What You Should Know About Accountable Care Organizations

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An Early Standard For ACOs?

You have likely heard of the Pioneer accountable care organization. The CMS chose Pioneer ACOs based on the infrastructure already in place that the CMS deemed closely related to an ACO model. This was an early “testing” phase for the Medicare Shared Savings Program ACO. Pioneer ACOs are subject to different shared savings methodology. There are 32 Pioneer ACOs throughout the country.

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Author(s): 
Beth A. Kase, JD

   Is ACO just another name for HMO? While the ACO network bears some resemblance to health management organizations (HMOs), there are significant differences. Unlike with HMOs, patients are free to seek services or providers outside of the ACO network. The cost to the patient does not change if he or she sees a provider outside of the ACO network. Also unlike HMOs, generally the ACO does not function as a pre-paid per capita (i.e., capitation) model although ACOs could move in this direction in the future. Medicare patients enrolled in a Medicare Advantage Plan are not Medicare ACO beneficiaries.

Understanding The Role Of DPMs In ACOs

Podiatrists may provide podiatric medical care to ACO patients and may also participate in shared savings. However, a DPM is not an ACO “professional” who is eligible to form an ACO under the Patient Protection and Affordable Care Act.

   An “ACO professional” is a role that is limited to an MD, DO, NP, PA or clinical nurse specialist. There are various arrangements that satisfy eligibility to form an ACO:

1) accountable care organization professionals in group practices
2) networks of individual ACO professionals
3) partnerships or joint venture arrangements between hospitals and ACO professionals
4) hospitals employing ACO professionals
5) federally qualified health centers
6) rural health clinics
7) some critical access hospitals

   Since a DPM does not qualify as an ACO professional, you cannot form your own ACO with other DPMs. However, the practical effect of podiatric physicians’ exclusion from the definition of ACO professional appears to be minimal given your ability to participate in the ACO and receive shared savings.

   Even though a DPM is not an ACO professional who is eligible to form an ACO, a DPM may be an “ACO participant.” ACO participants are eligible to participate in the ACO’s governing body. There is no requirement that all or any specific specialties be represented within the governing body.

   An accountable care organization must have a senior-level medical director overseeing clinical management. Among other requirements, the medical director must be a “board-certified MD.” Keep in mind that all ACO participants must comply with the ACO’s processes and are accountable for the ACO’s performance standards. There may be other leadership positions that DPMs may fulfill. To stay informed about your ACO’s activities and reinforce the podiatrist’s integral role in the provision of coordinated care to the ACO’s patients, it is beneficial for you to seek leadership responsibilities when they are available.
Unlike primary care physicians who are generally limited to participating in only one ACO, podiatrists, like other specialists, may have a contractual relationship with more than one ACO. You would then be responsible for any potential risks, rewards or requirements associated with each agreement.

   At this time, podiatrist participation in an ACO is largely limited to podiatrists who are part of or who contract with a large physician group or health system. The sizable start-up costs, information technology requirements and care coordination requirements necessary to qualify for an ACO contract with the CMS impede small physician groups from applying to the CMS for an ACO contract. An ACO network is not required to accept any specialty or “any willing provider” into its network. Therefore, your ability to demonstrate quality outcomes, evidence-based medicine and cost containment is particularly important if you are interested in participating in an ACO.

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