ACO - FAQs for Patients
How We Got Here
Health care is too expensive. The rising cost of that care threatens state and local budgets, adversely impacts the ability of businesses to compete and stresses family finances.
CHI Health is making a Three-Part Commitment to stabilize health care costs for employers and families. As part of that commitment, CHI Health is bringing the first commercial Accountable Care Organization (ACO) to the regional market. The purpose of this FAQ is to answer, in layman’s terms, the most common questions about ACO’s and how they will impact patient and their care experience.
What is an Accountable Care Organization (ACO)?
Think of an ACO as a team of hospitals and doctors who have agreed to work together to deliver great care and to make that care more affordable. The members of the team are selected based on their ability to deliver high quality care; they must agree to participate in efforts to measure and report on how well they perform and to be accountable to each other to improve cost, quality and the patient experience. As an incentive if cost and quality performance meets or exceeds agreed upon targets or improves, the team members can earn additional compensation.
What is the Difference Between an ACO and a HMO?
Many of remember the Health Maintenance Organizations (HMO) of the 1990s. We don’t remember them fondly, mostly because it felt like their job was to reduce cost by preventing people from getting care and limiting their ability to go out of network for service.
There are very important differences between an HMO and an ACO. With an ACO you can get care out of network – without asking anyone’s permission. The ACO is organized and the physicians often have incentives to make sure patients get the care they need. The basic premise is that the ACO will focus on connecting patients to the right care at the right time and place, thereby keeping them healthier and reducing costs.
Why is CHI Health Bringing a Commercial ACO to the Market?
We have made a ten year investment to deliver on a three-part commitment to make health care quality and cost transparent so that people can make informed decisions about care. We have promised to be accountable for improving outcomes and cost and to report on our progress to the public. And, we are backing up those efforts with a commitment to affordability made possible by the success of our efforts to reduce the total cost of care. This ACO arrangement is one of the means by which CHI Health can accomplish those goals. Our regional network of hospitals and doctors is collecting performance data, and already has made great strides to reducing avoidable emergency room visits and hospital admissions duplicative tests, and readmissions that drive up cost and premiums.
How Will an ACO Change Access to Doctors?
An ACO should not change access to people’s trusted doctors. So long as your personal physician shares a commitment and willingness to measure and improve quality and reduce cost and is willing to be accountable to his or her peers for that improvement, you will see no change in your care experience. And, even if your doctor chooses not to participate in the ACO, you can still go out-of-network to continue to see that provider without having to first ask permission to do so. We think, though, that most people will be attracted to the idea of having their doctor work as part of a team that is incentivized to improve outcomes and cost, and to share best practice ideas with their peers. That is one reason we are so excited about our ACO. Weren’t Hospitals and Doctors Already Incented to Improve Performance? Not necessarily. While almost all clinical providers truly want to deliver the best care for their patients, the traditional fee for service plan that you might purchase from a Blue Cross of Nebraska, for example, did not include any “carrots or sticks” for doctors to work together and be accountable for improving care. Mostly, hospitals and doctors were paid based on how many billable events they performed – regardless of whether that care delivered value to the patient. The industry is moving quickly away from that model. The Aetna Whole Health - CHI Health Accountable Care Network is part of that movement that CHI Health has been leading for almost ten years.
Are ACOs Controlled by Insurance Companies?
No. While insurers can play a role in an ACO, they are not in charge of medical care or decision-making. ACOs can include hospitals, specialists, post-acute providers and even private companies that want to organize better care for patients. The only must-have in an ACO is primary care physicians, who serve as the linchpin of the program. More than half of the current Medicare ACOs are actually run by physicians and don’t include a hospital partner.
So, What Could Go Wrong?
One of the most important purposes of an ACO is helping people stay well and out of the emergency room and hospital. Today, of course, hospital admissions and ED visits are an important part of how providers get paid. So one vulnerability is that the ACO members fail to truly invest in the programs and experts needed to keep people healthy and to slow the progression of their chronic disease.
Fortunately, CHI Health’s founding ministry and mission is about building healthy communities. We have made a very public three-part commitment to make great care affordable. We know that will mean fewer patients in our hospital beds and (hopefully) emergency departments. But we also know that is what people want, and that in the long run as CHI Health and others take full accountability for medical outcomes and financial risk, our ACO will have been an important step toward fulfilling our mission and business goals.