Medicare and "ACO" Accountable Care Organizations

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557880yvi
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Joined: Wed Mar 06, 2019 2:11 pm

Medicare and "ACO" Accountable Care Organizations

Post by 557880yvi »

Dear Fellow Bogleheads,

As I continue my research on joining Medicare in a few months (and only considering traditional Medicare with Massachusetts Supplemental Part B & D plans - strongly leaning towards Blue Cross/Blue Shield), it appears that many MA providers have joined an ACO - Accountable Care Organizations (18 Organizations in MA at the current time). There appears to be very significant financial motives for these providers to join an ACO.

I just learned that my current provider (the largest independent physician-led healthcare organization in Northeast) is part of an ACO. For the latest full year of data reported from Medicare (2019) for the 40 Medical Groups participating with Medicare, that their quality rating is abysmal 37/40 -although it does not surprise me. :?

After much additional research (and reading some older posts in Personal Finance, Not Investing) a significant and confusing concern is that it appears that going to providers in an ACO can become almost like being in an HMO and the "coordination of care" is among the providers in their ACO. Yet the 2022 Medicare and You brochure and Medicare websites say they can't limit who you can see. Yet other information warns that you might not be able to go outside the ACO's "network within a network". I think it is clear that you can Opt-Out so that your ACO can't provide YOUR data to Medicare but not clear if they can restrict your access outside THEIR ACO (or put a lot of pressure on you?)

Does anyone understand/have experience with this or could point me to something more definitive? Thank you!
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David Jay
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Re: Medicare and "ACO" Accountable Care Organizations

Post by David Jay »

I think I am seeing the same information as you are. All of the links below are official Medicare sources, the first one specifically states: “An ACO can't limit your choice of health care providers, and your Original Medicare benefits won't change.

https://www.medicare.gov/manage-your-he ... anizations
https://www.cms.gov/Medicare/Medicare-F ... ayment/ACO
https://innovation.cms.gov/innovation-models/aco
It's not an engineering problem - Hersh Shefrin | To get the "risk premium", you really do have to take the risk - nisiprius
Topic Author
557880yvi
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Joined: Wed Mar 06, 2019 2:11 pm

Re: Medicare and "ACO" Accountable Care Organizations

Post by 557880yvi »

Thanks for the links. Have seen several articles warning those on original Medicare with supplemental B&D plans that doctors will only refer you within there ACO. Although you can theoretically go to any provided that accepts Medicare, many will not even book an appointment unless you get referred to them from a PCP or other MD (we have experienced this numerous times this year, pre-Medicare with a PPO).
Rex66
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Re: Medicare and "ACO" Accountable Care Organizations

Post by Rex66 »

I’ve never required a referral unless a patient’s insurance required it

No advantage to me for having a referral to me
Topic Author
557880yvi
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Re: Medicare and "ACO" Accountable Care Organizations

Post by 557880yvi »

Rex66 wrote: Sun Oct 24, 2021 3:43 pm I’ve never required a referral unless a patient’s insurance required it

No advantage to me for having a referral to me
This is becoming almost the norm here in MA. Many specialist physicians will not book an appt without a referral even though they are in-network and we have the top tier PPO plan. Experiences this year trying to find an orthopedist and a neurologist - had to get a referral from a PCP WITHIN THEIR practice. So could not see many of the specialists who were highly qualified in specific areas because the PCP was part of MA General Brigham and the specialists were part of Lahey/Beth Israel. Could not easily change PCP just to get referred inside that practice (and our plan does not even require a PCP!) Getting ridiculous.
Rex66
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Re: Medicare and "ACO" Accountable Care Organizations

Post by Rex66 »

Those places must then have enough business that they don’t want extra business.
Topic Author
557880yvi
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Re: Medicare and "ACO" Accountable Care Organizations

Post by 557880yvi »

Rex66 wrote: Tue Oct 26, 2021 7:46 pm Those places must then have enough business that they don’t want extra business.
No, because they have plenty of appts - it has to do with being part of an ACO. Seeing patients who are not part of the organization's ACO does not contribute to the metrics that provide significant, financial incentives to the practice and providers. For example, even though one of our PCP's was a provider in the larger corporate entity that owns the practice that one of the specialists works in - that practice also had PCP's at their location (all same corporate ownership) but would only see patients whose PCP as in their physical location and part of "their practice". This was because they have their own metrics within the ACO (resulting in financial compensation for the providers) for "their practice" and seeing a patient of a PCP in the organization, but not in "their practice" does not count towards the ACO metrics. The patient who would want to see a specialist at their location would literally have to change PCP's, see that PCP and get referred to that specialist (even if the patient's insurance was a PPO with no requirement for referrals). This is due to the convoluted way incentives in ACO's are structured and drive behavior.
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