Download(1 page PDF)(1 page PDF) the Goverance and Related Issues decision map.
Governance and structure should be your central concern in evaluating an accountable care organization (ACO). Questions to consider include:
The organizational structure of the ACO can have implications for its behavior and likelihood of success.
An ACO developed by an IPA may be:
A hospital-led ACO or one developed by an IDS may be:
An ACO that includes employed and aligned physicians may have different expectations of and for the two groups. If you are looking at such an ACO, make sure you understand how the groups differ for primary care physicians and for referral specialists.
An ACO may hire or include a management services organization (MSO) to help with administrative functions. That is not a good or bad sign in itself. It may indicate that the ACO recognizes the value of professional management. Still, you may want to ask the ACO, colleagues, and your state academy for any information they can give you on the reputation and abilities of the MSO.
You should be confident that the policies that will govern your practice are ones you can be comfortable with. Given that processes and workflows are likely to be standardized in an ACO, family physicians and other primary care physicians should be involved in the development of workflows, clinical policies, and policies in general – anything that affects primary care practice.
Even if you know from the outset that patients are attributed to the ACO by virtue of where they get the largest proportion of their primary care, you will want to ask whether attribution is carried out prospectively or retrospectively:
The MSSP tries to balance the strengths of these respective methodologies by using a hybrid approach comprising a preliminary prospective attribution with updates during the year and a year-end retrospective reconciliation to count only those beneficiaries who met the attribution requirements for the whole year.
Patient attribution can be further complicated if the primary care physicians or other providers on whom attribution is based have some patients inside the ACO and some outside, or some in one ACO and some in another that contracts with the same payer. To avoid this problem, the MSSP requires providers on whom attribution is based to be exclusive to one participating ACO, except under special circumstances.
Naturally, you will want to know all you can about how the payer shares any shared savings with the ACO, and how those savings are distributed. Important questions about payments to the ACO include:
The successful ACO is likely to distribute at least some of the savings in proportion to providers' contributions to value: care improvement and cost reduction. Shared savings can also be distributed based on percentage of attributed patients. That is, the physician who manages 5% of the patients in an ACO might be entitled to 5% of a portion of the savings.
The ACO that contains a hospital faces the question of how to divide savings fairly among the hospital and individual physicians; make sure you consider the division fair.
Whatever the ACO's distribution rationale, be sure you understand it. Ask for a conservative estimate of what the ACO expects your portion of the shared savings will be, if any. If the ACO accepts downside risk, ask how much risk you will be taking on.
An issue that cuts two ways is whether the ACO requires physicians to buy in when they join:
Buy-in fee or not, be sure you understand how the ACO plans to fund all the infrastructure development it will need to succeed. Startup costs can begin at as much as $1 million. (Another way an ACO can fund its ongoing activities is through a practice assessment, for which providers pay a small percentage of their collections to the ACO. Ideally, this percentage is small enough to be offset by shared savings in the future.)
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Accountable Care Organizations
Governance and Related Issues