Frequently Asked Questions

1
What is an Accountable Care Organization?
1
What is an Accountable Care Organization?

An Accountable Care Organization (ACO) is a partnership of healthcare providers who choose to work together in a way that will improve the quality, coordination and efficiency of the care they deliver to a defined group of patients. The providers in this partnership can include primary care doctors, specialists, hospitals, therapists, and other medical professionals.

Practicing accountable care means that healthcare is organized for patients around these five principles:

  1. Preventive care
  2. Care team coordination
  3. Electronic health records
  4. Treatment based on proof
  5. Day or night access

ACOs are now being formed around the country for people over 65 to meet the new care guidelines of Medicare, and for people who have insurance through their employers, like Blue Cross, United, Aetna, etc.   ACOs are also being considered to serve Medicaid patients in order to improve the coordination of care.

ACOs measure and report on the quality of their medical care—this is what makes them “accountable.”

ACOs are being designed to serve all patients, but the patient groups that will benefit immediately are Medicare patients, chronically ill patients, those with high hospital usage, and patients with mild health risks such as asthma or high blood pressure.

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2
Are ACOs good for me and my family?
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Are ACOs good for me and my family?

Yes, an ACO is good for you and your family.

ACOs are organized to emphasize preventive care and proactive care:

  • The goal of preventive care to keep people healthy and to prevent illness.
  • Proactive care means that medical professionals reach out to patients who have chronic conditions to ensure they receive early treatment, appropriate health monitoring, and timely follow-up care.

ACOs also strive to coordinate care among all of your providers, monitor your health using advanced technology to enter and share health information through electronic medical records. This  allows physicians to keep track of the individual care each patient needs and identify patients who need more education and assistance to take care of themselves.

To see how accountable care can benefit you specifically, take the quiz at the bottom of this webpage.

          

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3
How can I find an ACO?
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How can I find an ACO?

New ACOs are forming all the time. Ask your doctor if s/he is already affiliated with one of the ACO pilots enabled by Medicare, including the shared savings program or Pioneer ACO program, or one of the commercial ACO pilots being formed with health plans, like Blue Cross, Cigna, Aetna, and others.

You can find some organizations that are providing (or striving to provide) accountable care by clicking on the Medicare ACO links above, or you can search the case studies on this website. The accountable care movement is very new, so as of 2012, there is no list of accredited ACOs yet, although the National Committee on Quality Assurance (NCQA) has developed an accreditation program for ACOs.

You can also find out if your doctor or medical group is working on providing accountable, coordinated care by using this guide, "5Questions to Ask About Your Doctor."

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4
Will I be able to keep my doctor if I am with an ACO?
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Will I be able to keep my doctor if I am with an ACO?

Yes, you will continue to get care from your doctor if your doctor is participating in an ACO.   

 ACOs do not affect your choice of a doctor.  And there is no limitation on the doctors you see or how many times you see them.

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5
Is an ACO the same as an HMO?
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Is an ACO the same as an HMO?

ACOs are not health plans like HMOs and PPOs.

  • HMOs are health plans that a patient chooses to join. HMOs have a limited physician and hospital network.
  • PPOs are health plans that offer more choice in physicians and hospitals than HMOs.
  • ACOs are voluntary partnerships of physicians and hospitals, created with the goal of improving quality and cost efficiency.

ACOs actually contract with health plans (and Medicare) by agreeing to measure and report on the quality of the health care delivered. There is a particular focus on preventive care, team coordination and continuity; these traits have proven it’s possible to improve patient health while reducing long-term costs. ACOs are rewarded financially when they improve the health of patients while containing expenditures.

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6
Will being in an ACO cost me more?
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Will being in an ACO cost me more?

At this time, you will not pay more if your doctor decides to participate in an ACO program. In fact, if you have insurance coverage through your employer, your insurance plan will not change. If you have Medicare and participate in an ACO program, your benefits and rights are exactly the same.

ACO providers are organized to improve quality and keep patients healthy.  If doctors and hospitals are able to control the costs of care by being more efficient and eliminating waste and redundancy, this should control the price of health insurance in the future.

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7
What does ObamaCare have to do with ACOs?
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What does ObamaCare have to do with ACOs?

The Affordable Care Act allows federal support for the testing and development of Medicare ACOs. Since the law was upheld in 2012, the progress being made by Medicare and health care providers to improve America’s health care system will continue.

It is important to know that many groups of physicians, specialists and hospitals were already well on their way to developing ACOs in response to the demands for health care improvement being made by the those that pay for health care: Medicare, large employers and commercial health plans.

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8
Are ACOs only for Medicare recipients?
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Are ACOs only for Medicare recipients?

Theoretically, ACOs (once developed) will serve everyone.  However at the present time, Medicare funds are supporting ACO formation around the country to serve Medicare beneficiaries.

At the same time, commercial insurers are supporting ACO development for their own members.

Some physician-led organized groups—like the ones featured in this website—have been delivering accountable care to all of their patients for decades.  Some of these groups are participating in both Medicare and commercial ACO pilots.  Others are not. 

Additionally, some states are looking at the ACO to service Medicaid patients in their attempt to improve quality and reduce costs.

So, until the country has completed its transition to accountable care, ACOs may not be accessible everywhere for everyone at the same time.

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9
I am confused. I have received a letter from my doctor about something from Medicare called an accountable care organization (ACO) and I have a friend who said her health plan is doing something called an ACO, too. Are they the same thing?
9
I am confused. I have received a letter from my doctor about something from Medicare called an accountable care organization (ACO) and I have a friend who said her health plan is doing something called an ACO, too. Are they the same thing?

The answer is yes. . . and no.

Many doctors groups, hospitals, and physician-led organizations like those you see on this website are doing a lot of work to improve care processes for their patients. These providers are trying to improve care coordination, communication, prevention efforts, and hand-offs between providers in ways that will improve the care experience for their patients.

Payers—like Medicare and Medicaid (the government), large employers, and commercial health plans are working with many of these providers to make sure that payment for these doctors and hospitals are based on health outcomesnot just on the number of services the doctor or hospital provides (fee-for-service payments). In other words, ACOs are paid for the value they bring in care delivery.

For seniors, Medicare has put several programs in place, through the Affordable Care Act, to help doctors, hospitals and patients work better together to make the delivery of care more efficient and cost-effective. (Click here for a full list of Medicare initiatives under the Affordable Care Act.)

But to control the nation’s healthcare costs, it is also important for care delivery to be improved for ALL patients, not just those on Medicare. This is why commercial health plans (like Cigna, Aetna, Blue Shield and others) are also developing or supporting ACOs to improve care and value. This is why your friend may have received some information from her doctor about being in an ACO.

So, you see, the term “accountable care organization” is being used to describe these payment initiatives, and it is also used to describe the provider organizations that actually deliver the care. The goal for all of these programs is “accountable care.”

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10
What is care coordination?
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What is care coordination?

When a patient gets care from multiple doctors and health care facilities, all care providers need to be well informed about the patient and should be communicating with each other to ensure that the patients get the right care at the right time. Achieving this is care coordination.

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Compare Accountable Care
& Traditional Care

Bill Gipson

Bill Gipson woke this morning with heart palpitations. Follow Bill’s experience to understand how health care delivered in a traditional system differs from care delivery in an accountable care system.

Defining Moment #1
Getting an Appointment
Traditional
  • Calls for appointment with his doctor.
  • Bill gets an appointment 5 days later when his doctor returns from vacation.
Accountable
  • Calls for an appointment with his doctor.
  • Bill’s doctor is out, but he gets a same-day appointment with another doctor in the group.
Defining Moment #2
At the Appointment
Traditional
  • Doctor views paper records of Bill's medical history, or perhaps a computer file stored only in that office.
  • Doctor thinks about what could be wrong, does an EKG test, orders urine, blood and treadmill tests.
  • Test results will be available in a few days. Bill is told "no news is good news." Doctor tells Bill he should lose weight.
  • Bill leaves appointment trying to remember what's been done, and what he needs to do next.
Accountable
  • Doctor views an electronic medical record that includes info from all of Bill's care providers.
  • Doctor thinks about what could be wrong, reviews current medical guidelines on computer, and decides to order EKG test, urine, blood and treadmill tests.
  • Doctor tells Bill he needs to lose weight. Test results will be available online in a few days. Doctor will call Bill to discuss lab results.
  • Bill leaves appointment with written end-of-visit summary explaining what has happened and what to expect next.
Defining Moment #3
Referrals to Specialists
Traditional
  • Doctor refers Bill to cardiologist. Bill can make cardiology appointment after he receives the authorization letter from health plan.
  • If Bill wants his cardiologist to see the full picture of his health history, Bill must deliver his own medical record to the cardiologist.
Accountable
  • Doctor refers Bill to a cardiologist with automatic approval from health plan, so cardiology appointment can be booked for Bill before he leaves his doctor’s office.
  • The cardiologist will see Bill’s entire health picture because he is connected to Bill's central electronic medical record (EMR).
Defining Moment #4
Prescriptions
Traditional
  • Bill carries his paper prescription for blood pressure medication to pharmacy across town.
  • Waits an hour for prescription to be filled while sitting in the pharmacy.
Accountable
  • Bill’s prescription is electronically transmitted to his favorite pharmacy.
  • Prescription is ready for pick up when Bill arrives at the pharmacy.
Defining Moment #5
Specialist Appointment
Traditional
  • Cardiologist can’t find faxed notes from Bill’s doctor, so he repeats tests for blood pressure and EKG.
  • Cardiologist wants to write Bill another prescription for his blood pressure. Bill says he already has one but can’t remember what type or dosage.
  • Cardiologist notes his findings in his paper file at cardiologist's office. Report is faxed to Bill's doctor, and gets deposited into Bill's paper medical record there.
Accountable
  • Cardiologist has real-time access to test results and primary care doctor notes through Bill’s shared EMR. No tests are repeated.
  • Cardiologist views Bill’s current prescriptions in his shared EMR and avoids prescribing unnecessary duplicate medications.
  • BiIl's doctor reviews the cardiologist’s findings online after notification through EMR that cardiologist has added notes to Bill’s record.
Defining Moment #6
Lab Results
Traditional
  • Bill never hears anything from his doctor about lab results. He assumes everything is okay, but never really knows.
Accountable
  • Bill receives email notification and logs into his secure patient portal to view full lab results online, read patient education about specific diets he should follow, and request an appointment for follow up. His primary care team calls him to review results again so Bill understands importance of managing his weight.
Defining Moment #7
Follow Up
Traditional
  • After cardiologist checks him, Bill is told he must lose weight and manage blood pressure to prevent heart attack.
  • Bill takes a pamphlet listing local classes on managing stress and weight, but leaves pamphlet in his car.
  • Bill doesn’t hear anything from his primary doctor or the cardiologist after being advised to lose weight and better manage his blood pressure.
Accountable
  • After cardiologist checks him, Bill is told he must lose weight and manage blood pressure to prevent heart attack.
  • Cardiologist' assistant reviews health education classes available to Bill and schedules appointment with nutritionist.
  • Bill gets a call from his primary care team to reinforce cardiologist findings and set a treatment plan for weight loss and blood pressure.
  • Bill gets a phone call to schedule regular follow-up appointments with his doctor to monitor his progress.
Susan Healey

Susan Healey hurt her knee during a recent training run, and found herself in the emergency room. Follow Susan’s experience to understand how health care delivered in a traditional system differs from care delivery in an accountable care system.

Defining Moment #1
Getting an Initial Diagnosis
Traditional
  • ER doctor X-rays Susan’s knee, sends her home with a splint and tells her to see her primary care doctor for follow-up.
  • X-ray images stay at the ER until requested by Susan or her doctor.
Accountable
  • ER doctor X-rays Susan’s knee, makes a preliminary diagnosis.
  • The ER nurse immediately schedules appointment with orthopedic surgeon who specializes in diagnosing and treating sports injuries.
  • X-ray images automatically added to Susan’s electronic medical record.
Defining Moment #2
Prescriptions
Traditional
  • ER doctor is unaware of Susan’s blood pressure medication.
  • ER doctor prescribes a common but potentially dangerous pain medication.
  • Pharmacy is across town. Susan picks up medication later that night.
Accountable
  • ER doctor is aware of Susan’s blood pressure medication (and complete medical history) through her electronic medical record.
  • ER doctor prescribes a pain medication that is safe with Susan’s other medications.
  • Prescription is automatically faxed to Susan’s pharmacy. She picks up her prescription on her way home.
Defining Moment #3
The Follow-up Appointment
Traditional
  • Susan calls her primary care doctor for an appointment the morning after she returns from the ER.
  • Her doctor is on vacation, so she waits 3 more days to see her doctor to get a referral to orthopedist.
  • Waits another week to see the orthopedist.
Accountable
  • ER nurse schedules appointment directly with orthopedic specialist in Susan’s medical group.
  • Primary care doctor appointment not necessary for referral to specialist.
  • Susan sees the specialist within a couple days.
Defining Moment #4
Getting Advice After-Hours
Traditional
  • Her knee feels worse, so she calls for advice at night.
  • Doctor’s office is closed.
  • Gets advice from doctor next day during regular business hours.
Accountable
  • Her knee feels worse so she calls for advice at night.
  • Susan’s medical group answers her call with its 24-hour nurse hotline.
  • Nurse advises the right way to take care of her knee.
Defining Moment #5
Getting a Final Diagnosis
Traditional
  • Sees the specialist more than a week after the ER visit.
  • Must pick up and bring her own X-rays to the specialist, but she forgets.
  • Orthopedist repeats the X-ray before ordering a costly CT scan, which requires a fourth appointment.
Accountable
  • Sees the specialist two days after ER visit.
  • Orthopedic surgeon reviews X-ray through EMR before Susan even arrives.
  • MRI is ready to be performed when she arrives at the specialist.
Defining Moment #6
Continuing Care
Traditional
  • Three weeks after ER visit, Susan reports for physical therapy.
  • Therapist knows nothing more about Susan’s health other than her knee sprain.
  • The therapist makes paper notes about Susan’s treatment and progress, which are filed at therapy center.
  • Susan forgets to schedule her two-month follow-up with her primary care doctor.
  • Susan’s medical condition continues to decline because of missed prevention opportunities.
Accountable
  • Ten days after her ER visit, Susan reports for physical therapy.
  • Therapist has a complete view of Susan’s medical situation and designs a therapy program perfect for her.
  • Therapist types notes directly into Susan’s EMR so the entire care team can keep track.
  • Two-month follow up appointment is scheduled automatically by her primary care doctor’s computer system.
  • At the follow-up appointment, Susan’s doctor gets reminder from computer about flu shot, screening mammogram, and a blood pressure check. Susan gets an end-of-visit summary from her doctor explaining what has happened during her visit and what’s next.

How Can Accountable Care Help You?

Is Accountable Care right for you? Answer these 8 questions.

Do you or a member of your family have a chronic medical condition? (diabetes, COPD, coronary artery disease, obesity, asthma, etc...)

How many different doctors or specialists do you see in a year?

Have you been hospitalized in the last 5 years?

What is your age?

What is your gender?

What is your marital status?

Do you have children under 21?

Do you take care of another adult?

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