As the healthcare industry continues to shift toward value-based care, accountable care organizations (ACOs) have increased in appeal. ACOs aim to improve group performance, increase payer reimbursements, and provide high-quality, coordinated care at a lower cost.
By providing high-value resources to improve member practices’ operations and integrate patient care networks closer together, we have seen how ACOs can drive optimal outcomes – but only when providers choose the right fit for their practice. Over years of managing and supporting Medicare ACOs, we have frequently heard from physicians about the following lessons learned.
1.) Seek Transparency in Performance
When providers seek an ACO that best fits the needs and goals of their practice, it is critical to have access to performance data that provides an overview of past outcomes. This information can include data related to any associated gains or losses incurred by the practice and ACO, financial performance, quality or care metrics, and population health outcomes. Transparency during this process is key.
Additionally, providers and ACOs benefit from leveraging benchmarking metrics. These key indicators from other ACO participants will enable you to compare performance and track progress in real-time. By encouraging the sharing of best practices and allowing participants to measure outcomes against industry standards, primary care physicians can manage risk more efficiently, drive toward cost savings, and maximize patient satisfaction.
With access to this data, you can evaluate whether the ACO is a good fit for your practice, such as assessing potential gains or risks in joining their network. By digging into an ACO’s metrics, you can gain a thorough understanding of its commitment to helping you reach higher levels of efficiency, quality, and cost savings in your practice.
2.) Fully Understand Shared Savings Disbursement and Risk of Penalties
An ACO is responsible for ensuring physicians and staff fully understand when and how shared savings will be distributed among participants. By understanding shared savings disbursement, you can feel confident you will receive the fair compensation you have earned.
Depending on the ACO, there may be different incentives associated with each payment structure, so it is critical to ensure your practice meets all requirements before signing up. Accurately interpreting the agreement, and understanding the structure of shared savings disbursement, will help prevent surprises down the line with ACO payment structure.
If performance across the ACO does not align with Medicare’s expectations, accountable care organizations and their participants may face penalties. Many ACOs will pass these penalties along to their participants, who will have to sacrifice practice revenue to cover the cost. Other ACOs, like Advantage ACO, may cover all or some downside risk and potential penalties on behalf of their member providers.
3.) Support Services are Critical to Achieving Savings
To help ensure success in managing costs, it is recommended physicians look for an ACO that offers comprehensive and reliable support services. Effective ACO member support includes opportunities for regular in-practice and virtual visits with expert coaches, who will work closely with you and your staff to improve clinical and financial outcomes.
When choosing an ACO, it is best to look for a broad spectrum of support including:
- Performance reporting, with portal access to analytics and reports that provide the insights necessary to effectively manage your patient population
- Hands-on support with best practices in annual wellness visits, advance care planning, risk adjustment and more
- EHR services, including staff training, template improvements, and enhanced quality reporting
- Billing, coding, and revenue cycle training, plus consulting to ensure maximum reimbursement from payers on submitted claims
- Payer contracting, including access to multiple payer contracts and support in improving patient outcomes to maximize reimbursement
- MACRA MIPS performance assistance, with access to QPP Advisors for guidance on issues related to MIPS eligibility, participation, and performance
- Practice marketing to attract and engage patients in your community, such as website services and online reputation management
With support and guidance from experienced practice consultants, you can take full advantage of the benefits offered by your ACO.
4.) Ensure Practice Autonomy
As support services are critical, the task at hand for practice consultants is to work as partners who enable you to achieve enhanced performance – all while respecting your desire to preserve practice autonomy. For best outcomes, consultants will support your operation in optimizing cost and utilization performance with data-driven interventions and recommendations.
However, it is even more important you are empowered with autonomy within the ACO model. As an ACO member physician, you will continually make decisions that directly impact patient care and the organization’s ability to meet shared savings goals. Ideally, your participation in the ACO should never hinder your ability to provide high-quality care for your patients within the ACO framework.
Additionally, developing relationships with other physicians within the ACO system can provide you with valuable insights — especially when faced with unfamiliar challenges, such as new and changing regulations. By gaining a greater understanding of the ACO model, you can join with confidence knowing there will be no expectation to sacrifice your independence.
5.) Be Cautious of Auto-enrollment and Penalties for Leaving
Unfortunately, some ACOs have enrolled physicians without their knowledge – and there may be financial penalties for leaving them. In addition, some ACO’s make deductions from shared savings for management fees and other costs associated with services. By reading all the terms and conditions thoroughly before committing, you will have a solid understanding of any implications if you decide to opt out later.
“During the enrollment process for our ACO this year, we were surprised to learn that one of the physicians was already part of another ACO, and without their knowledge or permission,” shared Advantage ACO President Darline El Reda, “It’s unlikely that they would have ever know about their participation had we not been alerted to this by CMS.”
Darline El Reda Dr. PH, MPH, Advantage ACO President
It is also important to understand group size requirements, specific provider or facility type exclusions, and fee schedules when evaluating different ACOs. With due diligence, you can make a fully informed decision and avoid financial risks.
While the vetting process can be arduous, finding the right ACO for your practice is well worth the effort. As a physician, you can maintain autonomy in the practice of independent medicine. You also can be proactive to protect the financial health of your practice – an achievement achieved with the benefits of access to invaluable resources and shared savings.
Brandy Smuzeski, LMSW, is the Treasurer for Advantage ACO and a Clinical Manager at Medical Advantage. She has a history of success in the healthcare industry and has experience working with ACOs, hospitals, mental health facilities, SNF’s, HHC, and physicians. She has a Master of Social Work (M.S.W.) from Michigan State University and Bachelor of Science in Clinical Psychology from the University of Michigan.