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Reimbursement and Practice Management

ACO HMO 2.0 Here We Go

Doctor With Patient

The advent of the Accountable Care Organization (ACO) as part of the 2010 Patient Protection and Affordable Care Act has the attention of specialty groups as well as primary care providers (PCPs).

In the next few years specialists will be called upon to play a key role in integrated care delivery, especially for people with chronic medical conditions. Many specialists are trying to determine a strategic course of action for their groups. Others are pausing to collect their thoughts and to focus required resources to understand and meet requirements for specialists related to communication between multiple providers, new data reporting, risk, patient engagement, satisfaction and safety, and cost savings. (Recall “meaningful use” with its primary care emphasis and the “fit” for specialists?)

Joining large multispecialty group and/or forming affiliations with integrated delivery systems are ways specialists are getting ACO ready. These specialists are positioned to collect and report performance data – independently or through a network or association of providers.

Payers are also developing ACOs. To meet ACO requirements these entities may look to limit referrals to out-of-network ASCs or labs, implement additional utilization review protocols, add new case rates and more bundling of codes. You might also watch for appended ACO language in new payer agreements. New language might impact how providers are paid for achieving predetermined cost savings. You might also take a look at the specialist’s role in integrated systems like Cleveland Clinic, Kaiser Permanente and Mayo Clinic. Their quality measures may eventually find their way into requirements for specialists participating in ACOs.

Is it HMO 2.0 Here We Go (Again), ACO-Oh No or ACO A-Go-Go for your specialty group?

United States