within an ACO model will really depend on what the ACO’s looking for. Everybody has the opportunity.”
Consider This Before joining an ACO, Lowe recom- mends that ASCs think through the following: 1. Are your physicians who work in the ASC well-aligned with the primary care providers (PCP) of the ACO? Because the PCPs will take on more responsibility patient referrals to
directing specialists.
PCPs that know your physicians and trust their quality will be excellent partners and drive even more volume to your facility. If that trusting relationship does not exist or cannot be developed, changing referral patterns of the PCPs could negatively affect your physicians’ office and surgical volume.
2. The ACO has incentives to reduce costs and unnecessary services and also to keep people as healthy as possible, which may mean making referrals for surgery. Especially in
Medicare ACOs, the value
proposition of the ASC is clear: ASC rates are almost half that of the hospital outpatient Medicare rates, so every shift in site of service to the setting creates shared savings opportunities for the ACO participants. Many PCPs and even some surgeons are not aware of how big the price differential is between the settings. Be sure to have a conversation with the PCPs in the ACO about price, quality and patient
satisfaction—all of which
are metrics on which the ACO is evaluated and that affect the amount of shared savings it can receive.
3. You may have primary care providers of an ACO thinking surgeons only want to do surgeries. It
is important to help them
understand how your physicians try everything possible before
progressing to surgery. They
want to know when they refer a patient that your physician—the specialist—will walk that patient through all nonsurgical options before suggesting surgery.
4. Getting the patient back to his or her PCP is also very important to those PCPs. If the patient loses contact with his or her PCP after surgery, the ACO may no longer have that patient attributed to them because patients are attributed to ACOs based on which PCP they use. Help- ing the PCPs maintain relationships with their patients increases the like- lihood for future referrals and helps them capture shared savings from effective use of the ASC setting. This helps the PCPs see your physi- cians as partners in their success. Todorovich emphasizes, “Involve
your partners, whether they are doc- tors, hospital partners or both. Be a part of the process and use your phy- sician champions with the hospital to ensure that the ASC is part of the ACO model. ASCs in California, be involved in the medical groups or inde- pendent physician associations (IPA) that are involved in this ACO model. Also, be a part of the health plans; they will help as much as they can. When push comes to shove, go back to your physicians/hospital partners.” In an IPA, the members are assigned or select a group that will manage their care. The group is paid via capitation
or contract rates by the health plan. In California, some of these groups are well-funded and have a lot of capital behind them, Todorovich explains. “These groups are going out and almost competing against the hospitals. In other states, hospitals are allowed to buy the physician practices and integrate them in their whole delivery model.” ASCs that are affiliated with a hos- pital system will become part of an ACO because the hospital will bring them in when they join the ACO, he says. “Although we have had situations where the hospital has started with the hospital employees and put us on the lower tier. You have to be assertive and aggressive to be on the table with the ACOs or you will get left out. Hospi- tals are putting this thing together.”
Stay Prepared
A couple of things have changed since the ACOs first began. First, Lowe says, “PCPs are more worried about leakage out of their panel of patients under the ACO model, as mounting evidence sug- gests that ACOs with high patient turn- over (churn) capture less shared savings than those that maintain a consistent panel. In the past, you heard more con- cern that groups wanted to maintain a consistent size panel of patients; now, the incentive is both consistency of size and composition.” Because Medicare attributes patients to the ACO through their PCPs, the ACO is at risk of losing responsibility and savings for patients who drift away from their PCP and seek primary care services from other pro- viders, she says. Second, Todorovich says, the payers
have identified certain groups to man- age. “They are in dialogue with certain large employers, not so much national employers but local employers,” he explains. “However, it is difficult for these plans to build long-term mod- els because any year an employer can change payers and walk away. Provid- ers have walked away from one-third
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