Why Urgent Care Centers are Aligning with Accountable Care Organizations
Accountable Care Organizations (ACOs) are a part of the healthcare industry that has gained immense popularity over the last few years. Initially created to deliver high quality, coordinated care to Medicare patients, physicians, commercial payors and other health entities have started to create their own ACOs.
“An ACO is a grouping of healthcare related companies, individuals or entities that attempt to provide coordinated care of some type at a high degree of competence, but for an effective price,” Mike Segal, partner at Broad and Cassel Law Firm, says.
There are several different types of accountable care organizations that exist. There are physician-led and commercial payor ACOs, and then there is the more commonly known governmental payor ACO.
“The one that people talk about the most is the ACO that was created by ObamaCare: the Medicare Shared Savings Plan (MSSP),” Segal says.
“It was under the Affordable Care Act that an ACO became defined in the context of an MSSP,” Lisa Han, partner at Jones Day Global Law Firm, says. “The program is trying to reduce the cost of healthcare but improve the quality of care of the population.”
“The goal of the MSSP is to meet the triple aim: provide a better quality of care, at a lower cost, to a specific population,” Segal says.
How does an MSSP work? Segal explains:
“When Medicare costs go down, the government shares part of that benefit. Let’s say that the overall cost of care for the group for all of their patients in the previous year was $20 million. And this year, they were able to reduce the cost to $18 million because they kept people out of the emergency room, provided preventative services and patients didn’t get sick as much. Half of the $2 million that was saved will be given to the ACO and shared. Services were provided at a lower cost, and not as many services were needed either. Medicare ACOs must have a minimum of 5,000 beneficiaries, or lives, but they need to have that many people. There’s always going to be an outlier that didn’t have a heart attack the year before, but had one this year, so their cost of care is going to go up. Having such a large number of beneficiaries help with the outliers.”
Different types of ACOs will have different rules. Medicare ACOs have very specific federal regulations that they have to abide by, whereas commercial ACOs may only have some rules that vary by state.
“There are some waivers and some exceptions you can get to the anti-kickback and stark rules when you form an MSSP/Medicare ACO, but there are no such exceptions for commercial ACOs,” Segal says. “Any time you have a relationship between two healthcare organizations, you have to be careful that there’s no kickbacks, no patient brokering and no violation of the stark law.”
In addition to the creation of new ACOs, urgent care centers (UCCs), ambulatory surgery centers and other outpatient care centers are aligning with ACOs. Hymin Zucker, M.D. and former Chief Medical Officer of Palm Beach Accountable Care Organization, says that this alignment is useful, so long as it’s organized and coordinated.
“The urgent care center is one of the key tactics to reduce patients from going to the ER, as long as it acts as an extension of the primary care physician,” Zucker says.
Directing patients to an urgent care center is an effective way to drastically reduce unnecessary healthcare expenses.
“ERs are very expensive, so you wind up with urgent care centers being a less expensive substitute for the ER,” Segal says. “It all relates back to trying to reduce the cost of care, without reducing the quality of care.”
“If a patient needs to come in and see me, but I don’t have any available open appointments in my office, I could offer them nothing or just tell them to go an ER,” Zucker says. “However, if I am aligned with an urgent care center, and they agree to follow ACO protocol expectations, they can identify who their primary care physician (PCP) is, and the urgent care center can retrieve pertinent patient medical information from the PCP and transition the patient back to the PCP for follow-up.”
Zucker says that UCC-ACO alignment can really improve the quality of care that a patient receives.
“When I can refer a patient to a UCC that’s part of an ACO, then that clinic will be performing as an extension of the physician’s office, instead of just a dumping ground,” Zucker says.
The ACO and the UCC can communicate back and forth to exchange relevant patient medical information.
“By the time a patient shows up to an urgent care center, the center will already have all their information and know why the patient is there,” Zucker says. “This can help ensure the safety of a patient across all healthcare services, and reduce wasted service that an ER may incur.”
Before urgent care centers reach out to an ACO to join, Zucker says it’s important for the center to know how they can add value to the ACO.
“Some centers don’t know how to approach an ACO, and vice versa,” Zucker says. “If you know that your center is a good fit for the ACO, then you can send a letter to the executive director saying you have ‘xyz,’ and ask to talk about enhancing a relationship.”
It’s also important to know some of the risks associated with UCC-ACO alignment.
“If I send my patients to an urgent care center, but they never show up, some people will say that’s a risk,” Zucker says. “If an urgent care center doesn’t know how an ACO works, or how the rules work, then that’s also not a good thing.”
Zucker says that the biggest concern in UCC-ACO alignment will be patient safety.
“The UCC needs to make sure that they are going to take care of the ACO’s patients in a responsible way,” Zucker says.
With ACOs having similar goals of increasing the quality of care while decreasing costs, Segal says that it’s hard to peg one type of ACO as better than another.
“They’re just different,” Segal says. “One is Medicare, while commercial ACOs have different payors involved.”
However, Segal does say that more hospitals are involved with commercial ACOs, and that Medicare ACOs have the most savings potential.
“Medicare ACOs will have older patients, with higher costs of care,” Segal says. “With higher costs, there’s more potential for reducing those costs.”
There’s no limit to the number of health entities that can be a part of an ACO. In addition, an ACO can have multiple owners. Urgent care centers and other outpatient care centers can even form their own ACOs, but in order to be an MSSP ACO, they must get at least 5,000 beneficiaries.
As ACOs become more and more prominent in the healthcare industry, UCC-ACO alignment will also increase. As long as both entities don’t forget the goals to increase care quality while decreasing healthcare costs, the alignment can extremely beneficial.
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