10 Things You Need to Know to Succeed and Be Happy in an ACO

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July 28, 2015

In This Article

3. An ACO Is Very Different From an HMO

ACOs have frequently been likened to health maintenance organizations (HMOs), because both models try to save money. But Dr Pogue says ACOs take a very different approach than HMOs, without the features that have made HMOs so distasteful to doctors and patients alike.

"The HMO model is mainly about reducing cost," Dr Pogue says, "but an ACO focuses on quality and the patient experience, in addition to cost."

Another difference between the two models is in how they realize savings, says Joseph Habis, MD, medical director for the Meritage ACO, which is run by an independent practice association (IPA) in the wine country north of San Francisco.

The HMO saves money by putting primary care physicians (PCPs) in the uncomfortable role of "gatekeepers," where they have to mete out referrals, tests, and prescriptions, Dr Habis says. If these doctors don't keep a lid on costs, they'll wind up spending more than the per-member, per-month payment they're given. In an ACO, by contrast, patients can go wherever they like without having to get the PCP's permission, and physicians continue to get a fee-for-service payment, he says.

In Meritage's case, freedom of choice extends to physicians in the parent IPA. They don't have to join the ACO, and in fact, only 250 of the 700 doctors in the IPA have done so. Dr Habis says giving doctors a choice means that those who have signed on are committed to the concept.

Observers have been concerned, however, about ACO patients' ability to "wander" wherever they like, and rack up unnecessary expenses in the process. To combat this real threat, the Palm Beach ACO works hard to keep patients within the ACO. "You can mitigate the wandering. We educate our patients," says Dr Sukienik. "We tell them, 'If you want to go to a specialist, please give us a call first.'"

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