“Fee-for-service is about doing more. ACOs are about keeping people well. It flips the incentive. But the devil is in the details,” says Dr. Skea.
The Centers for Medicare and Medicaid Services (CMS) has implemented the provisions of the 2010 Affordable Care Act with two ACO models: the Shared Savings Program and Pioneer. The basic outline of each, which is contained in a 429-page document, is this: the ACO adheres to a set of 65 clinical measures for managing the illnesses common in this patient population. At the same time, Medicare makes a prediction about how much care will cost in the upcoming year if nothing were to change in the way care is provided. If care ends up costing less than Medicare predicts, the ACO receives a portion of the savings in the form of a bonus. But if the care ends up costing more, the ACO takes a financial hit at the end of the year. Interestingly, under the government model, patients will be retrospectively assigned to an ACO at the end of the year, making it impossible for treating physicians to know which patients will be accounted for in the risk-sharing arrangement, but ensuring that all patients receive the same level of coordinated care.
In the Shared Savings Program, the number of beneficiaries can range from 5,000 to 20,000. Payments are made on a fee-for-service basis, and bonuses are given after at least a 2% savings is demonstrated. Patient assignment in the Shared Savings Program is always retrospective. Organizations don’t need experience with other shared savings programs or performance-based contracts to be eligible. In contrast, the Pioneer program prefers to enroll organizations with experience in shared savings or performance-based contracts. ACO participation is voluntary. Physicians in large groups would likely be enrolled as a group, while members of solo and small-group, single-specialty practices would have to seek out an ACO if they wanted to participate. Physicians could opt out of the plans after three years, but not before.
“In an ACO, you take on the responsibility for the health of the patient through the continuum, and as a physician, you must assure availability of services to keep patients as healthy as possible, as well as treating them when they are ill,” says James Dwyer, DO, executive vice president for physician services at Virtua Health in Marlton, N.J. “Doctors have always wanted to do what’s best for their patients. We’re trying to get to the point where the reimbursement process provides for the care of the patient during times of health as well as during episodes of illness. Coordination improves care and efficiency. We must improve upon the fragmented systems we have now,” he says.
