Tracking and organizing results that reflect efficiency and quality improvements are obviously a must, but before a provider even considers joining an ACO, the following questions must be asked and answered:
What level of risk are you willing to take on?
First, know what level of risk you are willing to take on. For example, are you comfortable taking on risk at all, or do you want to enter this area more slowly and only share in the savings? A core challenge when converting to a value-based rather than service-system fee is the lack of consistency in payment measures.
What are your base goals for the quality goals?
The ACO will identify quality measures as part of the agreement. Currently, a single set of metrics, adopted by all payer sources, is missing. To negotiate your position, you need to know your baseline and whether you can meet the identified benchmarks. For example, quality metrics may include HEDIS targets, AHRQ targets, and CMS targets.
What are your base goals for financial measures?
Financial measures can also be included and it is important to know your baseline measurements. For example, under the Affordable Care Act, insurers have a medical loss ratio (MLR) that must be complied with. MLR is defined as the percentage of premium that an insurance company spends on damages and expenses that improve the quality of health care. In other words, how much does it cost the managed care company for you to take care of their members? It is imperative. These statistics can and should be requested.
Have you completed financial risk modeling?
Financial risk modeling will include the methodology for allocating ACO members, financial benchmarks to evaluate the overall cost of care, and a risk-sharing formula, if applicable. This modeling helps you predict how certain members will impact your financial measures.
Do you have any public health management strategies in place or under development?
Population health is part of Triple Aim. Under this model, you need to learn how to identify the 20% of your patients who spend 80% of your resources and implement a strategy to proactively manage their health. The Camden coalition and the strategies they implemented are a good illustration of this model.
Have you requested references from the ACO?
Referrals from other providers should be sought. If possible, you can request referrals from the providers that have left the ACO as well as the providers currently in the ACO. The providers currently in the ACO may highlight what works well, while remaining providers may share experiences and areas that they would like to improve.
Have you reviewed sample quality reports and financial reports?
To measure quality and finances, ensure that you receive reports with useful information instead of only rows of data. It is this data that will help you evaluate whether your population health management strategies are working. The reports must contain information that is “real-time” data. Data that is 6 months old after receipt is too late to have a real impact on the patient’s health and your precautions.
How are patients assigned?
How patients are assigned is important as this affects your financial metrics.
What type of reporting is needed from your practice?
Do you need to fill out additional forms or reports to get credit for your metrics, both quality and financial? How long does it take to complete? Do you have someone in your practice who can complete this for you, or is this an extra workload for you as a provider?
When and how does reconciliation end?
Whether you are in a shared savings or risk model, how does voting end? More importantly, when the poll is completed, do you have the opportunity to contest the data provided? Do you have complaints rights?
How is ACO structured and managed?
Is ACO controlled by part-time or full-time staff? What type of services are provided as part of the ACO?
Have you reviewed your resume or resume for leadership in the ACO?
Do ACO managers have any management experience in a managed care setting? What type of data analytics experience do they have?
By proactively answering these questions, providers will be armed with answers that make a difference to their practice and their patients, and they will be properly positioned to explore and negotiate an ACO contract.