Communications, Connected Care and ACOs, Part 1

What are ACOs? 

Accountable Care Organizations (ACOs), in the opinion of most national authorities, are the direction healthcare care delivery and reimbursement is going. An ACO refers to a group of physicians, hospitals and other suppliers of services that work together to provide coordinated team-based care to insurance beneficiaries. Several groups of providers and suppliers are eligible to participate as an ACO:

• ACO professionals in group-practice arrangements. 
• Networks of individual practices of ACO professionals. 
• Partnerships or joint-venture arrangements between hospitals and ACO professionals. 
• Hospitals employing ACO professionals. 
• Such other groups of providers and suppliers as the Secretary determines appropriate. 

ACOs are popping up everywhere. CMS is not the only organization driving them. In fact, the majority of ACOs in existence today are commercial ACOs not tied into CMS initiatives such as the Shared Savings Program. See the CMS list of 27 ACOs and compare it against the other list of 80 ACOs. The lists show locations, so be sure to see which ones are in your back yard.

• CMS releases list of 27 ACOs  
• 80 Accountable Care Organizations to Know

Another group, estimated at 150, will begin getting bundled payments from Medicare on July 1, 2012, then another on Jan 1, 2013. 

How will ACOs affect my eye care practice?

It's important to understand the effect of this trend on your practice. There are two important points:

Reimbursement. The way providers get paid for patients covered through an ACO will change. The ACO will receive a “bundled” payment for the care of the patient and the ACO will pay the providers delivering the care. You will no longer be able to bill the insurance company under a fee-for-service payment system.

Access. Your access to patients covered by the ACO will be affected. A fundamental concept of the emerging healthcare delivery system is that outcomes for patients with chronic conditions is best delivered through teams of providers communicating closely about the patient, with the patient an integral part of the process, in order to determine the best management plan. Coordinating this team delivery of care is one of the main functions of the ACO. If you are not part of the team delivery system, you will likely lose access to these patients. As a part of the coordination of care, the ACO not the patient actually schedules the patient's routine appointments with team members. 

The ACO also is responsible for ensuring that every provider who sees the patient has the appropriate patient medical information. This is information shared among all team members. The ACO, as part of its reimbursement, gets a specific fee for doing this coordination. Thus, the ACO is becoming your new referral center.

There are three things you need to be doing before you'll be considered by an ACO to be part of a care team:

1. You must be using a certified EHR;
2. Your EHR must have the capabilities to communicate electronically with the ACO; 
3. Most likely, you will need to demonstrate a changing culture in your practice, that you are embracing the implications of being an effective team member versus a standalone practitioner, as is now the dominant model.

To be continued ...

Alistair Jackson, M.Ed.