Selecting a primary care provider (PCP) is an important first step in supporting your personal health and longevity. In today’s healthcare system, your PCP is the gatekeeper for most of your medical needs – wellness visits, routine screenings, as well as non-emergency illnesses – that cough or sore throat you can’t seem to shake. Your PCP is your “go-to” for health questions and concerns at every stage of life’s journey.
When searching for a primary care physician who can support your needs, does it matter whether your PCP is part of an accountable care organization (ACO)?
Absolutely.
When your physician is part of an ACO, it benefits the patient, the provider and the healthcare system.
According to the Centers for Medicare and Medicaid Services, “ACOs are designed to put patients at the center of their care and help them navigate a complex health system.” When you select a provider who’s part of an ACO, you may benefit from:
- Additional health and resources for managing chronic disease
- Improved coordination of care between physicians, specialists and other care team members
- Greater preventative health services to support your well-being and longevity
- Additional recovery services after a surgery or hospital stay
- Services tailored to your convenience, such as home care or telehealth visits
Improved services matter. However, the trusted relationships PCPs form with their patients can also prove essential for improving population health. Studies show that an increase of just one PCP per 10,000 people can generate 11% fewer emergency department visits, 5.5% fewer hospital visits and 7% fewer surgeries, according to the Primary Care Development Corporation.
In today’s age of big data, many ACOs provide their network physicians with a dashboard able to highlight care gaps among their patient population – a difficult task for PCPs to monitor on their own. The dashboard can identify patients who aren’t coming into the practice for regular check-ups, making it easier for the clinic to follow up regarding wellness appointments or important screenings. For example, patients with diabetes need their hemoglobin A1C measured every six months, at minimum. If a patient hasn’t received a lab test within this timeframe, the dashboard can alert the physician. Utilizing data to assist with preventative care and chronic disease management reduces costs because these patients are less likely to need hospitalization.
Another benefit of the ACO relationship is assistance with insurers. If PCPs have challenges with claims processing, the ACO can help resolve issues. When the Centers for Medicare and Medicaid Services (CMS) changes rules or regulations, the ACO has teams that help educate and support the providers in their network.
“ACOs help reduce the administrative burden on PCPs and let physicians do what they are meant to do, which is take care of patients,” says Kristen Woods, MD, SWHR Chief Network and Physician Experience Officer.
With a large population of patients and providers in the network, an ACO can negotiate contracts with payors which advance population health and value-based care rather than a more costly fee-for-service model. Payors build in incentives to reward physicians who provide high-quality, preventive care that keeps patients out of the hospital and reduces unnecessary interventions. ACOs work with payors on these incentives which are then passed to physicians.
“If a single provider tries to negotiate with a payor on contract terms, they’re less able to show the same level of impact individually as compared to the collective population impact of a network of physicians working in a coordinated fashion with a health system,” says Dr. Woods. “That’s how we become stronger together as an ACO, so PCPs have incentives to focus on producing better outcomes for their patient populations.”
In addition, the ACO helps advance health equity by addressing social determinants of health a PCP may not have the resources to tackle. For example, the Care Transformation and Innovation (CTI) team is a shared resource at Southwestern Health Resources and provide wraparound services for patient members who are socially and economically disadvantaged. Services might include connecting a patient with transportation to reach doctor appointments, grocery stores and other critical services. A Registered Dietitian may provide one-on-one support and education to help patient members learn to manage chronic conditions through better nutrition. Community Social Workers on the care team can help a patient sign up for Medicaid and connect to community resources that help combat loneliness and depression.
These are only some of the ways the CTI team holistically addresses social and economic factors.
When a PCP needs a specialist referral, the ACO has a referral platform to help match a patient with top-tier specialists within his or her community. “The tiering mechanism supports PCPs so they know patients will receive the best outcomes,” Dr. Woods says. SWHR partners with Texas Health Resources to offer meet-and-greets between PCPs and specialists to strengthen those relationships.
“Nationally, our healthcare system is on a journey of transformation, and the ACO supports that transformation to drive improved quality and to advocate for patients – whether at the payor level or government level,” explains Dr. Woods. “Patients are at the center of what we do and deserve access to better healthcare.”
The statements contained in this article are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this article.
