ACOs should develop specialist integration programs

Integrating specialists into accountable care organizations (ACO) requires a combination of leadership, clinical coordination, equitable reimbursement, good governance and a team-oriented culture of care. Although seemingly obvious, putting this into practice can be easier said than done.

The importance of specialists to ACOs has drawn increasing attention over recent months as policymakers have examined results of the first year of the Medicare Shared Saving Program (MSSP), says David Muhlestein, Ph.D., director of research for Leavitt Partners, a healthcare consulting firm.  

“Until now, there has been a general belief that ACOs primarily would reduce costs and improve patient outcomes by facilitating primary care practitioners in providing comprehensive preventive services and thereby preventing illness,” Muhlestein says. “It has now become evident that many of the greatest cost savings can be achieved by better managing patients who already have health conditions such as diabetes or cardiopulmonary problems.”

For that reason, ACOs should start developing specialist integration programs. The best way to begin is with small, individualized pilot projects, says Muhlestein. Rather than arbitrarily integrating specialty care, ACOs should assess opportunities to introduce specialist services. 

“The key is to integrate the types of specialists who will effectively replace the general practice physicians for subsets of patients with specific health conditions, such as cardiologists, endocrinologists or oncologists,” Muhlestein says. “Integration of a transplant surgeon may not be as important.” 

It’s important to be selective, he adds, and look for specialists with an understanding of coordinated care who are interested in being part of a team.

Pros and cons for specialists 

Affiliating with ACOs will be more important for specialists in areas like New England and Southern California that have a high rate of ACO development compared to other parts of the country. MSSP rules mandate that ACOs must provide adequate access to specialist care. Additionally, they encourage specialist involvement in MSSPs by allowing patients to be assigned to an ACO on the basis of primary care services provided in a specialist’s practice and exempting specialists from downside risk. 

With MSSP rules specifically allowing ACO patients to obtain specialist care from the provider of their choice, many specialists do not see affiliating with an ACO as necessary for ensuring referrals. At least one MSSP rule could serve to discourage MMSP involvement.

Exclusivity provisions of the MSSP regulations could potentially preclude physicians within many specialties from participating in more than one ACO, when patients are assigned to an organization on the basis of primary care services provided in their practices. Specialists who express concerns over exclusivity should be advised to seek qualified legal guidance regarding their options.

Many factors could serve to spur specialist interest in ACO in the not-too-distant future, Muhlestein says. The Medicare Payment Modernization Act, narrowly defeated in Congress earlier this year, would require Medicare doctors to participate in either ACOs or a new Merit-based Incentive Payment System (MIPS), beginning in 2018.

The legislation enjoyed strong bipartisan support and Washington observers now say it is almost certain to be re-introduced in Congress next year. The Centers for Medicare & Medicaid Services (CMS) hopes to implement the payment reforms in 2018.

Growing the ACO presence

ACOs have potential to grow their presence. States expanding their Medicaid programs under the Affordable Care Act may use ACOs to limit the cost of care for complex chronic disease patients. In the new exchange marketplaces, ACO-exclusive plans with their generally narrow networks might emerge as the low-cost winners among shoppers. Large employers may turn to ACOs to help control costs, according to Muhlestein.

As the number of ACOs grows, and as many create “preferred specialist” programs, specialists who are not part of an ACO might see themselves at a disadvantage. It’s clear that accountable care-whether under Medicare or in the private market-is the emerging model, and providers will need to define their roles.

Practical guidance

Also helpful may be new information posted to the federal Agency on Healthcare Research and Quality (AHRQ) Innovations Exchange website on clinical integration and shared saving distribution strategies. The strategies were developed by North Carolina’s Toward Accountable Care (TAC) physicians consortium. TAC reportedly is being emulated by other ACOs around the nation.

Medicare’s final MSSP ACO regulations require that 75% of an ACO board be selected by the ACO’s providers. The regulations also state that ACOs should “have established a mechanism for shared governance that provides all ACO participants with an appropriate proportionate control over the ACO’s decision-making process.”

Specialists may wish to participate in ACOs as owners, executives, board members or on  physician-directed quality assurance and improvement committees, as well as seek reassurance that all arrangements comply with all federal and state laws. ACOs require collaboration, referrals and sharing of revenues among practitioners, who may be competitors, which can raise a variety of challenging legal and compliance issues.  

Bob Pieper is a freelance healthcare writer based in St. Louis.