Can Ophthalmologists Participate in ACOs?
Dr. Steinert: ACOs are basically organized around primary care. Correct?
Brock K. Bakewell, MD: Correct.
Dr. Steinert: We are ophthalmologists. How will this affect us?
Dr. Bakewell: It is going to be difficult for us to participate in ACOs according to the way the laws are written right now. The ACO is groups of physicians who take care of approximately 5000 patients, the minimum number that an ACO group can provide for. Ophthalmology specialists will contract with ACOs. Originally it was meant that specialists could contract with multiple ACOs, but that is going to be very difficult the way it is right now because as it stands, if you have only 1 tax ID number and you contract with an ACO, you can't contract with another ACO. You either have to have multiple tax ID numbers or you have to contract as what Medicare calls an "other entity," which does not let you gain in any of the shared savings that come about from managing patients appropriately.
Ms. McCann: To piggyback on what Brock is saying, basically the intent of the law was that primary care providers could be full participants in only 1 ACO and share in the savings, and specialists could be in more than 1 ACO. Unfortunately, the Centers for Medicare & Medicaid Services (CMS) is implementing it in such a way that, regardless of specialty, as long as you bill for evaluation and management (and almost every specialty does so, except perhaps pathology), you can be in only 1 ACO as a full participant. In the case that Brock was talking about, if I am in an ophthalmology practice and we have signed on the dotted line as a full participant (meaning that we share in the savings and the risks with an ACO), we may not participate in any other ACO and share in the savings.
You can provide care to patients who are in other ACOs because the patient can go outside of an ACO at any time. It is just that you, as the ophthalmic practice provider, are set in with that ACO, and that is where the shared savings would come from. You could participate, as Brock said, as an "other entity." Another entity is basically just a contract on a case-by-case basis with each ACO, but under that scenario you could not share in the savings because it is all based on the patients and which ACOs they are attributed to, which gets really complicated.
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Cite this: Understanding What the ACA Means for Ophthalmology - Medscape - Nov 22, 2013.