Just One Type of Coordinated Care, ACOs Come in Many Forms

There are 35 ACOs participating in the Advance Payment ACO Model.

“If you’ve seen one ACO, you’ve seen one ACO,” said Jerry Sude, OD, chairman and co-founder of OD Excellence, an alliance of ECPs in the forefront of educating optometrists about joining accountable care organizations. “They’re all different, some are hospital based, some not hospital based, some are owned by primary care physicians or groups of physicians, and some are very small that only need a location or two of optometrists, and some are large that need a lot of optometrists.” Some are Medicare based, following federal rules to be paid by the government, while others are commercial based, reimbursed by private health insurance companies.

“There are a lot of different kinds of ACOs,” said Alistair Jackson, M.Ed., founder of EyeCare Advice. “There are Medicare ACOs and non-Medicare ACOs. Some of them have open panels, and some of them have closed panels.”

“Under Medicare, you can’t have an exclusive closed network of providers, but under a commercial payer contract it could be totally closed,” said Lendy Pridgen, MBA, MHA, director, AOA Third Party Center.

There are 35 ACOs participating in the Advance Payment ACO Model. Source: Centers for Medicare and Medicaid Services.

While ACOs are getting the hype, CMS lists seven categories of innovation models for payment and service delivery defined both through the Affordable Care Act as well as through previous legislation. ACOs are just one of these models. Within ACOs themselves, CMS currently lists eight models, initiatives and demonstrations that are either in the review stage, ongoing, or no longer active.

Each model is slightly different. The Advance Payment Model, currently with 35 ACOs, according to CMS, is for physician-based and rural providers to help smaller ACOs with less access to capital participate in the Shared Savings Program. Designed to improve the quality of care for Medicare fee-for-service beneficiaries and reduce unnecessary costs, the Medicare Shared Savings Program rewards ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first.

Another example, the Pioneer ACO Model coordinates with private payers. For providers already experienced in coordinating care, the Pioneer Model allows them to move from a shared savings payment model to a population-based payment model separate from the Medicare Shared Services Program. There are 23 ACOs in the Pioneer ACO Model, according to CMS.

One example of a Pioneer ACO Model, the Florida-based JSA Medical Group has contracted with Florida-based John Wachter, OD, owner of Eye Associates of Pinellas, a practice in a unique position to bring both optometrists as well as the ophthalmologists that it employs. However, although Wachter told Vision Monday that he signed the contract with JSA in April of 2013 in an effort to get more “good-paying” patients, he has yet to see any.

Patient-centered medical homes are another model of coordinated care and can exist both within or outside of the scope of ACOs.

“Some states, such as Minnesota and New Jersey, are implementing ACOs for their Medicaid programs,” said the AOA’s paper on What Optometrists Need to Know About ACOs. “States will generally follow the same approach in Medicaid as the federal government chose in Medicare: Measure the cost of care of the patient population served by the ACO, and measure quality of care provided by the ACO to make sure that medically necessary services are not eliminated.”

As the country’s biggest payer, CMS is fueling the growth of ACOs. However, private insurance companies are doing so as well. In July of last year, UnitedHealthcare announced it would double its ACO contracts to more than $50 billion of reimbursements by 2017.

“Private payers are all over this,” Smith Anderson law firm partner Julian D. (“Bo”) Bobbitt, Jr., J.D., told Vision Monday. Bobbitt compiled the information for the AOA’s The Accountable Care Guide. “On the private side, there are plenty of insurance companies around the country paying for ACOs,” he said. “Physicians and hospitals will also have a dramatic impact on the transfer to value-based care.”

“Currently, private pay ACOs are a much smaller percentage of the pie,” added 4PatientCare’s Guterman, “but if the model proves successful and Medicare shows true savings, which I think it will, the private sector will quickly adapt.”

ACOs: What You Must Know

  The goals are to improve care for people and communities while reducing costs.
  ACO growth is projected to accelerate.
  Payments will become outcomes based, not fee-for-service.
  Financial incentives encourage providers to work together and reduce costs.
  Evolved from HMOs, ACOs are a different model of coordinated care.
  Both CMS-based and commercial, ACOs come in many forms.
  You need electronic health records to participate in ACOs.
  Networks of ODs will be more attractive to ACOs than sole practitioners.
  ODs must be proactive to be included, or risk being left behind.
  ODs must prove their value to ACOs by improving quality and reducing costs.
  A major role for ODs will be identifying and managing chronic diseases.
  ACOs are local and regional, not national, different in every state and every community.