Questions about my Situation
It is important to assess your personal situation and that of your practice as well as where you want to be in the intermediate and long term future. Evaluate the ACO opportunity in light of your practice's strategic plan. Questions to consider include:
- What special circumstances does my practice have that would bring value to both the practice and the ACO? Does my practice have significant knowledge and experience in population management?
- Does the culture of my practice fit with the goals and mission of the ACO?
- What is currently happening in my practice and community? Do I need to make a change in order to survive financially, and if so, how quickly?
- How close am I to retirement?
- How large is my practice, and does it have enough authority to negotiate effectively with hospitals or health insurers?
- Does my practice utilize alternative payment methodologies beyond fee-for-service currently? If not, can my practice negotiate alternative payment methodologies with health insurers directly?
- Are some of these other options more feasible for my current situation?
- Do not do anything o Try to grow your practice to have more leverage o Employment by or partnership with an area hospital
- Form a large clinically integrated practice group that can negotiate as a "group without walls"
- Change to concierge or direct practice model
Questions about the ACO
From an organizational perspective, "ACOs must have a strong and robust primary care infrastructure and robust electronic medical records/information technology systems to capture performance data and quality metrics. Health information technology (HIT) tools will be necessary both for sharing data and evidence-based and/or informed best practices with clinician. To achieve the savings championed by the ACO design, approaches other than the traditional fee-for-service system should be considered. Bundled payments, shared savings, quality performance payments, risk-based compensation, outcomebased reimbursement, and case-management fees are all currently under consideration. These schemes will certainly stimulate the provider network to focus on quality and cost performance goals and should align physician and hospital incentives." Additional information is available on the American Academy of Pediatrics (AAP) Accountable Care Organizations (ACOs) and Pediatricians: Evaluation and Engagement Web page.
Organizational Structure and Governance
Ideally, there should be equal representation on all governance and clinical committees between primary care and specialty physicians. The ACO board must be a separate and distinct entity (i.e., if a hospital or payer developed ACO, the board must be separate from the hospital or payer board of directors). Determine whether your interests are adequately represented at the Board level of the ACO both in terms of representation and voting authority. Questions to consider include:
- How long has the ACO been in existence?
- What is the size and make-up of the provider network? How many primary care physicians are there in relation to specialty physicians? What is the ratio of employed physicians and independent physician practices?
- What do pediatricians and pediatric subspecialists who have already joined think about the ACO? What do they consider to be the most significant pros/cons?
- What does the structure of the ACO look like? Who are members of the ACO? (Hospitals, employed physicians, contracted physicians, subspecialists, others?)What does the governance structure look like? Are pediatricians included in the governing board and leadership positions of the ACO? Are consumers included in the governing board of the ACO?
- What payers are contracted with the ACO? How many patients are part of the ACO?
- What is the financial viability of the ACO? How have financial and clinical performance been to date?
- Will I be joining the ACO as an employed physician, or as an affiliated physician/practice? How do the pros/cons differ?
- If joining as an employed physician, is the proposed contract fair?
For additional information, review the AMA Resource on Hospital Physician Employment Agreements.
Health Information Technology (HIT)
Although there are several factors impacting the success of an ACO, a focused HIT strategy that aligns the organization's resources with the ACOs goals and objectives is paramount. Additionally, it is important to assess the degree the ACO supports health information technology and the impact to your practice. Pediatricians and hospitals must have effective communication processes in place to ensure information is shared on a timely basis and are designed to ensure effective and efficient coordination of care and reporting on all dimensions of quality improvement. Questions to consider include:
- How is data collected and integrated from multiple clinical, financial and patient specific sources?
- Will I be obligated to change EHR systems if I join this ACO? If so, will the ACO support the transition to a new EHR financially? Does the new EHR have pediatric-specific functionality? For additional information, review the AAP statement, Special Requirements of Electronic Health Record Systems in Pediatrics.
- Will I be obligated to report data to the ACO, and if so, will my EHR support this data transfer?
- Will joining the ACO provide me with additional data or information to help me better care for my patients?
- How will the ACO share data with providers?
- What measures are being implemented by the ACO to ensure the privacy and security of the data?
- Does the ACO's system include a mechanism to record, monitor and support patient/family/caregiver relationships? If not, how is this data retrieved and managed?
- Does the system permit the transmission of data during transitions in care?
- Does the system support patient/family access to online educational resources?
- Does the system have risk sharing analytics in place to support the financial analysis of riskbased contracts? (shared savings, cost sharing algorithms.)
- How does the system manage the multitude of payer contracts and their financial effect on participating practices?
Quality and Performance Measurement
The ACO must have clinical and organizational elements in place to ensure the successful performance of all clinical care activities. Quality-performance metrics that pertain to children should be developed with strong input from primary care and subspecialty care pediatricians. Questions to consider include:
- How are quality and performance metrics developed and what systems are in place to collect and assess the data? Are they weighted based on their importance to influence either resource use or quality improvement goals?
- What is the degree of input by pediatricians to the quality and performance metrics and data collection?
- Does the ACO have any specific quality improvement initiatives?
- Will the ACO provide opportunities to participate in quality improvement initiatives that would be meaningful for my practice?
- How will performance data be shared will all members of the care team?
- Does the ACO monitor provider and staff satisfaction?
- What patient and family satisfaction measures are included as elements of the performance metric portfolio for the ACO? How active are family representatives in the organization's quality improvement initiatives?\
- What criteria are used in determining medical necessity?
For additional information, review the AAP statement, Essential Contract Language for Medical Necessity in Children
that may serve to guide pediatricians encountering issues with authorizations and medical necessity.
Patient- and Family-Centered Medical Home
It is important to ascertain how the ACO supports practice transformation to a patient- and familycentered medical home. This includes but is not limited to practice management support, technical assistance (including HIT), and resources for clinical and nonclinical (community, socioeducational, etc) care. Practices should be rewarded for achieving medical home recognition by agencies deemed to provide such recognition. For additional information, review the AAP Accountable Care Organizations (ACOs) and Pediatricians: Evaluation and Engagement Web page. Questions to consider include:
- Does the ACO require Medical home recognition/certification? Specialty practice recognition?
- To what extent does the ACO provide direct and indirect support to primary care practices that are committed to transforming to a patient- and family-centered medical home?
- Will the ACO provide a care coordinator or other clinical support staff in my office?
- Has the ACO developed linkages to key community resources to support care coordination, particularly for children and youth with special health care needs?
- Is there a family advisory council to advise the ACO leadership group?
- Does the ACO meaningfully involve patients and families, and encourage participating practices to do likewise?
- Is the ACO well-connected with other community-based resources that would be of benefit to my patients and their families?
Within the ACO, payment systems and incentives need to be aligned internally and externally among providers and payers. The payment methodology must be designed to ensure adequate supports for the primary care backbone of the ACO but should not compromise participation of subspecialty physicians. Systems need to be engaged to ensure appropriate payment that recognize the special elements of pediatric care, and are distributed to participating providers of care in an equitable manner.
Two valuable resources to pediatricians on financing and ACOs are the AAP paper titled ACOs and Pediatricians: Evaluation and Engagement at and the AAP statement, Principles of Health Care Financing. Questions to consider include:
- What is the payment methodology used by the ACO?
- How am I eligible for enhanced payment (i.e. bonuses, shared savings, etc)?
- Does the ACO include a down-side risk where my practice is at risk for sharing in any loss?
- What type of risk-adjustment methodology is in place to ensure adequate and appropriate payment for the delivery of care to children and youth with special health care needs?
- How are shared savings and pay for performance payments calculated? How will these be sustained in subsequent years, or will payments diminish over time?
- What is the anticipated revenue to the practice from participating in the ACO? How does this compare to my current revenue?
- What are the financial implications for joining this ACO? For example, are there membership fees associated with joining?
- Will I receive better contracts as a result of joining this ACO?
- Will I receive savings on expenses due to improved group purchasing and more negotiating authority?
- Will I be obligated to accept different insurance products as a result of joining this ACO?
- Will I be prohibited from accepting certain insurance products as a result of joining this ACO?
- Will I be obligated to accept uninsured patients within the ACO catchment area as a result of joining?
- Will I receive non-financial benefits from joining, such as additional staff, HIT technology, etc?
Questions about the Practice Implications of Joining an ACO Participating with an ACO may require substantial changes to the practice. Questions to consider include:
- What am I obligated to if I choose to join the ACO?
- In what areas will I lose autonomy if I choose to join this ACO (i.e., clinical care decisions/protocols, referral patterns, administrative decision-making, etc)?
- How much additional work will this take for me or my staff?
- Are there changes to administrative functions if I choose to join this ACO?
- If my practice joins an ACO, what are the implications to my professional liability and malpractice coverage? In an ACO arrangement, what are the malpractice, professional liability and disability insurance and related risks, exposures, and costs?
For additional information, review the Physicians Practice article, Physicians Need to Explore Personal Risk of Joining ACOs.
Special Considerations for Small and/or Rural Practices and Specialty Pediatrics
In addition to the questions posed above that pertain to any pediatric practice, additional considerations need to be addressed for specialty pediatricians as well as those practicing in rural and/or small practices. An important consideration for practices in rural or medically underserved areas is the provision of and access to an integrated and comprehensive network of care. Providing this level of integrated care will consequently require coordination among various providers and how the ACO accomplishes this is a vital consideration.
Concerning specialty pediatrics, ACOs have primary care physicians at the core, but the ways in which specialists can be engaged vary. Medical surgical and specialists may join an ACO:
- As a member of a large multispecialty or specialty group that contracts with an existing ACO.
- As an employed physician in a hospital that joins or forms an ACO.
- Joining a network of individual practices with primary care physicians to form an ACO.
Existing referral networks are a key factor in determining whether to participate in an ACO. The potential effect on referral patterns may be medical and surgical specialists' greatest concern with regard to joining an ACO. For patients who seek referrals for specialty care, physician participants in ACOs will likely encourage their patients to see specialists with whom they have good working relationships and those who are within the referring physician's ACO.
ACOs with high rates of specialty referrals may look at ways to reduce referrals or control their costs. It is important for specialists to not only establish good working relationships with referring members of ACOs, as well as demonstrate the cost-effective benefits of your specialty care. Specialists who provide prompt access and are regarded as providing cost-effective, quality-based care can demonstrate to the ACOs the value of their services.
Specialist input into any clinical guidelines used by the ACO is vital. Review the opportunities for specialist input and advocate to ensure that clinical guidelines and performance metrics used by the ACO are evidence based or evidence informed.