By Norma Bowyer, O.D., Greg Caldwell, O.D., Clarke Newman, O.D., Jason Ortman, O.D., David Redman, O.D., Harvey Richman, O.D., and Richard Soden, O.D
The AOA strongly encourages optometrists to seek opportunities to participate in Accountable Care Organizations (ACOs). Demonstrate that you can save time and money in the care of patients. In Medicare, meaningfully use EHRs, report PQRS measures, and implement some of the tools and solutions provided by AOA Excel.
The ACO program is called the Medicare Shared Savings Program. It's not a demonstration program or pilot program. It's open to as many ACOs as want to participate. In its first year, 220 ACOs accepted shared accountability with Medicare in search of shared savings. There are also Pioneer ACOs comprised of early adopters (primarily very large group practices) and Advance Payment ACOs (smaller organizations that get an extra boost to innovate).
Medicare ACOs are not required to include optometrists or ophthalmologists. But when a patient attributable to the ACO has cataract surgery or an eye exam, the cost of that care is attributed to the ACO. Eventually, the ACO will also be responsible for the quality of the outcome of the surgery, or other care. If, say, the Medicare beneficiary loses eyesight and enters a nursing home, then the ACO will be accountable for the cost of that nursing home stay, as well as readmissions, or treatment after falls, or any other medical expenses patients may have. Optometrists should explain to ACOs that eye care provided by ODs can protect eyesight, and save money. For example, if an optometrist can prevent or correct a vision problem that would otherwise leave a patient disabled, the enormous costs of assisted living can be avoided. So optometrists should explain to ACOs not just about eye care quality, and about patients with diabetes, but also about how optometrists can help keep patients out of hospitals and nursing homes. These are services that ACOs will be desperate for.
Importantly, in Medicare, ACOs may not restrict patient choice. Medicare beneficiaries may continue to see the doctor of their choice, including their optometrists, even if the optometrists are not part of an ACO. Medicare ACOs are part of the open Medicare fee-for-service network, not closed panels like managed care. If you come across a closed panel serving Medicare patients, then you're looking at a Medicare Advantage plan, the Medicare version of managed care organizations (MCOs).
Medicare ACOs may include any type of individual or entity enrolled in Medicare to provide care to the patient population. All ACOs must have enough primary care MDs and DOs to be accountable for the care of at least 5,000 Medicare patients. Neither the doctors nor the patients will know whether the beneficiary's costs will be attributed to the ACO until the year is complete. However, CMS is notifying ACOs about which patients would have been attributed to them in the past, and sharing patient claims data with the ACO. The ACOs in turn are giving those patients notice about the shared savings program and an opportunity not to have Medicare claims data shared. The ACO's performance on costs will be compared to the expected costs for its actual patient population, including considerations of the relative health of the beneficiaries.
ACOs might not realize the benefits optometrists provide, so optometrists will need to market their services and demonstrate their value to ACOs. All optometrists know the need for diabetic eye care and the important role that optometrists play in recognizing and treating patients with diabetes, and how eye care can prevent costly complications of diabetes. Many of the accountants and lawyers and consultants and medical doctors leading the ACO charge also understand the need for eye care in the diabetic population. Optometrists should use this to your advantage. This is one of the profession's strongest selling points to any payer or policy maker, and it applies even more so in ACOs where the providers are accountable for the cost and quality of care provided..
For Medicare, optometrists need to actively demonstrate value. This means participating in the Physician Quality Reporting System (PQRS), electronic prescribing, exchanging health information, implementing EHRs, exchanging health information with local optometrists, and tracking your results through clinical data registries. The more you can show you're a Medicare physician just like an MD, the more you can show that you are engaged with the program, the more an ACO will treat you like a valued member of the team.
Here are some suggested steps for optometrists to take to prepare for ACO participation:
- Participate in PQRS.
- Meaningfully use EHRs.
- Use eRx.
- Plan to join AOA clinical data registry under development.
- Exchange health information with other practitioners.
- Follow AOA Evidence-Based Clinical Guidelines.
- Use other AOA Excel Tools to grow and enhance your practice.
The situation with private payer (commercial insurance) ACOs is a little different. Some ACOs in the private market at the state level are just rehashes of managed care, giving another acronym to go with HMO and PPO. Many states will need to update their laws to ensure that ACOs do not devolve into border guards. Many of the Medicare ACOs will seek to participate in state-level or local-level value-based contracting arrangements centered on incentive payments to providers. But the participation with third party payers will be less transparent compared to Medicare ACOs. Third party payers might not place the same requirements on non-Medicare populations, such as not maintaining patient freedom of choice in provider. With private payers, optometrists will have to study ACOs carefully. What are the incentives (for the optometrist and for the ACO)? What are the risks (legal and financial).
Here are some suggested steps to advocate for inclusion in ACOs:
- Tell about your highly specialized education and training.
- Optometrists are primary eye care.
- Role of optometry with chronic diseases.
- Role of optometry in early detection of systemic diseases.
- Role of optometry as gateway to health systems.
- Role of optometry reducing readmissions.
- Role of optometry reducing falls in the elderly.
- Diversion of emergency services from expensive hospital settings.