After the presentations from Dr. Dunlap, Dr. Collins and Mr.
Waxman, the speakers addressed a series of questions from the audience. The
following summarizes the dialogue.
1) As a small practice, what should I
consider before joining an Accountable Care Organization or Integrated Delivery
System (ACO/IDS)?
Deciding whether or not to join an accountable care
organization (ACO) or integrated delivery system (IDS) is a strategic decision
that must be carefully considered relative to your unique circumstances. While participation in an ACO/IDS may
facilitate the transition from a traditional fee-for-service to a value-based
reimbursement environment, physicians must carefully assess their current
situation and environment, and consider the possible benefits and challenges of
joining an ACO/IDS.
Step 1: Assess Where You Are in Your Career,
What Organization You Belong to, and Your Panel of Patients
Assessing what stage your career is in, is an
important first step. Organizationally, you will want to know if you have the
support of a contracting entity to assist you with the ACO/IDS process.
Additionally, you may want to be familiar with the dynamics of the health care
environment in your area. Consider the following questions when exploring your
interest in joining an ACO/IDS.
- Do You Currently Belong to an IPA/PHO or Other
Organization? If you belong to an IPA/PHO or other organization, what can it do to help you meet the future challenges of operating in a value-based reimbursement environment? Does the PA/PHO have resources to assist your transition to an ACO/IDS? Is there a strong physician voice in your IPA/PHO or other organization and are they having discussions with potential ACO/IDS partners?
- Where Are Your Primary Referral Sources?Will your decision to join an ACO/IDS impact your
referral stream? Have your competitors joined an ACO/IDS?
- What Are the Local Hospital and Health Plan Dynamics
Within Your Community?There are a significant number of new partnerships and alternative payment models underway that may impact your practice, therefore it important to consider your environment. Are there other, similar practices in your area that have aligned services? Do other providers in your region seem equipped to help you succeed in value-based care environments? Are hospitals and other proviers in your area aligned and are competing for your patients? Are payers you contract with supportive of the transitions and alignments in your area?
- Are You comfortable Transitioning to an ACO/IDS at This
Stage of your career?
Some physicians considering retirement
may choose to remain independent, while others may want to position themselves
for the future healthcare landscape as they leave their clinical practice.
Step
2: Determine if Your Practice Is Ready by Conducting a Practice Assessment
Approaching the decision from an informed position, in which you have done the research and understand your particular practice’s current capabilities and potential challenges, will help in shaping important conversations and eliciting the information necessary to determine whether joining a particular ACO makes sense for your practice. A critical component of this process will be to assess your practice’s readiness for value-based reimbursement in order to identify crucial gaps and prioritize strategic activities. The subsections below further detail the factors to consider and approach for assessing your practice’s readiness level. Consider your level of readiness in the following domains:
- Information Systems and Infrastructure: Is your practice using an EMR? What level of EMR
integration is currently in place? Do you have the infrastructure (staff,
resources, etc.) in place to be able to support the transformation from a
small practice to an ACO/IDS?
- Practice Operations: How do you
currently manage chronic care populations? Does your practice use care
managers or other non-physician extenders to support the monitoring of
patient adherence to clinical treatment recommendations? How does your
practice handle patient handoffs and communication with referring
physicians, specialists, hospitals, etc.?
- Data Analytics: What data analytics tools does your practice have that
can help you measure and meet quality and cost targets?
Step 3: Learn About the ACO/IDS by Asking
the Right Questions
Understanding the
organization, its culture and structure is important prior to joining an ACO/IDS. Expectations should be clearly defined ahead
of time so that you understand your role within the organization.
Before engaging in discussions with various ACO/IDS’s and
attempting to determine which one may be the best fit you may want to consider
asking the following questions:
- What are the costs involved and/or
support provided when participating in the ACO/IDS?
- What are the requirements related
to exclusivity to the given ACO/IDS, and what are the
expectations/requirements for any existing relationships with other
providers not participating in the ACO/IDS?
- If you decide to leave the ACO/IDS
at any point in the future, what is the process for doing so?
- What are the quality of care and
cost standards and metrics required for participation?
- How does the ACO/IDS communicate
information concerning, and provide support related to, clinical, quality,
and cost-based metrics?
- What are the electronic data
capture and reporting requirements?
- What is the ACO/IDS policy regarding
medical records? Who owns your
performance data and reports?
- What are the specific terms of the
ACO/IDS contract? We advise that you seek legal consultation to fully
understand legal implications
- What does the governance structure
look like? Is there physician representation
and leadership?
- Review the ACO/IDS mission, vision, values,
goals, and expectations. Are they
aligned with what you are looking for in an ACO/IDS?
- What is the ACO/IDS track record with population
risk assessment and management?
If you are interested in approaching an ACO/IDS, contact its
medical director, its director of operations, or another high-level
administrator in the organization to find the appropriate individual who can
help answer your questions.
2) In an ACO/IDS,
patient compliance plays a role, specific to meeting targets on quality
metrics. How could joining an ACO impact patient compliance?
In an ACO/IDS and in new payment models, improvements in
patient health are often associated with financial incentives, creating an additional
value to maximizing patient compliance with treatment plans. ACOs/IDS’s may
provide an opportunity for physicians to more easily engage patients in their
healthcare through disease management, resources, communication, education,
etc. Patients who are knowledgeable
about and engaged in their care are often more likely to adhere to provider
advice, which hopefully will improve overall outcomes, enhance patient
satisfaction, and reduce complications.
You should consider what patient engagement tools are
available in your current practice and find out what the ACO/IDS would be able
to offer. Here is a checklist to help you make this comparison:
|
Patient
Engagement Resource
|
Available
in my current practice
|
Available in ACO
|
| Tools to reach patients, such as a patient portal
| | |
| Community resources for educating my patient population
| | |
| Wellness
and behavioral programs focused on providing patients with education on
self-care and health maintenance strategies
| | |
| End-of-life care management and planning
| | |
| Educational
videos, Web- and/or paper-based information guides, and counseling sessions
that help patients understand treatment options, outcomes, risks, and
benefits | | |
Will joining an ACO bind me to exclusive
participation in that one ACO?
Contract dependent with private payers and organizations.
Under federal regulations regarding Medicare ACOs, all
members of an ACO with a TIN that bills for primary care services must be
exclusive to a single Medicare ACO. “Primary care services” are defined broadly.
This means that:
- Primary care physicians may only participate in
one ACO
- Specialists who bill for services that could
fall under Medicare’s scope of primary care services, such as office evaluation
and management services, may only participate in one ACO
- Specialists who share a TIN with another
provider who performs primary care services may only participate in one ACO
- In this situation, the specialist may contract
with an ACO on an individual basis and bill using his/her individual Social
Security number (SSN) in order to work for more than one ACO. However, billing
under multiple TINs and SSNs may cause administrative burdens or require
written consent by payors to avoid breaching existing contractual obligations
- Specialists may also furnish services under a
separate entity that bills under a different TIN rather than the TIN associated
with a group practice that provides primary care services
Aside from the regulatory exclusivity requirements, prospective
ACO participants should review ACO agreements for additional exclusivity
provisions and are well advised to negotiate to avoid any type of exclusivity
arrangement. Additionally, participants
can negotiate whether participation in an ACO will be for Medicare/Medicaid
plans only or in additional payor arrangements as well.
Source: Mark Waxman, Esq. Foley & Lardner LLP
How can I best position myself to meet the
required quality and cost measures of an ACO/IDS?
In an
ACO/IDS model, it is important to be able to identify and monitor high-risk
individuals, apply evidence-based practice guidelines when appropriate, and use
clinical data to help meet quality and performance benchmarks.Below are tips that may help you achieve success
in these areas:
Access/Understand Your Data: Physicians participating in an ACO/IDS will need
access to key data in order to make sound decisions about patient care. In order to meet the specific requirements of
your ACO/IDS, you will need to be able to interpret data, including quality and
cost benchmarks, to help identify opportunities for improvement. Data analytics, data warehouses, as well as
other tools are important features of an ACO/IDS, especially in risk-based
contracting scenarios.
Know the ACO’s Expectations Regarding Metrics, Targets, and Reporting
Guidelines: In an ACO/IDS environment, physicians are required to
meet quality and cost metrics and maintain targeted levels of performance in
order to be reimbursed. Physicians
participating in an ACO/IDS should find out the expectations regarding
metrics, targets, productivity, and reporting guidelines so that they can make
informed and timely decisions in areas including: Utilization, care
coordination/patient safety, and treatment options. Physicians should be certain that they have
the ability to develop individualized care plans, based on the patient’s unique
needs, preferences, values, and priorities.
As physicians are the medical professionals best qualified by training,
education, and experience to provide diagnosis and treatment of patients, it is
important to ensure clinical decisions will be made by the physician, with
input from the team providing the care of the patient.
How do I know if I can take on risk and what
measures can be put in place to guard against the possibility of loss under a
risk-based contract?
It is important to recognize that ACO/IDS payment models may
involve the possibility of financial loss if the participating organization
does not perform well under the defined economic arrangements. The risk of such loss can and should be
mitigated by the ACO/IDS, but participating provider organizations should
understand:
- What mitigation measures have been taken by the
ACO/IDS to guard against the possibility of loss under the risk-based contract
- What mechanisms the ACO/IDS has in place to
measure performance so that the risk of loss/population risk can be identified
early to allow for corrective measures to be taken
- Whether the ACO/IDS secured reinsurance to mitigate
the costs if performance targets are not met; and
- Under what scenario(s) would participating
practices face financial liability for poor performance on behalf of their
group or the network as a whole?
As you plan for the future in a risk-based environment, you
will need to assess your current capabilities and ability to transition your
practice to be able to take on risk.
How Can I Get Started?
The following considerations can help you in getting
started:
- Start
with the High Risk Patients. Interventions that are targeted to specific
patient populations and clinical areas typically have a greater impact on
quality improvement and cost. The most
immediate areas for opportunity are often target chronic diseases and
highest-cost conditions. Targeting
higher-risk patients may result in a greater likelihood of reduced costs and
utilization. For example, chronic
diseases are generally responsible for a
large portion of overall healthcare spending.
Ultimately, the evaluation and adoption of evidence-based clinical
protocols and practice guidelines targeted for these patient cohorts may result
in fewer preventable complications and emergency department (ED) visits,
shorter average hospital length of stay (LOS), and less gaps in care.
- Develop a
Protocol for Effective Care Coordination.Interventions aimed at improving
follow-up care and communication across providers in a continuum of care
settings is key. Examples include the
sharing of patient records, follow-up calls, and medication review and
reconciliation.
- Know Your
Data. As mentioned before, it is
important for physicians to collect and interpret their patient data to be able
to improve patient care, incorporate patient feedback into care delivery, and
demonstrate that cost savings and care improvement are occurring simultaneously. Because ACOs and IDSs are inherently data-driven,
the management and analysis of data are core organizational requirements. Additionally, a quality measurement strategy
is needed to ensure that maintaining cost thresholds are contingent upon
achieving care quality goals.
- Understand
the Terms of Your Contract.Finally,
in order to minimize risk, it is important to examine and evaluate the contract
and make certain that the agreement contain the appropriately protective and
legally compliant terms.
6) What are the governance models that work best for physicians?
The following are important components of a
successful governance /organizational structure:
- Physician participation (at least some
who are still practicing) on the boards of each entity/ACO arrangement.
- Physician participation in leadership
roles to keep patients central to the organization; physician directed
organizations have the largest number of advantages when it comes to patient
centric solutions.
- Governance model for ACOs will probably not
be the same as the governance model of the hospital or health system that
preceded the ACO, as a significant number of physicians should be on the
management team.
- Physician alignment with strategic
initiatives, through working committees that they participate on, delegated by
the board to accomplish specific tasks.
- Physician
managed ACO’s, with an aligned relationship between hospitals and physicians,
helps accomplish strategic priorities; adequate physician group size and
capital are requirements for physician owned ACO’s. These physician driven
organizations have successfully partnered with hospital systems to improve
quality and lower costs.
