ACOs and Independent Radiologists Presented by Wendy WilkinsRussell

ACOs and Independent Radiologists Presented by Wendy Wilkins-Russell of Washington Managed Imaging 1

ACOs – A Fact of Life for Independent Radiologists • ACOs will be looking to contract with independent radiology groups. In fact, they are already doing so. • Independent radiologists should seek out information about ACO planning in their communities and make efforts to be involved in the process, BUT • We have a cautionary tale. Past history of capitation in Washington State demands vigilance in seeking out ACO partners. 2

Considerations for Finding a Good ACO Partner • • Legal Structure Administrative Structure Financial Structure Clinical Structure NOTE: None of the following lists is intended to be all inclusive. There are many additional considerations when choosing to contract with an ACO. 3

ACO Legal Structure Considerations • The ACO must address multiple legal issues (some of which are listed below) and create safe harbors where possible: – Antitrust – The Federal Trade Commission and the US Department of Justice will ensure ACOs do not facilitate unlawful agreements between competitors that result in price fixing or inappropriate market allocation. 4

ACO Legal Structure Considerations (cont. ) • The FTC is heavily regulating how independent physicians participate in an ACO and how many ACOs a physician may participate in. John Wiegund of the FTC is an excellent resource on this issue. • An ACO’s clinical integration is key to meeting the antitrust requirements of the FTC and the US Dept. of Justice. An ACO’s financial integration is another means. Financial integration may be achieved through captitation, predetermined Fee for Service rates, and/or physician incentives/bonuses for meeting predetermined cost containment goals. 5

ACO Legal Structure Considerations (cont. ) – Stark Law (A provider cannot refer to an entity with which they have a financial relationship). – Anti-Kickback Statute (No remuneration can be made to induce referrals) – Physician Incentive Plan Law (Hospital cannot pay a physician to induce reduced care) NOTE: Each ACO should utilize the services of an attorney with subject matter expertise while developing their structure to ensure they are not violating any of the above laws. 6

ACO Administrative Structure Considerations • The right leadership structure – Full time physician administrators and financial and administrative leaders experienced in capitation and shared risk arrangements. • ACO is first piloting within a given population, such as Medicare, to develop a successful track record. 7

ACO Administrative Considerations (cont. ) • Secure, HIPAA compliant, and exceptionally maintained IT Infrastructure is absolutely crucial: – Integrated technological platforms across the continuum of care. – Real-time information that is accurate and relevant. – All ACO providers, whether employed or independent, should report on the same platform. 8

ACO Administrative Considerations (cont. ) – ACO must clearly identify and report on – • Quality measures • Cost measures • Provider Performance • HEDIS • Pay for Performance metrics 9

ACO Administrative Structure Considerations (cont. ) – An excellent provider network to ensure all care can be provided within the ACO. Note that the ACO model financially penalizes the physician team if a patient member receives care out-ofnetwork rather than financially penalizing the patient member. – Ensure that the ACO leadership has expert level understanding of the patient membership assignment and eligibility rules utilized by the government agency/payer. 10

ACO Financial Structure Considerations • A clear and comprehensive, written financial model for financial integration that meets all legal requirements. • Ability for independent radiologist to contract under a fee for service payment model with an optional pay for performance incentive, until the ACO has proven its ability to manage risk and to grow its membership population to an adequate risk threshold. • An adequate member population threshold across which to spread risk (if ACO is capitated). Based on prior risk bearing in WA State, the 5 K patient member threshold cited by the regulations is not adequate. 11

ACO Financial Structure Considerations (cont. ) • If accepting risk, ACO has partnered with an excellent reinsurer and has assigned experienced staff to submit claims to and collect from the reinsurer. • Ensure that ACO leadership has expert level knowledge of the benefits structure(s) covering the patient membership. • Ensure that ACO has not accepted risk for items that should be maintained by the payer. 12

ACO Clinical Structure Considerations • A clear and comprehensive, written financial model for clinical integration that meets all legal requirements. • Exceptional “real time” Health Information Technology that links all providers within the ACO and provides reporting internal to the ACO and external to the payers on all metrics – cost, quality, physician performance, etc. • Continuous QA processes focused on finding and reviewing gaps that result in inefficient care. 13

ACO Clinical Structure Considerations (cont. ) • Exceptional evidence-based and integrated utilization management that includes: – Discharge planning that begins at admission, incorporating care transition planning and PCP follow up after discharge. – Support systems for high risk patient members. – Technology utilized to notify patient members of routine and recommended vaccines, annual exams, periodic screenings/imaging/labs. – Education on and adherence to best practices. 14

Last, but not least… • Few organizations are currently prepared for the extensive medical functions required for a successful ACO. • The train has left the station and ACOs are a fact of life, so be involved, but be cautious. • Ask a lot of questions and beware the “experts. ” Any questions? 15