Survival Tips

Providers Can Demonstrate Clinical Excellence By:

  • Incidence of preventive services such as mammography and Pap smears
  • Success of operations
  • Reduced complications after surgery
  • Rates of mortality, morbidity and infection
  • Reputation of specialists among peers

Some frequently asked questions before becoming employed by an Accountable Care Organization (ACO) include:

As a specialist, may I contract with more than one ACO?

If a specialist (other than an internal medicine, general practice, family practice, and geriatric medicine physician) submits a claim for management and evaluation under the ACO’s TIN, the specialist would be exclusive to participate in only one ACO.  Also, the wording of the contract with the ACO should be carefully reviewed for any exclusivity language that binds an individual specialist physician or group of physicians to practice with only one ACO. This could involve a hospital system that limits your ability to admit to other hospital systems.

Other than spending less than the national benchmark on patient care, what else is required?

Along with requirements for governing and management bodies, there are operational aspects for processes and reporting: design processes to promote evidence-based medicine, patient engagement, and coordination of care; develop a patient survey tool; initiate a process for evaluating the health needs of the population the ACO serves; implement systems to identify high-risk beneficiaries and develop individual care plans for target populations; maintain a database of all ACO participants and their National Provider Identifiers; and establish a compliance plan and conflict of interest policies and means to screen ACO participants.

Healthcare plans and purchasers of care want Outcomes Data such as:

  • Health Employer Data and Information Set ( HEDIS) and other demands of the National Committee for Quality Assurance (NCQA) for information to support accreditation
  • Consumer report cards

The following is a list of ten survival strategies for specialists:

  1. Demonstrate clinical excellence – measured by the incidence of preventive services such as mammography and Pap smears, success of operations, reduced complications after surgery, rates of mortality, morbidity and infection, and reputation of specialists among peers.  Healthcare plans and purchasers of care want outcomes data such as HEDIS (Health Employer Data and Information Set), consumer report cards, and the demands of the National Committee for Quality Assurance (NCQA) for information to support accreditation.
  2. Collect and analyze data for continuous quality improvement. For example, SF-36 forms can be administered in 10 minutes and gives a wealth of information related to a patient’s quality of like, a major gauge of the appropriateness and effectiveness of treatment. SF-36 described in the early 1990s by J.E. Ware, Jr., measures eight dimensions of overall health: physical functioning, social functioning, role limitations related to emotional or personal problems, mental health, vitality, general health perception and bodily pain.
  3. Be willing to work within guidelines.
  4. Align incentives.
  5. Maximize power of group or team.
  6. Be willing to innovate.
  7. Maintain strong relationships with PCPs and plans.
  8. Understand and accept managed care principles.
  9. Recognize importance of patient satisfaction.
  10. Use technology intelligently.

Survival Strategies for Specialists Include:

  • Demonstrate clinical excellence
  • Collect and analyze data for Continuous Quality Improvement (CQI)
  • Be willing to work within guidelines
  • Align incentives
  • Maximize power of group or team
  • Be willing to innovate
  • Maintain strong relationships with PCPs and plans
  • Understand and accept managed care principles
  • Recognize importance of patient satisfaction
  • Use technology intelligently

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