Top 10 Clinical Integration, ACO Physician Questions

Anyone attempting to lead physicians into a new venture such as a clinical integration program or an accountable care organization should recognize that physicians are trained to look for problems and to question everything. Physicians are perceptive and will know if the answers to their questions are substantiated by facts and evidence or if they are merely opinions and beliefs. 

Physicians are naturally and appropriately skeptical of the new arrangements under CI/ACO that will impact not only how they get compensated, but also how they care for their patients. Here are 10 of the most frequently asked questions physicians have about CI and ACOs.

1. Is this really going to happen? Yes, the term "ACO" is new since 2007, but the concept on which it is based is not. Some physician organizations have been functioning as ACOs for many years. CI as an organizational goal has been pursued for decades, and guidance has been available from regulators since 1996 on how to use CI as a contracting model for independent physicians. There is no question that the country needs to improve its coordination, quality, and efficiency of care. CMS intends for ACOs to work or will change/replace the ACO framework with another plan for improved coordination. CI/ACOs will emerge, or providers will find that they will become a commodity with ever increasing expectations by consumers and ever-diminishing price paid per unit of service.

2. Isn't this just like the HMOs of 15 years ago? No. On the economic side, ACOs will contract with payers for current rates rather than discounts as in the HMO era, and providers will be financially incentivized to provide appropriate care with bonuses based on quality rather than return of withhold. HMOs emphasized prevention and lower utilization, while ACOs will strive for improved management of chronic conditions and appropriate utilization. HMOs assigned enrollees to primary care providers ("PCPs") as "gatekeepers." ACOs will attribute beneficiaries to a PCP, and consequently the ACO with which that PCP is affiliated, depending on the "plurality" of PCP charges. Times are also different; HMOs developed in an era of a robust economy but limited informatics whereas ACOs are evolving in an environment of robust informatics and an unstable economy.

3. Are we emphasizing finances over quality? Achieving quality benchmarks is required in order to "earn" all of the savings generated in the proposed ACO regulations. The assumption, supported by evidence, is that quality is cost-effective. The development of care plans to address gaps in care, handoffs from one setting to the next, as well as readmissions, hospital-acquired infections, and duplication of tests, will not only address quality but also efficiency.

In addition to evidence-based preventive care, the underlying strategy is to identify the disease conditions driving increasing costs and the patients with those diseases and then target more resources toward those conditions and patients to improve overall quality and efficiency.

4. Why would my patients want this?  Given the complexity of today's healthcare delivery system, many patients would be well served by efforts to improve coordination of care. Some patients may find a traditional fee-for-service ("FFS") PCP office or a concierge practice adequate, but patients with chronic conditions will likely prefer a Patient Centered Medical Home ("PCMH"), with specialized care teams backed by a CI program or ACO to address their acute and chronic needs. In addition, as higher deductibles and coinsurance predominate, patients will want to know how valuable the care they receive is to their individual conditions and general well-being. Organizations willing to provide these answers and help them find the most value will be preferred by patients.

5. What if I want to refer my patients to a specialist not in the CI/ACO? Physicians will necessarily refer out of network for services not available within the network or if they determine that it is medically appropriate to do so. Under the CMS proposed regulations, beneficiary choice is protected; patients are not restricted to any group of providers or any ACO. However, the intent of a CI program or an ACO is to provide efficient, quality care by sharing data and coordinating care across the provider network.

6. Do I have to join just one ACO? The CMS proposed regulations limit PCPs to participate in only one ACO. Some commercial plans may not have this restriction, but many are likely to follow the CMS roadmap. There is no such restriction for specialists. There are also no proposed regulatory restrictions to PCPs being on the medical staffs of multiple hospitals in different ACOs, nor is there any requirement for a physician to be part of an ACO. Participation in ACOs will be optional for physicians, but most will join in order to be part of the contracts ACOs will enter into with CMS and other insurers.

7. Is it all about the PCPs? Even without the "gatekeeper" function of PCPs (i.e., expectation to limit access to care under the HMO model of the past), PCPs will be expected to provide basic outpatient services and to coordinate care for the patients that choose to see them and across the continuum, which may include various specialists, care managers, home care, pharmacies, rehab, and long term care facilities. PCPs are also central to the patient-centered medical home ("PCMH") concept, with offices run by PCPs and their teams to provide continuity and to focus on healthcare and prevention for their members. PCMH is a proven method to align health plans and providers to create greater value than what is found in the fragmented fee for service system.

8. What is the hospital's role in an ACO/CI initiative? Some physicians, notably a high percentage of newly trained physicians, hospital-based specialists, and a significant number of PCPs, are looking to hospitals for employment. Hospital administrators therefore need an employment strategy, if only to retain their referral base by employing physicians who might otherwise seek employment with a competitor. Hospital administrators with a vision of healthcare in the future also see the need to align with their private (independent, voluntary) physicians in ways that allow those physicians to be invested in continually improving quality and efficiency of care delivered by the network of physicians and the entire continuum of care. CI and accountable care development is becoming a necessary strategy for hospitals alongside an employment opportunity for those physicians who desire it. A management services organization to support these practices is yet another strategy. These strategies are market dependent, and the extent to which each can be used will depend upon the needs of the institutions as well as the physicians.

9. Does the organization just want to control my practice? No, the goal of CI/ACO is to deliver high quality patient care and patient satisfaction. There is nothing in the current regulations on CI or in the CMS proposed regulations for ACOs that would interfere with independent providers' operation of their practices. In addition, providers control their CI/ACO by participating on the committees that develop and maintain clinical protocols and govern the clinical and financial functions of the organization.

10. What's in it for me? By actively participating with CI programs and ACOs, physicians will not only be included in contracts with payers that might otherwise exclude them, but will also have the opportunity to participate in the development of protocols for their network of providers as well as the governance of these organizations. They will receive reports and prompts to help manage their individual patients and the populations of patients they serve, supported by care managers with the tools to help patients maintain or return to health. Branding of the organization will help to enlarge their practices and to broaden the populations they care for. Other benefits to be expected would be: being part of a high quality healthcare delivery system, feedback that the physician is doing the right thing (i.e., providing accurate and timely care), and increased satisfaction with one's career choice.

Dr. Nielsen is a Vice President at The Camden Group, a leading national healthcare business advisory firm, and Mr. Smith is a Senior Vice President. They are both based in the New York office.