What GIs Need to Know about Accountable Care Organizations

Beginning in 2012, physicians will be encouraged to join accountable care organizations (ACOs) through which they would be eligible for enhanced payment incentives for Medicare patients based on quality and efficiency improvement.

It is essential that GIs keep track of this issue since ACOs have the potential to shape the future health-care system.

AGA experts reviewed the final ACO rule released by CMS and offer important insights about the implications for specialists. We are pleased that CMS considered our comments to the proposed rule and included many of our recommendations in the final rule. Compare CMS’ changes to the ACO rule in response to AGA’s comments.

ACO Basics

Under the Medicare Shared Savings Program (MSSP), ACOs are required to have primary care physicians caring for at least 5,000 Medicare beneficiaries and have the ability to report data on cost, quality and overall patient care experience. Participating groups must agree to enroll for at least three years and demonstrate the legal structure that permits them to receive payments for shared saving from CMS and distribute a portion of those payments to the groups of providers. The shared savings would be generated when the group provides care to beneficiaries for less than a Medicare benchmark cost, while also meeting criteria for patient service and quality of care.

The goal of ACOs is to provide coordinated and more efficient patient care than is currently being provided. Members of an ACO work together on shared savings, which distinguishes it from health maintenance organizations, or HMOs.

Who Comprises an ACO?

The focus of the MSSP is on the role of primary care physicians in providing care to Medicare beneficiaries. However, specialists can participate in the MSSP as either an owner, an ACO CEO, an ACO participant, a member of the ACO governing body, a senior level medical director, or part of the physician-directed quality assurance and improvement program. Read more about the role of specialists under an ACO.

Outside of the MSSP, in the private sector, a common misconception is that ACOs need to include hospitals. But they don’t. ACOs are not provider networks, therefore, group practices can perform as an ACO. Every region is different and will have different needs for clinical integration, either horizontal or vertical.

What does all of this mean for you and your practice? Which ACO structure will work best for you? Will an ACO work for you in your region?


AGA Resources

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Listen to a podcast discussion between two GI thought leaders who are involved in ACOs in their areas. Featuring: Lawrence R. Kosinski, MD, MBA, AGAF, FACG, managing partner, Illinois Gastroenterology Group, and John Garrett, MD, past president and current Board Member, Asheville Gastroenterology Associates, about ACOs and what you need to know to help manage and position your practices wisely.

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Recommended Reading

The following resources have been reviewed and are recommended by AGA experts.

Government Resources
Other Resources

Updated Nov. 4, 2011