Pioneer ACOs in action

California Healthline looks at San Diego-based Sharp HealthCare’s selection as a Pioneer accountable care organization (we blogged about this brand of ACOs earlier this week). Here is an excerpt:

According to Alison Fleury, CEO of the Sharp HealthCare ACO, the ability to inform beneficiaries ahead of time whether they were assigned to an ACO was an important step in learning about the population Sharp will be managing.

Under the program, beneficiaries who received the majority of their care from a care provider within an ACO network during the past three years are aligned with that ACO.

Finally, the ability to move from a shared-savings model to a population-based payment arrangement was very important for many organizations.

“One thing at least some of the organizations are excited about is that eventually CMS would be willing to go to a capitated approach. I think a lot of these Pioneer ACOs, given that they are leaders in care coordination already, like that option,” said John Pickering, principal consulting actuary with the actuarial and consulting firm Milliman…

Despite years of experience operating in an ACO-like system, Lynn Dong, a principal consulting actuary with Milliman, said Pioneer ACOs are likely to find their infrastructure somewhat lacking, particularly as they take on functions historically performed by health plans.

“Some of the things that they’re going to need in place in order to be successful are utilization management functions, such as disease management, complex case management, preauthorization services, specialty referral management, and other analytic tools. In particular, financial and actuarial modeling, which has typically been performed at the health plan level, will be an important contributor to the success of these organizations,” Dong said.

Perhaps the biggest challenge Pioneer ACOs will face is that beneficiaries have the freedom to visit any health care provider accepting Medicare and not stay within their assigned ACO network.