Practice Impacts and Accountable Care Organizations

Decision Map

Download(1 page PDF) the Practice Impacts decision map.

Accountable Care Organizations (ACOs) and Practice Impacts

When you join an accountable care organization (ACO), you can expect your daily practice to be affected in several ways other than the transformation of data management. For many practices, this may involve minimal impact on day-to-day patient care, but it can intrude directly into your practice environment, and you should know what is involved before agreeing to participate. Keep in mind that the goal of such intrusions is to help deliver higher-quality care more efficiently.

Practice Evaluation and/or Ongoing Assessment

The ACO may want to start with a thorough review of your practice, including staffing, structure, business model, clinical quality, financial stability, etc. Doing so may require several days of site visits. After that, the ACO may need periodic on-site reviews and, at least until good data management practices and data-sharing infrastructure are in place, chart audits. It is important to know how much this is likely to disrupt your practice.

Protocols for Care Management and Coordination

Because faulty care management and coordination are seen as relatively low-hanging fruit in efforts to save money while improving care, you can expect the ACO to want to make changes in this area, probably including the development of protocols or imposition of existing protocols that will affect your practice directly.

You should understand at the outset what the ACO expects. Some of important questions include:

  • How are protocols developed?
  • How much autonomy does the ACO give individual practices?
  • What resources (financial and otherwise) are available for protocol development and implementation?
  • Are family physicians involved in the development process?
  • If the ACO employs care coordinators, how will they be integrated with existing staff?
  • Will the care coordinators be based in the practices or working from a central location?

Practice Transformation

Practices participating in an ACO will need a capacity for continuous practice transformation and process improvement. Family physicians can expect to see direct effects on their practices as they begin shifting from the current episodic, volume-based payment environment toward the new paradigm of value-based services and population health care:

  • If your practice is not already certified as a PCMH, you may find that the ACO is encouraging or requiring you to move in that direction – either to become certified or to take on most of the characteristics of a PCMH.
  • The ACO may require other changes in your practice, too, from accepting ACO-based case management to providing 24/7 care. You should know up front what to expect. For instance, will the ACO expect you to handle inpatient admissions, discharges, and transitions of care in certain ways? Will you be expected or encouraged to use certain labs, imaging services, and so on?

If you have not already developed a PCMH, you are still probably aware of the time and effort required of every physician and staff member involved in the process. Considering that commitment and the added stresses involved in becoming part of an ACO, you will certainly want to know how big the required changes are, how soon you need to make them, what support the ACO can offer in making the changes, etc., so you can arrive at your own determination of whether the changes are feasible for your practice. The outcomes – higher-quality care, better payments, and improved satisfaction for providers and patients – can be worthwhile, but don’t underestimate the amount of effort required to get there.

Efficiency and Autonomy

Linking to a larger organization is likely to change your practice, simply because the larger organization is likely to have processes and policies in place that your practice does not. Issues involving physician autonomy and clinical guidelines are particularly important to consider before joining an ACO.

Some autonomy is essential. No guideline, no matter how much evidence it is based on, will cover every patient situation. But, too much physician autonomy can negatively affect efficiency. The more that care processes can be reasonably standardized, the more potential there is for shared savings. The more these care processes reflect best practices, the more consistent the delivery of excellent care. The balance is a tricky one to maintain, even in a single group practice. In an ACO, the challenge is magnified, perhaps especially in a physician-network ACO. This is another area worth exploring with ACO leadership and with family physicians, if any, already in the ACO.

Finally, it is important to remember that in joining an ACO, you almost certainly will not be caring for all of your patients under the ACO contract – perhaps just your Medicare patients, for instance. How will ACO participation affect the rest of your practice? Will you be subject to two or more sets of protocols? Will you be working to improve the quality of care for one set of patients but not others?