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: |
What level of risk are you willing to assume? 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. What are your baseline metrics for the quality measures? 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.
What are your baseline metrics for economic measures? Economic measures may also be included and it is important to know your baseline metrics. For example, under the Affordable Care Act, insurers have a Medical Loss Ratio (MLR) that must be met. The MLR is defined as the percent of premium an insurer spends on claims and expenses that improve health care quality. In other words, how much does it cost the managed care company for you to take care of their members? It is imperative with. This statistic can and should be requested. Have you completed financial risk modeling? The financial risk modeling will include the methodology for assigning members of the ACO, financial benchmarks for evaluating overall cost of care, and a risk sharing formula if applicable. This modeling will help you predict how certain members will impact your financial measures. Do you have any Population Health Management strategies in place or in development? Population Health is one part of the Triple Aim. Under this model, you must learn to identify those 20% of your patients that are utilizing 80% of your resources and implement a strategy to manage their health proactively. The Camden Coalition and the strategies that they implemented is a great illustration of this model. Have you requested references from the ACO? References from other providers should be sought. If possible, request references from those providers who have left the ACO as well as those providers that are currently in the ACO. The providers currently in the ACO can highlight what is working well while providers who have left may share lessons learned and areas that they would like to see improved. Have you reviewed sample quality reports and financial reports? If quality and finance is going to be measured, you need to ensure that you will receive reports with usable information rather than just rows of data. It is this data that will help you gauge whether your population health management strategies are working. The reports should include information that is “real time” data. Data that is 6 months old upon receipt is too late to make a true impact on the patient’s health and your measures. How will patients be assigned? How patients will be assigned is important as this impacts your financial metrics. What type of reporting is needed from your practice? Do you need to complete any additional forms or reports to get credit for your metrics both quality and economic? How much time will it take to complete? Do you have someone in your practice that can complete this for you or is this an additional workload for you as a provider? When and how is reconciliation completed? Whether you are in a shared savings or risk model, how is reconciliation completed? More importantly, once reconciliation is completed, do you have the opportunity to dispute the data provided? Do you have appeal rights? How is the ACO structured and managed? Is the ACO managed by personnel on a part time or a full time basis? What type of services are provided as part of the ACO? Have you reviewed the CV or resume of ACO leadership? Do the ACO leaders have any leadership experience in a managed care setting? What type of data analytics experience do they have? By proactively answering these questions, providers will be armed with answers that make a difference for their practice and their patients, and they will be properly positioned to explore and negotiate an ACO contract.
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