tion in both the inpatient and outpatient environments. Physi- cians, on the other hand, can provide clinical quality data to the health plan.
Much of that historical and future data will factor into how payment is determined, too, and payers are expecting value. The Blues-Texas Health ACO will start off with a shared savings model, and to reap those rewards, the contract will delineate the cost and quality metrics for which the physicians and hospital are accountable, Mr. Albosta says. He added that the payment model likely will evolve toward fixed payments. Physicians are the foundation of
any ACO, and their role, he says, “is to change the way they’ve been prac- ticing in a fee-for-service world.” With that commitment, “we [payers] will instill additional resources into the care continuum — care coordinators, nurse navigators, a level of analyti- cal support — to help facilitate care through the physician.”
Positioning for the future Covering the spectrum of care, amass- ing the necessary infrstructure, and maintaining financial stability are among several barriers to entry for small physician practices. Meanwhile, ACOs face other challenges that make it difficult to predict whether the mod- el is here to stay.
As a pediatrician in Frisco, Seth Ka-
plan, MD, finds himself in the middle of a burgeoning ACO neighborhood, but he’s concerned about the econom- ic viability of the model. Cost savings is a key mechanism for generating ad- ditional payment, and he’s not sure his two-physician practice can squeeze out any more than it already has. “As pediatricians, we operate pretty lean already,” Dr. Kaplan said, adding that his practice has been a member of two IPAs for years. “If you start look- ing at payment models where every- body has a piece of the pie, ours is al- ready small. If it gets any smaller, it’s not going to be viable,” he said. His practice continues to do its part to adapt to the new health care delivery environment, for example, by seeking medical home certification to increase collaboration and efficiencies. But before he takes on additional fi- nancial risk, Dr. Kaplan says he wants some proof the proposed vehicles of change are not a retread of old ideas.
“The fear is, we’ve been down this road before,” he said. As hospitals look to position themselves as an ACO by em-
ploying physicians to bring more services in house, primary care physicians like Gregory M. Fuller, MD, of Keller, are eval- uating options to participate in the model while remaining independent.
On the other hand, he also wants to know what an ACO can bring to his four-physician practice. North Hills Family Medicine already is a certified medical home that has adopted electronic medical records and quality-reporting mechanisms.
ARE YOU ACO READY?
Deciding whether to participate in an accountable care organiza- tion (ACO) can be a daunting task. The models may take different shapes and sizes, but some fundamentals are necessary. Here are some questions that physician and industry leaders say practices can ask themselves to assess their ACO readiness. The more “yes” answers you give, the more ACO-ready you are.
• Do you practice in a group setting or in collaboration with other physicians?
• Are you located in an area where collaboration across special- ties and care settings is possible?
• Do you have affiliations that enable your organization to deliver and coordinate care for a population of patients across various settings?
• Does your group have strong physician leadership? • Do you participate in value-based initiatives that measure per- formance?
• Is your organization willing to be held accountable for the clini- cal quality and total medical costs for a population of patients?
• Do you have a data-collection system, such as an electronic medical record system, to track and report on quality and cost measures?
• Do you have information on the utilization of medical services by your patients?
• Do you have methods to track and discourage inappropriate emergency department visits by your patients?
• Do you have mechanisms to conduct patient outreach and so- licit patient feedback?
• Are you willing to forego strict fee-for-service payments for value-based payment initiatives?
July 2013 TEXAS MEDICINE 23
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