As accountable care organizations (ACO) continue to grow in popularity, payers are establishing new relationships with providers to help reduce healthcare costs and enhance quality care. But how can payers be sure to choose the right provider partner?
"You'd like for the program to work, to actually bend the cost curve," Mark Lutes, a healthcare attorney with Epstein Becker Green, told FierceHealthPayer. "Because you're going to invest a fair amount of time and management to put the ACO into place, you'd like to do it in a place that has a reasonable opportunity of succeeding."
One of the first steps payers can take to ensuring a successful ACO is to partner with the right providers. Lutes recommends payers look for providers that can follow through and implement the agreed-upon care management pathways. Often, those providers are the fully integrated medical groups or hospital systems like Aurora Health Care, which partnered with Aetna to form an ACO this past July.
Integrated providers bring an added advantage to the ACO table--the ability to offer non-physician resources to address gaps in care, for example, nurse practitioners who can improve hospital discharge transitions or social workers who can manage a certain population of chronically ill patients. "These are classic drivers of high cost where there's real opportunity to affect savings and utilization patterns," Lutes said.
Leadership is another key factor affecting the selection of providers for ACOs. Providers' leaders should be able to "efficiently interact" with payers and have the "tools within the group to effect change," Lutes said. "If the provider organization is a loosely constructed group like a loose IPA where the level of collaboration amongst the providers is limited, the opportunity for success to change day-to-day provider behavior is quite limited."
Aetna, which already has established several ACOs throughout the country, looks to partner with healthcare organizations "that want to change the healthcare delivery model and/or are committed to moving from a volume-based system to a quality-based system," Bill Berenson, president of Aetna's Midwestern markets, told FierceHealthPayer.
It decided to partner with Aurora in a new ACO wrapped around a narrow network health plan because the 10th largest provider group in the country "has had very positive results in bending the cost curve," he said, adding that "Aetna and Aurora have parallel objectives in terms of quality, outcomes and patient experience."
A bonus to joining forces with Aurora is its breadth and size, with a network of 1,500 physicians, 15 hospitals and 160 clinics in Wisconsin and Illinois, to help Aetna strengthen its market position. Dovetailing Aurora's market success with Aetna's strong brand recognition has a lot of the ingredients for an effective ACO partnership.
Essentially, deciding which providers to affiliate with, Lutes said, boils down to payers ensuring they can get the attention of the providers to make rooms in their schedules for certain patients to be seen and that nurse practitioners, social workers and others follow-up with those patients to verify adherence to the ACO program, Lutes said.
"It's an assessment of the structure and functioning of the medical group that is supposed to support the care paths that's central. It's whether providers have the structure, functioning, clinical composition, ability to see enough of your patients to make the interaction cost effective," he added. - Dina (@HealthPayer)