Last time, we reviewed some of the background information concerning ACOs and the objective of this care delivery model. In this installment of the five-part series, we will begin where health care truly starts: the patient. Medicare beneficiaries will be associated with an ACO based on their use of primary care services. Assuming a primary care physician participates in an ACO and has a sizable patient population of Medicare beneficiaries, those patients who receive the bulk of their primary care from that physician will be associated to his or her ACO. The beneficiary, or course, has the choice to be associated with an ACO or to ‘opt out.’ Although all types of providers along the care continuum would participate in an ACO, the beneficiary has no restrictions with regard to the providers he or she chooses to see. The beneficiary retains the ability to self-refer to any participating Medicare provider – regardless of the provider’s affiliation with the ACO or not – and to receive all the services the beneficiary or her physician chooses.
Let’s compare this scenario with that of a fictional MSO which is affiliated with an MA plan. When Medicare beneficiaries join an MA plan, they accept certain managed care restrictions in exchange for greater coverage, increased benefits and lower out-of-pocket costs. The restrictions may include a reduced subset of providers available for the patient to see (those who have executed a contract with the Plan and sometimes the group itself), greater coordination and gate-keeping, and limitations on certain services (not so much in quantity as in timing and location). Our MSO’s members see an MSO primary care physician (PCP) who coordinates their care with other providers who participate with the MA plan (and sometimes individually with the MSO itself).
Both the ACO and our fictional MSO are accountable for the care their patients receive across all the settings of care. The difference is in the amount of control each has over the utilization, location and even the cost of the services rendered to their patients, and the manner in which they themselves are reimbursed.
In part three of our five-part exploration of the Accountable Care Organization, we will delve into the financial aspect of this care model.