An accountable care organization (ACO) is a healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. The ACO may use differing payments models such as capitation, fee-for-service with asymmetric or symmetric shared savings, etc. According to the Centers for Medicare and Medicaid Services (CMS), an ACO is “an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it.”[1]
The value that you offer as a pharmacist is helping the ACO decrease costs and improve patient outcomes. In this model, the pharmacist is not functioning from a revenue generation standpoint, but rather from a cost savings one.
The consultant pharmacist can focus on increasing profit margins for the entity through maximizing the bundled reimbursements of a pay-for-performance model. For instance, the physician clinic may only get a certain amount for a patient with multiple chronic conditions. If you help cut down the time the physician needs to spend with that patient by optimizing medication regimens you can save the provider time.
Recently organizations such an BCBS, have started “strengthening the integrated care teams within its Accountable Care Organizations (ACOs) by helping provider partners add pharmacists to their health care teams, and making available a network of advanced practice pharmacists who can provide services on referral”.
As networks of providers, ACOs are composed mostly of hospitals, physicians, and other healthcare professionals. Depending on the level of integration and size of an ACO, providers may also include health departments, social security departments, safety net clinics, and home care services.
By enrolling their patients in chronic care management (CCM) services, conducting “incident to” MTMs and transitional care management services (TCM), the pharmacist can help decrease costs and improve patient outcomes.
Contracting with an ACO is just one of the many consulting options available to pharmapreneurs.
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