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ACO’s and the Tech Needed to Be Ready

Posted on April 22, 2014 I Written By

The following is a guest post by Barry Haitoff, CEO of Medical Management Corporation of America.
Barry Haitoff
For those not familiar with ACOs (Accountable Care Organizations), I want to provide some insight into ACOs and how a medical practice can better prepare themselves for the coming shift in reimbursement, which is epitomized by the ACO. This is a challenging subject since the ACO is a somewhat nebulous idea that’s rapidly changing, but hopefully I can provide you some strategies that will help you be prepared for the coming changes.

You may remember when we talked in a previous post about the Value Based Payment Modifier and its impact on healthcare reimbursement. As we talked about in that post, healthcare reimbursement is changing and CMS is looking to only pay those providers who are providing quality care. As part of this movement, an ACO is an organization that works on behalf of a community of patients to ensure quality care.

The metrics of how they’ll measure what they reimburse and what they consider quality care are likely to rapidly change over the next few years while CMS figures out how to measure this. However, one key to being ready for this shift is that you’ll need to be part of an organization or group of providers that will take accountability for a patient population.

In some areas of the country, the hospitals are leading these organizations, but in other areas groups of physicians are coming together to form an ACO of just physicians. Either way can work. The key is that the members of these groups are going to each share in the reimbursement the group receives for improving the quality of healthcare patients in the community receive.

Also worth noting is that membership in an ACO isn’t necessarily a prerequisite for value based reimbursement. Whether you choose to be a member of an ACO or not, you’re going to be impacted by value based reimbursement and will need to be ready for the change. Not being ready could lead to lower reimbursement for the services you provide.

While it’s great that organizations of doctors are coming together to meet the need for ACOs, much more is going to be needed to do well in an ACO reimbursement world. The reality is that an ACO can’t exist without technology. Don’t even think about trying to meet the ACO requirements without the use of technology. ACOs will base their reimbursement on trackable data that can be aggregated across a community of providers that are likely on hundreds of different systems. Try doing that on paper. It just won’t happen.

In fact, many people probably think that their EHR software will be enough to meet the needs of the ACO as well. I believe this to be a myth. Without a doubt, the EHR will play a major role in the gathering and distribution of the EHR data. However, unless you’re a homogeneous ACO with providers that are all on the same single instance of an EHR, you’re going to need a whole suite of services that connect, aggregate, and interpret the EHR data for the community of patients. Add on top of that the communication needs of an ACO and the care manager style tracking that will need to occur and it’s unlike your EHR is going to be up to the task of an ACO. They’ll be too busy dealing with meaningful use and EHR certification.

Let me highlight three places where an ACO will need technology:

One of the key needs in an ACO is quality communication. This communication will happen provider to provider, provider to care manager, provider to patient, and care manager to patient and vice versa. You can expect that this communication will be a mix of secure text messaging and secure emails. In some cases it will be facilitated by a patient portal, but most of the secure messaging platforms for healthcare are much slicker and more effective than a patient portal that so far patients have rarely used.

Are you using a next generation secure messaging system to communicate with other providers, your staff, and the patient? You’ll likely need to use one in an ACO.

Provider Data Aggregation
Much like paper charts won’t be enough in an ACO world, faxed documents won’t be enough either. Providers in an ACO will need to have patient data from across the entire community of ACO providers. At a minimum providers in an ACO will need to have their EHRs connected with Direct, but most will need to have some sort of outside HIE that helps transfer, aggregate and track all the data that’s available for a patient in the ACO.

The ACO and doctor will really benefit from all the patient data being available at the click of the button. Without it, I’m not sure that ACOs will be able to meet the required quality measures.

Patient Data Aggregation
While all of the providers will need to be sharing their patient data, I think most ACOs will benefit from aggregating patient data as well. At first the ACO won’t be aggregating all of the patient generated data that’s available. Instead, they’ll find a slice of their patient community where they can have the most impact. Then, they’ll work with those patients to improve the care they receive. This is going to require ACOs to receive and track patient generated data. Without it, the ACO won’t have any idea how it’s doing. With so many patients on mobile devices or with access to the internet, what an amazing opportunity we have to really engage with patients.

Those are just a few of the ways technology is going to be needed for the coming changes in healthcare reimbursement and the shift towards value based care in things we call ACOs. Far too many providers are sitting on the sidelines while they let ACOs settle into place. What a missed opportunity. The fact that the ACOs are rapidly changing means that if you participate and make your voice heard, you can help to shape the direction of them going forward. We definitely need more doctors involved in these conversations.

Medical Management Corporation of America, a leading provider of medical billing services, is a proud sponsor of EMR and HIPAA.

ACO Model Risks and Rewards

Posted on February 29, 2012 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I haven’t heard a single person say that the ACO (Accountable Care Organization) model is not here to stay. In fact, everyone that I’ve talked to is completely confident that healthcare is heading down the tracks of some sort of quality care model and away from our current fee for service model. The only real question is what form these ACOs are going to take.

With this as background, let’s consider something about ACOs that I haven’t really heard many (if any) people talking about: the risks and reward profiles of being an ACO (or part of an ACO).

I’ll save the detailed list of risks and rewards for a future post, but instead want to highlight how the risks and rewards of an ACO are quite different from our current fee for service model. In our current model, when you provide a service to a patient you have a pretty good idea of what the reward for that service is going to be. Sure, there are intricacies of insurance billing, but for the most part you know what you’re going to be paid for the services you rendered. There’s not very much risk associated with providing that service since the fee for that service is known. We could argue about whether the reward is worth it or not, but in the current model the reward is pretty solidly defined. You don’t get paid more for doing a better knee surgery than someone else. The payment is the same.

The opposite turns out to be the case in a true ACO world. Providers that are caring for a community of people will be rewarded based on the quality of care that they provide that community (at least that’s the idea). That means that providers and ACOs are taking on the risk associated with the care they provide. Bad care = less reimbursement. Better care = more reimbursement. While the associated risk is higher for providers under an ACO, so are the rewards. A provider that provides better care for their community has the possibility of making more money for the care they provided.

As an entrepreneur I must admit that the idea of getting paid more for doing something better than someone else is beautiful. This is even more true in healthcare where I love the idea of a doctor getting paid to really improve my health as opposed to getting paid for services that I may or may not need. Although, I can understand how many doctors might not feel the same way I do. Many doctors aren’t entrepreneurs. They just love medicine and patients. What are these types of doctors to do with this new and evolving ACO model for reimbursement?

I think there is a clear option for doctors that just want to practice medicine without the risk or rewards associated with the ACO model. The way they’ll get around this is likely working for someone else. There’s little doubt that there will be many organizations happy to take on the risk and rewards of the ACO model while paying a physician a salary for their work.

One thing seems clear to me: Providers take on a greater portion of risk in an ACO, but they also have the opportunity to take home a significantly higher net reimbursement.