Joel Mekler | Medicare Moments: What is an Accountable Care Organization and what does it mean for me? | Lifestyles

Andara Puchino

The other day as I was sitting in the waiting room of my primary care physician’s office, I noticed a one-page letter directed to all patients.

I must admit I normally don’t pay much attention to these notices because it’s usually something about new office procedures regarding COVID protocols. However, this notice was meant to inform patients of this primary care practice that they had recently joined an Accountable Care Organization (ACO).

Accountable Care Organizations (ACOs) are groups of doctors, hospitals and other health care professionals who work together to provide you with better patient care. They do this by coordinating their efforts and sharing information with one another, rather than working separately. The Centers for Medicare and Medicaid Services (CMS) projects that over 11 million fee-for-service or traditional Medicare beneficiaries will be served by an ACO this year. As of January 1, 2022 there were 483 ACOs most of which are large-scale hospital systems; however, primary care physicians serve as the linchpin of the program. It is important to know that although ACOs are networks of health care professionals, they are not Medicare Advantage Plans, HMOs, or Medigaps. In fact, if you are enrolled in a Medicare Advantage Plan, you cannot join an ACO.

•Why are providers joining ACOs? Providers join ACOs because by reducing unneeded or duplicate services, they can increase their reimbursements through Medicare. Simply put, health care providers who participate in an ACO are paid more if they can demonstrate better patient outcomes and lower costs. To be eligible to share in the savings ACOs must meet quality standards. Part of the grading relies on patient experience surveys.

•Who’s in charge — hospitals, doctors, or insurers? ACOs can include hospitals, specialists, primary care physicians and post-acute providers. Insurers can also play a role in ACOs though they aren’t in charge of medical care. Some regions of the country already have large multi-specialty physician groups that became ACOs on their own by networking with neighboring hospitals. In other regions of the country, large hospital systems are scrambling to buy up physician practices with the goal of becoming ACOs that directly employ the majority of their providers. Some of the largest health insurers in the country, including Humana, UnitedHealth and Aetna, have formed their own ACOs for the private market

What does it mean to “align” with an ACO? When your provider joins an ACO, you will be notified. It may be a letter, a notice posted in the provider’s office, or some form of in-person communication from your provider. If you continue to see that provider for a majority of your health care needs, you may receive notification asking you to align with or be assigned to the provider’s ACO. You should know that assignment is voluntary, used mainly to calculate shared savings. You can still see your provider, even if you do not want to voluntarily align with their ACO. Also, even after aligning or being assigned, you are still free to go to any provider, even those outside the ACO. You are not required to receive care from your ACO. However, you can only be assigned to one ACO.

•How is getting care at an ACO different from what I’m used to? You may not notice any changes. Although your physician may refer you to a doctor within the ACO, you still have the ability to see the doctor of your choice. All of your providers (e.g., physicians, nurses, social workers) at an ACO work together to avoid duplication of care and to improve your health care experience. This means, for instance, that you should not have to repeat the same tests or fill out the same form multiple times. Instead, your providers communicate with one another, sharing medical information and discussing treatment plans. They also receive health care information about you from Medicare to help give you high-quality care.

•What if I don’t want Medicare to share my information with an ACO? You always have the right to request that Medicare not share your health and coverage information with an ACO. To do so, call 1-800-MEDICARE. Also note, that if you ever received or are receiving treatment for drug or alcohol abuse, Medicare will not share your information related to this care with an ACO, unless you give them written consent.

•What other rights do I have at an ACO? Getting care at an ACO does not change your rights, including freedom to choose your Medicare provider, ability to get a second opinion, right to file a complaint, or your appeal rights.

•Will being an ACO member increase my health care costs? There are no additional costs for participating in an ACO. Again, ACOs are not health insurance plans. ACO providers use a value-based model to get paid. They are rewarded for keeping you healthy and out of the hospital. This is different from the fee-for-service model (Original Medicare), in which providers are paid based on the volume of care they provide.

•Are there any downsides to joining an ACO? Critics of the ACOs believe there is no evidence that people have better health outcomes under this model. In fact, they argue that “care coordination” is often a euphemism for delayed care, less care, and referrals to low-cost providers, none of which is by definition a good thing. Primary care doctors will simply have greater financial incentives to minimize costs. Many health care economists fear that the race to form ACOs could have another significant downside: hospital mergers and provider consolidation. As hospitals position themselves to become integrated systems, many are joining forces and purchasing physician practices, leaving fewer independent hospitals and doctors. Greater market share gives these health systems more leverage in negotiations with insurers, which can drive up health costs and limit patient choice.

Where can I find more information about ACOs? For more information about ACOs:

•Visit www.CMS.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/.

•Visit https://www.medicare.gov/manage-your-health/coordinating-your-care/accountable-care-organizations.

•Talk to your doctor.

•Call 1-800-MEDICARE.

(Joel Mekler is a certified senior adviser. Send him your Medicare questions at [email protected])

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