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To future-proof your primary care practice, you need to join an accountable care organization (ACO).
Why? Because whether your patients are privately or publicly insured, you’ll lose them as the reimbursement model for medicine shifts to pay-for-performance from fee-for-service.
The Centers for Medicare & Medicaid Services (CMS) is leading the way and the largest insurers in Florida are following. CMS just announced two goals:
• Tying 30 percent of Medicare payments this year to quality or value through alternative payment models, rising to 50 percent by the end of 2018.
• Tying 85 percent of fee-for-service payments this year to quality or value for patients not in alternative payment models, rising to 90 percent in 2018.
CMS is pushing for better care, smarter spending and a healthier Medicare population. Medical practices are advised to focus on wellness and prevention, as well as aggressively managing individuals with chronic conditions. While Medicare and private insurers still pay fees for services, they are tying much of the financial reward – and risk – to outcomes.
That was evident in April 2015, when Medicare Part B was replaced through the so-called “doc fix” legislation with the value-based Merit-Based Incentive Payment System, or MIPS. It changes the way physicians are paid, puts physicians’ MIPS scores online and allows consumers to rate doctors side by side. In this new system, physician practices can earn incentives of up to 27 percent of their Medicare Part B reimbursements or forfeit up to 9 percent.
Your practice can only align with one ACO for Medicare patients and privately insured individuals. So, choose wisely. When deciding which ACO to join, ask these questions:
• What resources does the ACO bring to bear to help generate individual shared savings? At the very least, the organization should provide technical and financial support to improve patient management and billing.
• Are shared savings split on a pooled basis, such as the number of patients of each medical practice, or based on individual effort? You’ll balance whether to throw your lot in with the group or be rewarded for top performance.
• If shared savings are based on individual effort, how is that calculated? Is it by quality or cost? Are outcomes and savings adjusted for patient mix? You can’t compare a group that has a high morbidity rate to one that has a low one or a low population age.
• How much are the administrative expenses? If they’re eating up the shared savings, you’ll see very little of the money you worked so hard to save.
Once you’ve chosen your ACO, work to guarantee shared savings. On the Medicare side, thoughtfully embrace chronic care and transitional care management by identifying the patients most likely to be engaged and most likely to be helped in terms of care.
Your ACO should identify patients through a predictive modeling program backed up by clinical review. The ACO should assist you in taking advantage of the Florida Health Information Exchange, sending you alerts on every patient going into an emergency room or hospital bed.
The ACO should also help your practice lower costs. In a chronic care management setting, a medical assistant can do 90 percent of the work. Your ACO should show you how to develop and bill that program, and track the time.
With the right ACO, you can reap significant rewards. For example, our ACO has paid its member physicians $500 per patient, per year, in shared savings. This is in addition to their regular CMS revenue.
The shift to value-based care is picking up speed. Your practice must adapt to it. Joining an ACO isn’t about incentives, it’s about survival in this new world of healthcare.
