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

1) timely care and appointments
2) how well doctors communicate
3) patient ratings of their doctors
4) access to specialists
5) health promotion and education
6) shared decision making among doctors
7) health and functional status

   These measures are more challenging to fulfill given they are subjective but you should work closely with your ACO team members to ensure you are adhering to the governing body’s defined ACO care processes.

   The “at-risk population” domain, which includes measures focused on care provided to patients with diabetes, also bears on the DPM’s role within the ACO. Although the quality outcomes measure biochemical changes, the very fact that this population is targeted for measuring the ACO’s performance is significant. Among other diabetes care considerations is recognition of the high rate of risk for lower extremity amputations. Accountable care organizations will likely need to coordinate care for the patient with diabetes with the DPM either as an ACO participant or outside the ACO structure if he or she does not participate in the ACO.

Comparing Commercial ACOs To Medicare ACOs

The ACO model exists in both the public and private sectors with many private health insurance companies having ACO-like contracts with providers. As with Medicare ACOs, typically the physician providers in commercial ACOs are large groups or independent practice associations that have the necessary infrastructure and information technology capacity to meet the ACO’s care coordination and reporting criteria.

   Health industry consulting firm Oliver Wyman reports that in addition to the 2.4 million Medicare beneficiaries who receive care under a Medicare ACO, up to another 15 million non-Medicare patients receive care through Medicare ACOs.7 Eight million to 14 million individuals are part of commercial ACOs run by large national and regional insurance companies for their non-Medicare populations. Commercial ACOs are having a growing impact on healthcare delivery throughout the nation.

   Commercial ACOs share a similar mission with Medicare ACOs, namely to reduce cost while improving care. However, the implementation of a commercial ACO can be different in a number of significant ways including eligibility requirements for physicians. Commercial ACOs do not need to adhere to the same number and types of quality measures as defined by the CMS. Nor does the commercial ACO need to adhere to the governance structure and cost sharing formula applicable to Medicare ACOs. The commercial payer, rather than Medicare, provides the financial incentive for quality and cost performance. Each commercial ACO differs. Therefore, your participation in a commercial ACO should be informed by the specific guidelines of the specific commercial ACO.

   A representative of a Blue Cross ACO commented that its commercial ACOs include large physician groups that may employ or contract with podiatrists, but the insurer does not dictate the group’s arrangement with the podiatrist.8 If the group shares any cost savings, it determines how such savings are distributed to group physician providers, including podiatrists and other specialists. Commercial ACOs are evolving and many variations are developing.

In Conclusion

There is an increasing number of ACOs across health systems in the United States. Providers who have the resources and infrastructure available to meet ACO requirements, such as health quality and expenditure data reporting, are in the best position to adopt this model. For DPMs who are interested in participating in an ACO, relationships with health systems, health plans, hospitals and independent practice associations will be critical.

   Medicare and commercial ACOs reward improved outcomes along with a reduction in the cost of healthcare spending. Whether you are interested in participating in an ACO or not, you are best prepared for continued changes in healthcare delivery and reimbursement if you have a process to monitor your quality, efficiency and expenditures. Demonstrating your provision of cost-effective care will continue to be an imperative in this healthcare market.

   Ms. Kase is an attorney at Fenton Nelson in Los Angeles.

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