Understanding What the ACA Means for Ophthalmology

Shared Savings and Shared Risks

Dr. Steinert: You have been talking about shared savings and emphasizing that, but there is also a shared risk, isn't there?

Ms. McCann: It depends on the ACO model. There are 2 different ACO models. One is one-sided, which means that you only share in the savings at the end of the year. The other is a two-sided model, in which you share in the savings and the risks. So that being said, at the end of the year if you do not save any money and costs actually go up, then you can be penalized by Medicare. But if you actually save money at the end of that year, and you are in the two-sided model, your incentives and your bonuses are higher than in the one-sided ACO model.

Dr. Steinert: In principle as a specialist, do you have the option of not signing up for any ACO? Can you just forgo the potential savings but also forgo the potential downside?

Dr. Bakewell: Yes, but then you are not going to have access to those patients. You may, but you may not if they stay within the ACO and you don't participate with any ACO groups. That would be the concern for the specialists -- that they might not have access to those patients.

Ms. McCann: It depends on the area of the country. If you are in Boston, which has a huge market penetration of ACOs, you will run the risk of having reduced access to the patients because they are all going to be caught up in the ACOs. But if you are in an area where there is only 1 ACO, it isn't that much of a concern because the patient can go to whomever they want. The incentive for the primary care doctor is that they could give the patient a list of specialists who participate in the ACO. Patients don't have to go to them, but they might receive a list. The primary care providers can't say, "You must go to these physicians," but they can certainly suggest that. We have heard of instances where ACOs have sent letters to patients of ophthalmic practices, saying that "you can no longer go to Dr. X because he is not in the ACO." The message that is really important for physicians to be aware of is that you need to educate your patients so they understand that under an ACO concept, they have the ability to go to whomever they want. If you find out that this is going on, you should send letters to your patients.

We have tried to do a better job of working with CMS to educate the ACOs as well as to what their requirements are, and what they can and cannot do. We talked about working with AARP to get it into their publication so that the Medicare population understands.

The other point that I want to make is that this whole exclusivity issue that Brock was talking about is something that we are still trying to get corrected. We have met with CMS (which is implementing this) at 3 different times. The last meeting we had was with top officials because they are moving Medicare into more of these types of models, and if you look at the Sustainable Growth Rate replacement proposal, it is all about moving physicians into these alternative payment models such as ACOs, medical homes, and bundled payments. We have been saying that if you want to do this and get specialists involved in these payment models, you have to fix this problem. So this is not the end of the story. We are still trying to get this changed so that, ideally, specialists could be full participants, sharing in the savings and the risks with more than 1 ACO. That would be the ideal situation.

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