What You Should Know About Accountable Care Organizations

Author(s): 
Beth A. Kase, JD

   Accountable care organizations have the opportunity to decide how to distribute shared savings among participants with agreements that encourage participants to adhere to quality and program measurements. A plan for distribution is part of the ACO’s application process that must be approved by the CMS. An ACO’s distribution of shared savings among its participants is exempt from Stark and anti-kickback laws although distribution of savings outside of the ACO entity is not. Again, your participation within an ACO is an opportunity to share in savings although an ACO will be calculating the cost/benefit of including you within the entity.

   How does the cost savings and risk mechanism affect the DPM? It varies by the ACO.

   One DPM ACO participant, who is a partner in a 300+ multispecialty medical group in Southern California, explained that because he has an equal membership share, he will share equally with other physician owners in any Medicare Shared Savings Program savings the ACO distributes to its physician members.5 He explained that his entry into ACO participation did not require a lot of effort on his part since the group practice’s administrative staff took care of the paperwork, and quality and care reporting mechanisms are already in place. He is not expecting a significant savings distribution from the Medicare Shared Savings Program. Other ACOs allocate only a small percentage of any shared savings to specialists, including podiatrists.

How Quality Measures Come Into Play

Eligibility for shared savings is predicated on complete and accurate data reporting for all 33 quality measures as deemed by the CMS.4 The 33 quality measures mostly focus on ambulatory care and are categorized into four domains: patient/provider experience; care coordination and patient safety; preventive health; and at-risk populations.

   For an ACO to be eligible for shared savings, it must perform at the 30th percentile on at least 70 percent of the measures in each domain. An ACO can fail a measure in one domain and still earn shared savings. There is one caveat though. A score of zero in any domain precludes an ACO from receiving any shared savings.

   The “patient/provider experience” domain, as measured by patient surveys, is seemingly the most relevant measurement for DPMs.6 All seven questions within this domain could include a patient’s experience with you. The questions address the patient’s perception of his or her experience with the practitioner. Specifically, patient surveys measure the following seven items:

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.

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