Is an ACO Right for You? The Complete ACO Checklist for Providers

AcoBy: Valerie Shahriari

As the movement to value based arrangements continues many providers are considering joining an Accountable Care Organization (ACO).  At the same time, regulators from the Federal Trade Commission (FTC) and the HHS Office of Inspector General (OIG) are signaling increased scrutiny of Accountable Care Organizations and other value based payment arrangements, especially those making creative use of the antitrust and fraud and abuse waivers in place for Medicare ACOs.  A recent article states that claims of higher quality of care may help in defense of antitrust action.  Tracking and organizing results that reflect efficiencies and quality improvements is obviously a must but before a provider even considers joining an ACO, the following questions must be asked and answered:

  1. What level of risk are you willing to assume?
    1. First know what level of risk you are willing to assume. For instance, are you comfortable assuming risk at all or do you want to enter this area more slowly and share in only the savings?  A core challenge when converting to a value based, rather than fee for service system, is the lack of consistency in payment measures.
  1. What are your baseline metrics for the quality measures?
    1. The ACO will identify quality measures as part of the agreement. Currently there is a lack of a single set of metrics adopted by all payer sources.  To negotiate your position, you must know your baseline and whether you can meet the benchmarks identified.  Quality metrics can include for example, HEDIS measures, AHRQ measures, and CMS measures.

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Eye on the Regulations: The Argument Against ACO Exclusivity

photo 3By: Jackie Bain

In an ACO, participating physicians, hospitals and other healthcare providers use a coordinated approach to provide improved care to beneficiaries. As an incentive to participate in ACOs, Medicare shares its savings when participating providers coordinate to provide quality care while spending Medicare dollars more wisely.

The Centers for Medicare & Medicaid Services (“CMS”) have determined that a certain amount of exclusivity is necessary for an ACO beneficiary to be accurately assigned to an ACO.  Exactly how much exclusivity is necessary has been the topic of much debate.  Initially, lawmakers envisioned that only primary care physicians were required to be exclusive to their ACOs.  After the public had the opportunity comment on the proposed law, the rule was changed.  Now, it is generally accepted that if CMS assigns an ACO beneficiary to an ACO because of primary care services previously supplied by the physician, then the physician must be exclusive to the ACO.  This is true whether the physician is a primary care physician or a specialist who provides primary care services to a patient with no primary care physician.Continue reading