ACOs What’s Next for DCs
Written by Editor   
Wednesday, December 31, 2014 04:00 PM

On November 2, 2011 CMS released their final rule regarding the CMS Shared Savings/Accountable Care Organization Program.  The CMS’ final rule indicated that nothing would “preclude Medicare enrolled chiropractors from participating in ACOs, or from sharing in the savings that an ACO may realize in part because of the quality and cost-effective services they may be able to provide.”

While doctors of chiropractic cannot independently establish an ACO, they can partner with other providers and share in savings demonstrated by the ACO. DCs who wish to participate in this program will need to partner with MDs or DOs who are establishing an ACO to participate in the Medicare Shared Savings Program.

As a first step, DCs will need to identify MDs/DOs in their state who intend to develop an ACO. When approaching other provider types to discuss the development of an ACO, information regarding the services that doctors of chiropractic provide may be helpful. 

When possible, state chiropractic associations may want to reach out to their state medical association to gather information regarding local efforts to develop ACOs and participate in the Medicare Shared Savings Program.

DCs who partner with other providers to form an ACO and participate in the Medicare Shared Savings program should seek a place in the governing body of the organization to ensure that DCs have input on the direction of the ACO.

DCs planning to participate in an ACO should carefully review the ACO’s participation agreement paying particular attention to how shared savings (incentives) will be disseminated among participating providers. CMS allows ACOs to determine how they will disseminate savings.

All DCs should be aware that All Medicare beneficiaries will retain the right to see any Medicare enrolled provider. CMS makes this clear in many places within the final rule. On page 241, CMS indicates, “Beneficiaries who are assigned to ACOs under the Shared Savings Program remain Medicare fee-for- service beneficiaries, retaining their full freedom of choice regarding where to receive services.”

CMS estimates that under the Medicare Shared Savings Program, at the most, approximately 270 ACOs will be formed and less than 5% of the Medicare population will be impacted by this program.

Since PPACA was signed into law on March 23, 2010 private insurers, doctor groups and hospitals have been negotiating contracts to form Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMHs). PPACA paved the way for these entities to grow for the purposes of reducing health care costs and increasing quality and access to care.

An ACO is defined as: “A group of health care providers who give coordinated care, chronic disease management, and thereby improve the quality of care patients get. The organization's payment is tied to achieving health care quality goals and outcomes that result in cost savings.”

Section 3502 of the PPACA defines a “patient-centered medical home” (PCMH) in simple terms as “a mode of care that includes: personal physicians; a whole person orientation; coordinated and integrated care; safe and high-quality care through evidence-informed medicine, appropriate use of health information technology, and continuous quality improvements; expanded access to care; and payment that recognizes added value from additional components of patient-centered care.” 

ACOs and PCMHs have the potential to become driving forces in the health care delivery system. These entities are essentially efforts to tie payment arrangements to quality care and cost-savings, thereby bringing increased accountability to health care. Through these organizations, doctors will initially be paid typically on a fee for service basis with incentives for providing quality care which achieves cost savings. Essentially, if providers meet certain criteria during the delivery of care, the providers will share in any related cost savings. These new payment arrangements will most likely transition away from fee for service and gravitate toward bundled payments, episode based payments, or comprehensive care payment systems to accelerate value-driven health care.

The rise of ACOs in 2012 has been explosive, with ACOs popping up in 45 different states. These ACOs are a mix of government partnerships and stand-alone private entities with care coordination and payment models varying depending on the organization leading the initiative. A good resource to obtain an outlook on the growth of these entities and to understand them further can be found here from Leavitt Partners. As of May 2012, there were some 221 ACOs.

ACOs can be divided into multiple categories: Insurer ACO, Single-Provider ACO, Multiple-Provider ACO and Insurer-Provider ACO. These ACOs may vary in their individual contracting details and their legal structure. Provider contracting and incentives may also vary depending on the structure of the organization.

ACA has sent a letter to many ACOs to position DCs as major partners in the ACO market. Doctors of chiropractic can get involved with ACOs in many different ways. DCs could provide care as a contracted provider, similar to contracting with an insurance company or provider network, or work directly in a hospital system or physician group that is a part of an ACO or PCMH. It is up to the individual DC or group of DCs to seek out these newly forming entities and educate themselves in the application of accountable care and determine their individual tolerance for handling the contracting details and nuances of these rapidly emerging care delivery systems and payment models. The ACA is studying these new health care models in order to offer some guidance to you in this transition to new health care models.