Attracting and retaining high quality primary care providers is critical to the success of accountable care organizations, says Daniel M. Grauman, president & CEO, DGA Partners. Not only must ACOs have primary care provider bases large enough to oversee a patient population of 5,000 Medicare enrollees, but they must also ensure these providers are engaged in improving care coordination and efficiency, so that the ACO produces savings that can be shared among its providers.
While the final regulations governing ACOs have yet to be released, hospitals that plan to develop ACOs can get a head start by taking the following four steps to assess and, if necessary, strengthen their primary care networks. "Primary care is a very important part [of an ACO] initially, and then becomes even more important in terms of directing and overseeing the care of patients," says Mr. Grauman.
1. Assess your primary care network. Hospitals should begin by assessing their current primary care provider networks. If the hospital employs PCPs, it can safely assume they will participate in the ACO. John Harris, a partner with DGA Partners, estimates that 15-20 physicians are typically needed to meet this threshold. If the hospital's employed ranks aren't large enough, or if it wants to further expand the potential market share of its ACO, it will need to begin recruiting independent primary care providers to the ACO. This can be achieved either through employment offers or contract arrangements.
2. Determine which enrollees are likely to be covered under the ACO contract. While ACOs can use the guideline of a minimum of 15 PCPs initially, it will eventually need to forecast a more precise number of Medicare enrollees that will be attributed to it. Again, the regulations have not been finalized, so no one can be sure how patients will be attributed to the ACO, but CMS has historically determined enrollment for similar projects by assigning enrollees to a provider based on Part B claims data, says Mr. Grauman. That is, a patient is assigned to the PCP who he or she visited most often over a certain period of time. Therefore, hospitals can analyze claims data on their employed and affiliated PCPs to determine approximately how many Medicare beneficiaries would be assigned to the ACO. This information not only helps the ACO to gauge its market share but will also allow the organization to begin analyzing these patients' claims data to determine risk.
3. Develop a plan for signing exclusive contracts with PCPs. Exclusivity within ACOs has been a hotly debated issue — some argue exclusivity is needed to ensure adequate physician engagement, while others argue exclusivity could create unfair competition. Mr. Harris favors exclusive arrangements, saying it would be almost impossible for a physician to work with multiple ACOs, because of attribution processes as well as processes of care. "If patients are assigned to an ACO based on whether their provider is in that ACO, there isn't an easy resolution to determine which patients go to which ACO [if a provider was part of multiple ACOs], says Mr. Grauman. Further, "each ACO will have its own processes and own way of managing patients that will affect the everyday operations of a primary care practice. I don't see how it would be possible or practical to participate in multiple ACOs given this," he says.
4. Think ahead to retention strategies. Finally, ACOs should begin the plan for how they will retain independent PCPs after the initial contract term, which for most ACOs is expected to be three years to mirror the program's minimum participation requirement. Mr. Grauman believes retention strategies should consider both operational and financial factors. Mr. Grauman says ACOs that provide practices with support — such as information technology and access to case managers — to better manage patients and those that are able to reimburse providers for the extra time and effort involved in managing patients are best positioned to retain providers.
"What's important to a typical PCP is to retain a significant amount of clinical autonomy. If an ACO is aimed at better managing utilization and cost, the PCP will want to see that this doesn't negatively impact the way he or she runs his or her practice or the patient."
Learn more about DGA Partners.
While the final regulations governing ACOs have yet to be released, hospitals that plan to develop ACOs can get a head start by taking the following four steps to assess and, if necessary, strengthen their primary care networks. "Primary care is a very important part [of an ACO] initially, and then becomes even more important in terms of directing and overseeing the care of patients," says Mr. Grauman.
1. Assess your primary care network. Hospitals should begin by assessing their current primary care provider networks. If the hospital employs PCPs, it can safely assume they will participate in the ACO. John Harris, a partner with DGA Partners, estimates that 15-20 physicians are typically needed to meet this threshold. If the hospital's employed ranks aren't large enough, or if it wants to further expand the potential market share of its ACO, it will need to begin recruiting independent primary care providers to the ACO. This can be achieved either through employment offers or contract arrangements.
2. Determine which enrollees are likely to be covered under the ACO contract. While ACOs can use the guideline of a minimum of 15 PCPs initially, it will eventually need to forecast a more precise number of Medicare enrollees that will be attributed to it. Again, the regulations have not been finalized, so no one can be sure how patients will be attributed to the ACO, but CMS has historically determined enrollment for similar projects by assigning enrollees to a provider based on Part B claims data, says Mr. Grauman. That is, a patient is assigned to the PCP who he or she visited most often over a certain period of time. Therefore, hospitals can analyze claims data on their employed and affiliated PCPs to determine approximately how many Medicare beneficiaries would be assigned to the ACO. This information not only helps the ACO to gauge its market share but will also allow the organization to begin analyzing these patients' claims data to determine risk.
3. Develop a plan for signing exclusive contracts with PCPs. Exclusivity within ACOs has been a hotly debated issue — some argue exclusivity is needed to ensure adequate physician engagement, while others argue exclusivity could create unfair competition. Mr. Harris favors exclusive arrangements, saying it would be almost impossible for a physician to work with multiple ACOs, because of attribution processes as well as processes of care. "If patients are assigned to an ACO based on whether their provider is in that ACO, there isn't an easy resolution to determine which patients go to which ACO [if a provider was part of multiple ACOs], says Mr. Grauman. Further, "each ACO will have its own processes and own way of managing patients that will affect the everyday operations of a primary care practice. I don't see how it would be possible or practical to participate in multiple ACOs given this," he says.
4. Think ahead to retention strategies. Finally, ACOs should begin the plan for how they will retain independent PCPs after the initial contract term, which for most ACOs is expected to be three years to mirror the program's minimum participation requirement. Mr. Grauman believes retention strategies should consider both operational and financial factors. Mr. Grauman says ACOs that provide practices with support — such as information technology and access to case managers — to better manage patients and those that are able to reimburse providers for the extra time and effort involved in managing patients are best positioned to retain providers.
"What's important to a typical PCP is to retain a significant amount of clinical autonomy. If an ACO is aimed at better managing utilization and cost, the PCP will want to see that this doesn't negatively impact the way he or she runs his or her practice or the patient."
Learn more about DGA Partners.