Top 10 Clinical Integration, ACO Physician Questions

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

6. Do I have to join just one ACO? The CMS proposed regulations limit PCPs to participate in only one ACO. Some commercial plans may not have this restriction, but many are likely to follow the CMS roadmap. There is no such restriction for specialists. There are also no proposed regulatory restrictions to PCPs being on the medical staffs of multiple hospitals in different ACOs, nor is there any requirement for a physician to be part of an ACO. Participation in ACOs will be optional for physicians, but most will join in order to be part of the contracts ACOs will enter into with CMS and other insurers.

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7. Is it all about the PCPs? Even without the "gatekeeper" function of PCPs (i.e., expectation to limit access to care under the HMO model of the past), PCPs will be expected to provide basic outpatient services and to coordinate care for the patients that choose to see them and across the continuum, which may include various specialists, care managers, home care, pharmacies, rehab, and long term care facilities. PCPs are also central to the patient-centered medical home ("PCMH") concept, with offices run by PCPs and their teams to provide continuity and to focus on healthcare and prevention for their members. PCMH is a proven method to align health plans and providers to create greater value than what is found in the fragmented fee for service system.

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