Providers are the building blocks of any Accountable Care Organization (ACO).
They are how patients (beneficiaries, members) get attributed, and through attribution, they are the unit at which payers measure ACO performance. It is in everyone’s best interest (providers, ACO leadership, patients, and payers) that the mechanisms for achieving shared savings are understood, and that the mechanisms for allocating those shared savings across providers are transparent and merit-based.
Understanding How Shared Savings Are Achieved
The old standard “if you’ve seen one contract, you’ve seen one contract” certainly applies in the shared savings/value based contract arena. Each contract is its own creation, with wide variation between payers, from one product line to another (Medicaid vs Commercial vs Medicare vs Employer-sponsored), and even across different health system agreements. And the nuances that vary from contract to contract really make a difference! Understanding the specifics of a contract’s attribution methodology is key — does the contract include attribution through urgent care? Does it consider an NP who works at a specialist clinic to be a “primary care” provider by virtue of being an NP? These things can make a big difference in ACO strategy and success. Other influential components in any shared savings or pay-for-performance contract: risk scoring methodology, benchmarking methodology (does it use historical claims or regional/national benchmarks, for example), and even how expenditures are calculated (are there exclusions, is there truncation, etc.).