Top 10 Clinical Integration, ACO Physician Questions

Eric Nielsen, MD, and James Smith, MBA, FACHE, The Camden Group, for HealthLeaders Media , June 9, 2011

3. Are we emphasizing finances over quality? Achieving quality benchmarks is required in order to "earn" all of the savings generated in the proposed ACO regulations. The assumption, supported by evidence, is that quality is cost-effective. The development of care plans to address gaps in care, handoffs from one setting to the next, as well as readmissions, hospital-acquired infections, and duplication of tests, will not only address quality but also efficiency.

In addition to evidence-based preventive care, the underlying strategy is to identify the disease conditions driving increasing costs and the patients with those diseases and then target more resources toward those conditions and patients to improve overall quality and efficiency.

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4. Why would my patients want this?  Given the complexity of today's healthcare delivery system, many patients would be well served by efforts to improve coordination of care. Some patients may find a traditional fee-for-service ("FFS") PCP office or a concierge practice adequate, but patients with chronic conditions will likely prefer a Patient Centered Medical Home ("PCMH"), with specialized care teams backed by a CI program or ACO to address their acute and chronic needs. In addition, as higher deductibles and coinsurance predominate, patients will want to know how valuable the care they receive is to their individual conditions and general well-being. Organizations willing to provide these answers and help them find the most value will be preferred by patients.

5. What if I want to refer my patients to a specialist not in the CI/ACO? Physicians will necessarily refer out of network for services not available within the network or if they determine that it is medically appropriate to do so. Under the CMS proposed regulations, beneficiary choice is protected; patients are not restricted to any group of providers or any ACO. However, the intent of a CI program or an ACO is to provide efficient, quality care by sharing data and coordinating care across the provider network.

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