Understanding the ACO Movement
The background information on the ACO movement is included the white paper. The paper addresses the factors driving the movement to ACOs, systemic challenges, current initiatives, and the expertise required to be successful.
As part of the assessment, eight key success factors have been identified. Those are:
- Coordination of care among providers
- Providers having the right information, on a timely basis, to make care decisions
- Changing physician behavior
- Utilization of services that provide the greatest value
- Benefit designs that provide the proper incentives to consumers
- Payment systems which create the proper incentives for physicians
- The ability to relate to and work with payers, be they insurers or TPAs
- Forming strategic partnerships to deliver the resources that the provider does not possess or cannot develop efficiently
Core Competencies
To achieve success, 21 competencies were identified. The number itself is indicative of the magnitude of the task. Below those are divided into groupings based on the owner, or the timing under which the competency needs to be developed.
When considering these competencies, it is important to understand that some may not be relevant for both Medicare and private markets. The private market will allow more flexibility in the arrangements between ACOs and payers, and will therefore require more adaptability from the ACO. Also, many of these competencies cannot be developed by the provider organization alone. Many issues will require working with a payer organization with expertise that relates to that competency’s area.
Providers will be solely responsible for these six competencies:
- Organizing the primary care base and developing the care model to support ACO objectives
- Developing physician leadership
- Changing physician behavior
- Assembling a network with an appropriate mix of providers
- Electronic health record development
- Legal and compliance issues, of which there will be a variety
Providers will own the decisions for nine (9) other issues as well. For these, however, a strategic partner (usually a payer) involved with the ACO will provide advice and guidance based on both its expertise and its experiences in other markets. This sharing of experiences and information will be one of the areas in which the payer organization can provide value to an ACO. The seven are:
- Plan Design, the structuring of benefits to drive behavior desired
- Provider Payment Models, to ensure that physicians and other providers have appropriate incentives
- Performance measure development, to support the objectives of the ACO
- ACO Governance Structures, to provide the right leadership structure to guide the ACO
- Prioritizing Savings Opportunities, to identify the areas in which savings are achievable
- Development and Implementation of Evidence-Based Protocols, to help ensure that best practices are followed and share that knowledge gained by other ACOs
- Disease management, to help manage patients with chronic illness that increases utilization of high-cost services
- Consumer Education, to ensure understanding of the objectives of the ACO and methods used to achieve those objectives, with the goal of avoiding a managed-care-style backlash
- Wellness Services, to help improve overall levels of health
There will be six (6) areas where the strategic partner/payer will be primarily responsible. In some of these areas, responsibility will be shared as the model evolves and the provider networks mature and gain experience. The eight are:
- Claims Processing
- Education and Training
- Quality/Price Transparency
- Sales and Marketing
- Data Analysis, Data Monitoring, and related IT
- Validation of Physician Incentive Payments
