Plans begin ACO development in commercial markets

October 1, 2011
John Otrompke
John Otrompke

Large health plans across the country are diving into accountable care with some degree of success.

NATIONAL REPORTS-Large health plans across the country are diving into accountable care with some degree of success. Yet, how commercial insurers might define an accountable care organization (ACO) doesn't necessarily equal how the federal government defines an ACO.

In the ACO model being developed by Blue Cross and Blue Shield of Minnesota (BCBSMN), for example, only 17 quality measures are employed, quite a bit less than the list of 65 measures referenced in the proposed federal Medicare rule, according to Scott Keefer, vice president of policy and legislative affairs for BCBSMN. The plan currently has seven ACO arrangements in place.

"Our model is based on the 17 measures used in the Minnesota Community Measurement tool, which has already been agreed on by the community," Keefer says.

The five ACOs now in development by Aetna rely on a set of measures that vary according to the circumstances, says Charles Kennedy, MD, head of aligned care solutions. Arrangements offer gainsharing instead of downside risk.

"When an ACO is in the formative stages and the numbers of patients are quite small, our efficiency measures are in the single digit range," Dr. Kennedy says. "But as the numbers grow, we move closer to the federal government approach, with both upside and downside risk."

Piedmont Physicians Group, a group practice of 150 primary care physicians, owned by Piedmont Healthcare in Atlanta, is operating a collaborative ACO pilot with CIGNA. The Piedmont deal is an addendum to the system's regular commercial contract with CIGNA, and is beginning its second year as an ACO.

"Our quality measures are focused around some of the high volume disease states," says Piedmont's medical director Jim Sams, MD.

The group currently operates on a shared savings model only, and does not include a risk component, Dr. Sams says.

If the group does not gain shared savings in the ACO, he still foresees participating in the ACO with CIGNA on a long-term basis. Commercial insurers offer opportunities for customized ACO arrangements.

"At this point of time, the Medicare ACO program is not something we see as having a lot of advantages, so we're not looking to participate right now," he says. "What we are doing with CIGNA should not be confused in any way with what the federal government is doing with Medicare. It's a distinctly different animal."