Following the recent release of the draft rules on Medicare accountable care organizations, facilities across the country are considering their position in the ACO model. George Whetsell and John T. Kelly, MD, managing directors of Huron Healthcare, discuss how ACOs may impact ambulatory surgery centers — and what facilities can do to prepare.
1. ASCs could participate in Medicare ACOs without joining ACOs. According to Mr. Whetsell, the recently released draft rules on accountable care organizations do not specifically discuss ASC involvement in ACOs. "There's not a hint that an ASC or a network of ASCs could in and of itself become an ACO," he says. "They don't say they can't, but it's not one of the examples of the types of organizations they see coming together to form an ACO." Instead, he expects that many ASCs — many of which exist in the for-profit sector — will act as suppliers or vendors to ACOs by establishing infrastructures to manage and coordinate care of Medicare beneficiaries. ACO-participating hospitals may develop a mechanism to determine which ASCs should deliver care when ambulatory surgery is the most appropriate choice for a patient. Because of the emphasis on primary care physicians coordinating patient care within an ACO, ASCs may have to strengthen their relationships with primary care providers to ensure they are considered as an ACO vendor when care is needed.
Mr. Whetsell adds that reporting requirements for non-participating providers are still unclear at this point. "If you're a provider that is part of an ACO, you're going to have to comply with data reporting requirements. If you're a provider that's not part of an ACO, that part gets a little bit fuzzy," he says. "If you're an ASC and you're taking care of Medicare patients, you're going to get paid by Medicare, and you don't have any real reporting requirements unless you sign an agreement with an ACO." According to Dr. Kelly, CMS projects that over the three-year project, there will be around 75-150 ACOs caring for 1.5-4 million Medicare patients throughout the country. This relatively small number of organizations means that most ASCs — and most other providers — will not be involved in ACOs.
2. Commercial ACOs could decrease volume for non-participating providers. Dr. Kelly says as Medicare moves toward ACO implementation, many commercial carriers are beginning to form insurance products modeled on the ACO concept of increasing quality and reducing cost. If Medicare ACOs do not necessarily have a place for ASCs, commercial models may present an opportunity. "There will be an effort to try to shift services to high-quality, cost-efficient providers," he says. Because commercial ACOs do not have to follow the complicated rules put in place by Medicare, the models could look different for different insurers. Mr. Whetsell expects that some commercial ACOs could offer a package or arrangement where patients receive a better deal if they use an ACO member for care. "That would have an impact on ASCs," he says. "If [commercial] ACOs become a little restrictive, if you're not part of the ACO, you wouldn't be at the front of the list for services."
Because of this expected pressure on volume, ASCs should collect information on their financial and clinical performance to present to insurers. "That information will be used by the insurers to decide which providers to include in their network and what kinds of discounts or other incentives to provide," Dr. Kelly says. "We're seeing value-based contracting with the largest insurers, regional insurers and even some local insurers."
3. Low complication rates will be essential. For an ASC to profit from the introduction of ACOs, it will need to prove low complication rates and high quality service, Mr. Whetsell says. "ASCs need to look at preventable incidents that happen in ASCs and that have big costs associated with them," he says. "If you have a problem where the patient comes out of the ASC, develops infections or other complications and has to get admitted to the hospital, ACOs aren't going to want to have anything to do with you." He says ASCs must be able to produce data that shows they are efficient with almost non-existent complication and infection rates. Patient satisfaction may play a role as well: On the CMS side, ACOs will be expected to measure, monitor and report on clinical indicators around clinical performance and patient satisfaction. "If you're an ASC with a track record of high quality and a customer-friendly set-up, that puts you in a good position," Mr. Whetsell says.
4. Freestanding ASCs could be in a stronger position than they might think. As hospitals and health systems move toward ACO participation, many standalone ASCs are worried that ACOs will exclude them from a more primary care or hospital-focused model of care. But Dr. Kelly believes that many hospital-owned ASCs are far from fully integrated, giving freestanding ASCs time to develop relationships with primary care providers and hospitals that do not include ownership. In order to compete with hospital-owned ASCs in terms of patient management, freestanding facilities should work on developing systems for communicating information with patients, clinicians and other facilities. "If a patient is referred into an ASC, there needs to be effective ways of communicating clinical information to make the care process more efficient," Dr. Kelly says. "ASCs must develop reliable communication methods to assure that they are able to provide timely information to patients and clinicians before and after surgery.” "
He says this need for communication and coordination underlines the strategic importance of EMRs. ASCs that have delayed implementing electronic medical records should think seriously about the transition. As communication between facilities becomes more electronic, ASCs with sophisticated IT systems will be in the best position to manage patients, communicate with other clinicians and participate in ACOs.
Learn more about Huron Healthcare.
Read more about the relationship between ACOs and ASCs:
-Involving Anesthesia in Transparency and ACOs: Q&A With Somnia Chief Medical Officer Dr. Rob Goldstein
-50 Things to Know About the Proposed ACO Regulations
-10 Key Points in Newly Released Proposed Rules on ACOs
1. ASCs could participate in Medicare ACOs without joining ACOs. According to Mr. Whetsell, the recently released draft rules on accountable care organizations do not specifically discuss ASC involvement in ACOs. "There's not a hint that an ASC or a network of ASCs could in and of itself become an ACO," he says. "They don't say they can't, but it's not one of the examples of the types of organizations they see coming together to form an ACO." Instead, he expects that many ASCs — many of which exist in the for-profit sector — will act as suppliers or vendors to ACOs by establishing infrastructures to manage and coordinate care of Medicare beneficiaries. ACO-participating hospitals may develop a mechanism to determine which ASCs should deliver care when ambulatory surgery is the most appropriate choice for a patient. Because of the emphasis on primary care physicians coordinating patient care within an ACO, ASCs may have to strengthen their relationships with primary care providers to ensure they are considered as an ACO vendor when care is needed.
Mr. Whetsell adds that reporting requirements for non-participating providers are still unclear at this point. "If you're a provider that is part of an ACO, you're going to have to comply with data reporting requirements. If you're a provider that's not part of an ACO, that part gets a little bit fuzzy," he says. "If you're an ASC and you're taking care of Medicare patients, you're going to get paid by Medicare, and you don't have any real reporting requirements unless you sign an agreement with an ACO." According to Dr. Kelly, CMS projects that over the three-year project, there will be around 75-150 ACOs caring for 1.5-4 million Medicare patients throughout the country. This relatively small number of organizations means that most ASCs — and most other providers — will not be involved in ACOs.
2. Commercial ACOs could decrease volume for non-participating providers. Dr. Kelly says as Medicare moves toward ACO implementation, many commercial carriers are beginning to form insurance products modeled on the ACO concept of increasing quality and reducing cost. If Medicare ACOs do not necessarily have a place for ASCs, commercial models may present an opportunity. "There will be an effort to try to shift services to high-quality, cost-efficient providers," he says. Because commercial ACOs do not have to follow the complicated rules put in place by Medicare, the models could look different for different insurers. Mr. Whetsell expects that some commercial ACOs could offer a package or arrangement where patients receive a better deal if they use an ACO member for care. "That would have an impact on ASCs," he says. "If [commercial] ACOs become a little restrictive, if you're not part of the ACO, you wouldn't be at the front of the list for services."
Because of this expected pressure on volume, ASCs should collect information on their financial and clinical performance to present to insurers. "That information will be used by the insurers to decide which providers to include in their network and what kinds of discounts or other incentives to provide," Dr. Kelly says. "We're seeing value-based contracting with the largest insurers, regional insurers and even some local insurers."
3. Low complication rates will be essential. For an ASC to profit from the introduction of ACOs, it will need to prove low complication rates and high quality service, Mr. Whetsell says. "ASCs need to look at preventable incidents that happen in ASCs and that have big costs associated with them," he says. "If you have a problem where the patient comes out of the ASC, develops infections or other complications and has to get admitted to the hospital, ACOs aren't going to want to have anything to do with you." He says ASCs must be able to produce data that shows they are efficient with almost non-existent complication and infection rates. Patient satisfaction may play a role as well: On the CMS side, ACOs will be expected to measure, monitor and report on clinical indicators around clinical performance and patient satisfaction. "If you're an ASC with a track record of high quality and a customer-friendly set-up, that puts you in a good position," Mr. Whetsell says.
4. Freestanding ASCs could be in a stronger position than they might think. As hospitals and health systems move toward ACO participation, many standalone ASCs are worried that ACOs will exclude them from a more primary care or hospital-focused model of care. But Dr. Kelly believes that many hospital-owned ASCs are far from fully integrated, giving freestanding ASCs time to develop relationships with primary care providers and hospitals that do not include ownership. In order to compete with hospital-owned ASCs in terms of patient management, freestanding facilities should work on developing systems for communicating information with patients, clinicians and other facilities. "If a patient is referred into an ASC, there needs to be effective ways of communicating clinical information to make the care process more efficient," Dr. Kelly says. "ASCs must develop reliable communication methods to assure that they are able to provide timely information to patients and clinicians before and after surgery.” "
He says this need for communication and coordination underlines the strategic importance of EMRs. ASCs that have delayed implementing electronic medical records should think seriously about the transition. As communication between facilities becomes more electronic, ASCs with sophisticated IT systems will be in the best position to manage patients, communicate with other clinicians and participate in ACOs.
Learn more about Huron Healthcare.
Read more about the relationship between ACOs and ASCs:
-Involving Anesthesia in Transparency and ACOs: Q&A With Somnia Chief Medical Officer Dr. Rob Goldstein
-50 Things to Know About the Proposed ACO Regulations
-10 Key Points in Newly Released Proposed Rules on ACOs