Ask the Legal Expert about ... participating in an ACO
John Durso, Esq. Nixon Peabody LLP
What are your top tips for participating in an accountable care organization or other multi-provider arrangement?
Post-acute organizations that serve seniors are increasingly being faced with payors offering “value-based” contracts and fewer fee-for-services contracts.
Many states are implementing Medicaid managed care programs to reduce their costs. Since the ACOs and other payors are focusing on value-based contracting, post-acute care providers must factor in the following:
1. Show you are cost-effective and efficient (reduced unit price).
2. Show you have full services (home care, rehab, subacute Medicare, case management).
3. Establish protocols and practices to reduce hospital readmission.
4. What services are you contracting to provide, and at what price?
5. What policies and procedures of the payor are being incorporated into the contracts?
6. How you establish that higher quality is being provided.
7. How you and the payor establish that you are a lower-cost provider.
8. Under the contract, do you share in the costs-saving bonuses or increased payments received by the payor, and do you share in the risk if there are no cost savings?
9. Do you help the payor establish cost saving or readmission reducing protocols, or establish other wellness outcomes by patient populations?
10. Should you become a part owner of the ACO and/or have a representative serve on the board of directors?
11. Can you help design how an ACO or provider keeps its data?
Undertaking risk-sharing and value-based contracting with payors will increase in importance and the process for such contracting should not be taken lightly.