new initiative, providers will continue to bill for their services and receive the same fee-for-service reimbursements. At the end of a calendar performance year, providers will be subject to retroactive adjustments in the form of risk-sharing, no change, or gain-sharing based on the providers’ average cost of the episode over all episodes that fall within an episode category in the calendar performance year. For each episode of care there is a provider who is deemed to be the “quarterback.” This quarterback is the principal accountable provider (PAP) for the episode and is determined to be in the best position to control cost and improve outcomes of care for an episode. The PAP leads and coordinates the team of care providers and is identified by the tax identification number under which services are billed. In the first wave of the initiative for perinatal episodes, the quarterback would be the provider delivering the baby (OB/GYN, nurse midwife or family practitioner), for total joint replacement it is the surgeon, and for an asthma exacerbation episode it is the hospital or facility where the patient went to the emergency department or for an inpatient stay related to the episode. Providers affected in the initial wave are those that participate in TennCare or that treat state employees in Blue Cross and Cigna networks as well as patients covered by BCBST fully-insured commercial plans. Participation by other commercial payers will be optional but is encouraged by the State.
“The concept is that it is the quarterbacks who carry the burden of the total cost of the episode, since they are the ones that are in the best position to affect cost and outcomes, and they will ultimately receive rewards or penalties based on the overall cost of the episode,” said Siroky. “The state sets an acceptable threshold for the average cost of each episode. Each MCO or payer sets its own commendable and gain-sharing thresholds. Basically, a quarterback’s average risk-adjusted cost for all episodes (that fall in a unique episode category) in a calendar performance year determines if there is risk-sharing in the form of a financial penalty, no change in the prior fee-for-service or other payment, or the opportunity for gain-sharing. If a quarterback’s average risk-adjusted cost for an episode falls above the acceptable level, there is a financial penalty. If a quarterback’s average risk-adjusted cost for an episode falls below the acceptable level but above the commendable level, the quarterback will see no change in the fee-for-service payment the quarterback already received. If a quarterback’s average risk-adjusted cost falls below the commendable level, then the quarterback is eligible for gain-sharing in the form of a financial incentive if the quarterback also satisfies certain quality metrics.” The reconciliation will not occur for the first calendar performance year until August 2016.
This new initiative, in Siroky’s opinion, reflects a push toward clinical integration at the state level in an effort to promote population health management across multiple providers. “Since the initiative was rolled out relatively quickly, we can expect there to be a lot of unanswered questions as it is implemented. One question is ‘how are the payers going to risk-adjust for individual patient episodes that are outliers in terms of high cost because of complications or co-morbidities outside of the quarterback’s control, and whether and to what extent these outliers will be excluded from the computation of the quarterback’s average risk-adjusted cost?’ Small practices may be more affected by this change in payment methodology than larger ones,” he said. “I foresee more clinically-integrated networks, Accountable Care Organizations, and networks of providers coming together with the common goal of controlling costs and improving quality of care so they can participate in gain-sharing and avoid financial penalties.
“The healthcare industry is constantly changing and adapting to new regulatory constraints and 2015 is going to be no exception. We are all watching and waiting to see how things play out and it will certainly make for an interesting road ahead,” said Siroky. “West Tennessee has some truly great providers who have embraced the adoption of the latest health information technology and are proactive about aligning their business models in response to change, so I am pretty optimistic about what 2015 holds in terms of our local providers’ and administrators’ abilities to adapt to these changes.
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