Receiving Care from an Accountable Care Organization

Summary

An Accountable Care Organization (ACO) is a group of doctors or hospitals who have agreed to work together to coordinate and improve their patients’ care. Coordinating care means that all of the people treating you know your medical history and treatment plan. In some cases, all of your medical information will be stored in a personal electronic health record. You, your doctors and other providers can share that record. That way, everyone has a full picture of your health. That helps you avoid getting the same screenings or tests twice. It also makes sure you get preventive care like flu shots or, if you have diabetes, regular blood tests.

An ACO is not a type of health plan. It is just a way of organizing your care within the plan you already have. Your doctor or insurer may invite you to join an ACO. You also may ask your plan whether you are already in an ACO, and if you are not, whether you can join one. There should be no extra cost for using an ACO. You may even get rewards for meeting certain “good health” guidelines.

In an ACO, doctors and hospitals are paid more if they meet specific quality goals. The goals may involve preventive care and taking care of patients with long-term health issues like diabetes or heart disease. Patients in an ACO may be able to visit providers outside the organization for care. But, if you are in a private plan, there may be higher costs for going outside this “network within a network.” If you are in a Medicare ACO, you can still see any doctor who accepts Medicare without paying more.

If you are in an ACO:

  • Talk to your primary care physician (PCP) about your care and understand who is in your ACO network.
  • Ask your plan if you will pay more to visit doctors outside the ACO, even if they are in your plan’s broader network.

An Accountable Care Organization, or ACO, is a group of doctors, or a group of hospitals, who have agreed to work together to coordinate and improve their patients’ care. Their shared goal is to improve the quality of care, keep patients healthier and reduce unnecessary services. If you receive care through an ACO, the provider who coordinates your care—often, this is your primary care physician—will work with other providers and specialists to make sure you are getting the preventive care and regular treatment that you need. This means that you shouldn’t get the same test twice, or have services you don’t need.

An ACO is not a type of health plan. It is just a way of organizing your care within the plan you already have. Keep in mind that there are many different types of ACOs. Medicare has been testing ACOs for a few years, and many private insurers are developing their own ACOs.  Your doctor or insurer may reach out to you about joining an ACO that they have started.  You also may ask whether you are in an ACO, and if you are not, whether there is an option that you can join.

How does an ACO work?

An ACO is a way of paying doctors and hospitals for the quality and value of care they provide, instead of just the amount of care. Typically, doctors and hospitals are paid on a “fee for service” basis. This means that they are paid for each service or procedure they perform. In an ACO, healthcare providers are paid more if they meet mutually agreed upon quality goals for preventive care and take good care of patients with chronic conditions like diabetes or heart disease.

What does “coordinating” care mean?

Coordinating care means everyone involved in your care knows your medical history and treatment plan. In some cases, your medical information will be stored in a personal electronic health record that you, your doctors and other healthcare professionals can share so that everyone has a complete picture of your health. In some cases, you may be able to opt out of having your protected health information shared among those managing your care within the ACO.

Ideally, your providers will know what tests and services you’ve had. That way, you won’t get the same screening twice, or have a bad reaction to a drug because a doctor doesn’t know about other medications you are taking. Your providers will also know if you are getting the preventive care you need, like vaccines and screenings. You may also have a care manager, like a nurse or social worker, who regularly stays in touch with you to keep track of your conditions and to help you take care of your health, like getting regular blood tests if you have diabetes.

Can I see doctors outside the ACO?

It depends. Think of an ACO like a “network within a network.” Based on the program, patients in an ACO may be able to visit providers outside the organization for care. For example, if you are in a Medicare ACO, you can still see any doctor that accepts Medicare without paying more. If you are in an ACO through a private health plan, you may also be able to see other doctors in your plan’s network.  But, if you see providers outside the ACO – even if they are in your plan’s larger network — you may have higher costs. You may also have higher costs if you go to a doctor who is outside both the ACO and your plan’s larger network. Be sure to check with your plan about coverage for out-of-ACO and out-of-network care first.

How much does it cost to use an ACO?

There should be no extra cost for using an ACO. You will still have the same premium, copayments, and deductibles that you pay for your health plan. You may even qualify for an incentive from your ACO if you meet certain “good health” guidelines.

How do I know if I am in an ACO?

You may not know if you are receiving care from an ACO, so it may be a good idea to ask your employer, provider or insurer. In many cases, if your doctor is part of an ACO, you will automatically be enrolled. If you are covered by Medicare, your doctor or health insurer will tell you that you are being enrolled in an ACO, and give you the option not to join. If you do not wish to receive care from an ACO, you can still choose to get care from another doctor.

How can I receive care from an ACO?

Many ACOs are still new and are designed for people who need regular care for chronic conditions such as diabetes or heart disease. At first, patients were not able to join an ACO on their own, but that is changing.  Some ACOs may allow you to enroll directly. If your doctor is not already part of an ACO, you can ask if there is an ACO option available to you. You can also view lists of Medicare ACOs on the Centers for Medicare and Medicaid (CMS) website.

 

Your Action Plan: Be Informed



  • Ask questions! If you are not sure whether you are in an ACO, ask your doctor or insurer.
  • If you are receiving care from an ACO, make sure you understand whether you can see providers outside of the ACO, and your coverage for out-of-ACO and out-of-network care.
  • If you are not receiving care from an ACO, but would like to—for example, if you have a chronic condition—ask your insurer or doctor whether there are ACO options open to you.

Remember, you are your own best advocate! Ask questions if there is something you do not understand.

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