A.C.O. Where Do I Fit In?

What You Need to Know About Accountable Care Organizations

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It may be a new name, but it’s not a new idea. However, it has the potential to dramatically change eyecare’s role within the culture of health care.

The concept behind Accountable Care Organizations (ACOs) is to provide patients with the right care, at the right time, in the right place. It seeks to do this by converting health care payments from fee-for-service to outcomes based and by creating financial incentives for health care providers to work together and reduce costs.

Better care for individuals and better overall health for communities, all while reducing per capita costs, was the “triple aim” proposed for health care reform by Donald M. Berwick, administrator of the Centers for Medicare and Medicaid Services (CMS), 2010-2011. “Even though he only lasted a couple of years, his imprimatur is still felt very strongly today,” Jeffrey Guterman, MD, MS, chief medical officer of 4PatientCare, told Vision Monday about Berwick. This triple aim remains the goal of ACOs.

Defined by the CMS as “groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care, the goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.”

ACOs are viewed by some as the solution to rising health care costs and by others as more work for less money. While the Affordable Care Act is catapulting ACOs into prominence, they did exist prior to the health care reform law being signed in 2010. And while they’ve evolved from the HMOs and PPOs of the 1980s and ‘90s, it’s their differences that their proponents believe will make them succeed where these other models failed.

“Some policymakers think ACOs are the most promising provision of the entire Affordable Care Act and an exciting opportunity to improve health care efficiency by improving quality and lowering costs. Some critics and skeptics think ACOs are gatekeepers that threaten patient choice and access to optometrists,” considered a group of optometrists who wrote a paper about What Optometrists Need to Know About ACOs for the American Optometric Association (AOA). “Both views could be correct, to some extent,” they said. Unfortunately, even those on the front lines of establishing ACOs can’t be sure of their outcome.

Whatever the outlook, ACOs are growing substantially. Premier Performance Partners expects hospital participation in ACOs to double in 2014, according to its fall 2013 Economic Outlook C-suite survey of senior health care executives. This growth is projected to accelerate, with about 50 percent of the survey’s respondents suggesting their hospitals will participate in an ACO by the end of 2014. Overall, 76.5 percent of respondents say their hospital does or will participate in an ACO. “About four million Medicare beneficiaries are now in an ACO, and, combined with the private sector, more than 428 hospitals have already signed up. An estimated 14 percent of the U.S. population is now being served by an ACO,” according to Kaiser Health News.

To prepare for participation in ACOs, “there have been more mergers and acquisitions in the hospital space than anywhere in the last five to 10 years,” Celina Burns, president of Davis Vision, told Vision Monday. “In addition, hospital systems that employ their own physicians have increased by the double digits in the last five years,” she said. “The best way to control them in the value-based model is to employ them. All of this is positioning for accountable care.”

With many independent optometrists currently griping about competition from corporate as well as online optical retailers, ACOs have the potential for rewarding those who focus on the medical side of optometric care. Instead of competing on price with other retailers of frames and lenses, optometrists who join an ACO can benefit from helping manage patients with chronic diseases and even from diagnosing them in the first place.

With these goals in mind countered by the caveat that the success or failure of ACOs is still unclear, the following sections provide the facts you need to know about accountable care organizations before you can even think about joining one. Or, as Stephen Montaquila, OD, chair of the AOA’s Third Party Center Executive Committee, put it, “building this airplane while it’s still in the air.” ■