What doctors should ask insurers before joining ACOs or medical homes

Before doctors commit to commercial insurers asking them to join an accountable care organization or patient-centered medical home program, they need answers to some key questions. These can be summed up by one consultant: “What’s in it for my patients, and what’s in it for me?”

John Redding, MD, a manager at Indianapolis-based Blue Consulting Services, and other experts aren’t recommending that doctors address insurers quite that bluntly. Instead, they say, physicians can ask other pointed questions to determine if an insurer-led ACO or medical home program is right for them and their patients.

First, consultants say, physicians need to ask about responsibilities and independence. What exactly must a practice do to participate? If a practice has to follow particular care guidelines, are the physicians comfortable with what is called for? Do they have flexibility that takes clinical judgment into account? If a program calls for patients to have same-day appointments or access to a physician or another clinician outside of usual office hours, how will that be done? If other practice redesigns are necessary, can they be accomplished?

Most programs call for some level of care coordination, and this may mean allowing an insurer to embed a case manager on site. Others provide money to practices to hire their own. Some practices may not be comfortable with an insurance company employee in the office and prefer the latter. Others may find it more onerous to hire and manage an additional staffer.

The next key questions are about money. ACOs and medical homes rely on payments based on quality metrics and savings in the cost of care. So for physicians, what bonuses are available, and what changes are required in a practice to get them? Will insurers encourage patients to go to the practice? How will that be counterbalanced by the additional money it costs to care for that population?

Will insurers pay for care management on top of fees for other medical services? How much will care management cost a practice? Can a practice earn a portion of the money saved caring for a particular patient population? What is the savings target? Is it achievable? Will there be a penalty if the amount of money spent caring for patients goes up?

“You have to get your arms around the data and understand what all the pitfalls are,” said Fred Geilfuss, an attorney and partner in the health care practice at Foley & Lardner in Milwaukee. “If there’s a downside risk, you need to understand that risk and be comfortable with it.”

Such calculations can be tricky, and the insurer may provide several projections. Consultants recommend using the more conservative numbers when making a decision.

“You want to be cautious and do more analysis rather than less,” said Phil Dalton, MPH, president and CEO of MDS Consulting in Torrance, Calif., and Costa Mesa, Calif.

Other questions should focus on exactly what the insurer will do to meet the goals of the ACO or medical home. What kind of data will they provide, and when will they provide that information? Will the data be sufficient and timely enough for a practice to make changes, if appropriate? Late or incomplete data are a common complaint when it comes to various pay-for-performance programs.

What will an insurer tell patient members about the program? Will it encourage patients to go to participating practices? How will the insurer support a practice that decides to participate? What kind of charge, if any, will there be for those services?

The next issue to consider is how a practice’s performance will be assessed. For instance, some programs require practices to reduce the cost of care that their physicians provide. Others tally the total cost for caring for a population, including money spent on hospital and emergency department care, on which an outpatient primary care practice may have little influence.

“If the payment model is based on you being able to control costs that you would have a great deal of difficulty controlling, you should be wary,” said Harold Miller, executive director of the Center for Healthcare Quality & Payment Reform in Pittsburgh.

Practices also need to know how outliers — those with unexpected health crises and accompanying health costs — will be taken into account. And they need to know how patients are attributed to the practice — meaning, who is considered the doctor with the most control over a patient’s care and costs.

“You need to know who is being attributed to the practice, not just the patients the physician thinks are assigned to them,” Miller said. “There can be serious disconnect in that area.”

With many aspects of these programs non-negotiable, consultants say it’s important that doctors get answers to their questions. Otherwise, they said, physicians should think twice about signing.