Negotiating Contracts with ACO’s

There are several types of Accountable Care Organizations that a physician may be asked to sign a contract with, including the Medicare Shared Saving Program ACO, Pioneer ACO, and private insurance providers.

All ACO’s have certain attributes in common, including risk participation and assessment, patient participation, integrated care, evidence based care, utilization of non physician professionals (physician assistants, nursing assistants, etc.) data analysis and use of technology for improving communications and care.

As a physician entering into any contract, but particularly a contract for an ACO, you should make sure you understand the contract. In most cases, if it’s not in the contract, it doesn’t exist. If you are promised some benefit from an ACO plan, like help with achieving meaningful use (technology), make sure it’s spelled out in the contract.

Here are some other things you should review In the contract:

1. Risk Participation: Shared Savings is a concept that has not been completely defined. Providers should understand how the billing works, and how the shared savings works. Some plans have penalties for physicians who do not meet benchmarks. This is an important part of the contract. Your payment should be clearly spelled out.

2. Exclusivity: Most plans require primary care physicians (including internists, general practitioners, family doctors, and geriatric doctors)to be exclusive with the ACO. Specialist can usually contract with several. Again, this should be clearly designated.

3. Corrective Action: What corrective action will take place if a physician does not meet benchmarks?

4. Benefits Provided: ACO’s need to provide infrastructure to help achieve cost savings. These include integrated care, behavior counseling, nurse phone availability, and improved technology. These benefits should be spelled out in the contract.

5. Regulatory Issues: Physicians have certain obligations under law to notify their patients about their medical plans and particularly for information sharing. A major goal of ACO’s is to review data for performance, but patients can opt out of sharing data. There should be a clear plan for complying with regulatory issues.

6. Payer Viability: If the payer fails, a clear exit strategy should be part of the contract.

All contracts have hidden agendas and concerns. Will there be an arbitration clause? Is there an attorney’s fee provision should there be litigation? Who exactly is contracting. ACO’s have particular issues that need special care so the contract should be carefully analyzed to make sure that all terms are carefully understood.

Submitted by Matthew L. Kinley