Be proactive to ensure a place for yourself with local ACOs

Take-home message: Ophthalmologists have a choice in dealing with accountable care organizations (ACOs). Take the initiative and work with ACOs, or ignore them, suggests one consultant.

By Fred Gebhart

Ophthalmologists have a choice in dealing with accountable care organizations (ACOs): Take the initiative and work with ACOs, or ignore them. Working proactively to gain a place on ACO provider panels is far more likely to lead to success than waiting for an ACO to take the first step.

“A growing number of Medicare and Medicaid beneficiaries, consumers, and patients are obtaining their care through an ACO,” said Bruce Maller, president of BSM Consulting, a fee-based consulting service for ophthalmology practices. “If you are not a provider in an ACO network, you may find that your access to patients is inhibited or curtailed. As ACOs gain market share, they may be a threat to ophthalmologists in terms of patient access.”

Maller explored the changing world of ACOs and hospital insurance companies during the American Society of Cataract and Refractive Surgery annual meeting in San Diego earlier this year. For better or for worse, ACOs are beginning to transform practices nationwide.

ACOs emerged from the Affordable Care Act, Maller said, but have taken on a life of their own thanks to healthcare market economics. The federal government envisions ACOs as a primary driver to implement strategies that will improve the quality of care, improve access to care, and lower the cost of care. Medicare and Medicaid populations are first in line for this transformation, but the commercial health insurance market is adopting similar strategies as well.

As of mid-2015, there were about 425 Medicare ACOs and 375 private or public ACOs across the country, he said. Medicare ACOs cover about 7.2 million lives, while the public and private ACOs cover another 15.2 million lives.

ACOs are very similar to similar to HMOs and PPOs in terms of directing patients to in-network providers. The biggest difference is that Medicare ACOs have the additional advantages of federal regulatory support.

ACOs may use their network to leverage negotiations with commercial payers and to participate in the expansion of state Medicaid programs. Some ACOs have begun to market their “network” product directly to consumers to boost market share. They also work to aggregate providers to achieve better care coordination and lower cost.

“These 800 or so organizations are essentially consolidating the market,” Maller explained. “In the past, you may have been seeing Medicare fee-for-service patients because they chose to see you. In the ACO world, those patients are going to be redirected to ACO providers. And if you are not on that ACO panel, that provider may not be you.”

Gaining a place on a conventional PPO panel was not difficult, he continued. Almost any provider willing to accept a PPO’s contract could join the network and gain access to network patient referrals. Getting into an ACO network can be more difficult.

The first step is to determine how important ACOs have become in your geographic location. In some areas, ACOs have been relatively inactive and do not have significant market share. However, in major metropolitan areas such as New York, Boston, Los Angeles, Phoenix, and Chicago, ACOs may dominate the market.

“Some ACOs are limiting provider access to a significant degree,” Maller said. “If you, the provider, are not at the table or are not paying attention, you could find that these ACOs have contracted with other providers and you are left out in the cold. Depending on where you are, it can be a significant access issue. It is up to you to uncover and understand the local ACO landscape.”

ACOs often send out blanket invitations to all providers in a geographic coverage area to learn about participation. Providers who attend those meetings may have an opportunity to join the ACO network. Providers who do not attend will likely miss that opportunity.

“I recommend that you attend those meetings,”Maller said. “Demonstrate that you are interested, assuming you are considering an ACO network as a channel in which you may want to participate. If you choose not to participate, recognize that you may not be a part of that provider network in the future.”

Market dynamics have overtaken the Affordable Care Act in driving consolidation of both payer panels and patient populations. Consolidations such as the recent combinations of Aetna and Humana and Anthem plus Cigna are already pushing efforts to expand provider networks to serve ever-larger consolidated patient populations.

“Health plans are going to be contracting with provider groups that are able to accept financial risk, manage quality, help support reporting requirements that health plans must meet for their STAR ratings, and assist with preventive care such as regular diabetic vision screenings and glaucoma screenings,” Maller said. “Many ophthalmologists are going to hard pressed to meet those demands in some markets because of the sheer size and scale that is needed to respond to the needs of these contracting groups. But unless you’ve got a 100% cash pay practice and don’t need to deal with Medicare and other third party plans, you need a seat at the table.”