Health care reform initiatives offered through an ACO entity creates opportunities for both providers and payers to deliver affordable and high quality care for consumers. Each partner comes to the table with valuable resources to achieve common goals and outcomes.

1. Payers and Accountable Care
Organizations
Opportunities for A
Value-Added Delivery
System
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2. Challenges for an ACO
 Unknown patient population (aligned
membership) and their underlying costs
 No assigned membership- freedom to self-
refer (Medicare fee-for-service)
 Little or no formal process for directing
patients through health care system or
resource consumption
 Requires lots of coaching by primary care
practitioner (medical home and care
coordinator role)
 Must manage risk through care
coordination, education and collaboration
with partner providers for cost efficiency
 Quality metrics requires disease-specific
and individual case management
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3. Complementing ACO and Payer
Delivery Systems
ACO Payer
Access to payer contracts and broader
network of care sites
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4. ACO and Payer Partnership
ACO Value Payer Value
• Organized business entity with • Existing IT resources
shared governance • Ability to provide:
• Internal performance structure  Claims payment & data
and oversight  Population demographics
• Common goals established  Actuarial & underwriting support
• Knowledge of delivery system • Medical cost management techniques
and practice relationships  On-site UM/case mgmt
• Adoption of practice protocols  Pre-certification
• Willingness to accept risk or  Alternative care settings
shared-risk contracts • Tracking and reporting outcomes data
• Basis for care collaboration and  Performance feedback from data
patient-centeredness • Access to broader health care delivery
• Ease in payer contracting system (Payer’s contracts)
4 • Access to payer’s clients and marketing

5. Risk Management = Medical Management
and Disease Management
 Overall goal: provide best care at affordable cost
in most appropriate setting
 Adopt health plan-like utilization management
practices:
– Pre-authorization
– Concurrent review with Interqual® criteria
– Discharge planning and follow up
 Seek lower cost care settings
 Utilize network of providers under contract at
predetermined prices and conformance
 Adopt health plan-like disease management
programs for high risk and chronic care
population:
 CAD  COPD/emphysema
 Diabetes  CHF
 Hypertension  ESRD
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6. ACO and Payer Collaboration and Sharing of
Clinical Data
• Utilizing paid claims data
• Identifying trends
• Focus on areas of improvement
• Consulting on care plans and alternatives
• Conducting patient experience surveys
• Evaluate quality and cost performance standards across
ACO delivery system (based on benchmark cost
management goals and clinical outcomes)
• Reporting/feedback on non-ACO (payer) network provider
performance
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7. Coordination of Care and Patient Outreach
Programs*
 Establish clinical staff of care counselors
 Conduct welcome calls and introductions for
identified patient population
 Conduct risk assessment surveys from
prospective data and patient base
 Enroll targeted patients in disease
management and education programs
 Follow up with post-discharge patients
(inpatient and select outpatient procedures)
 Conduct periodic assessment and adherence
calls for high risk/chronic care patients
 Invest in home monitoring devices for at-risk
patients
* Shared role between payer and ACO
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8. IT Resource Needs*
 Architecture of practitioner’s EMR/EHR
system
 Capability to interconnect with other ACO
participants (e.g. specialists, hospitals,
labs etc.)- providing results and care plan
histories
 Medical informatics (data mining) capability
and technical help:
– For identifying and flagging high
risk/at-risk patients from prospective
data for targeted interventions
– Conducting cost (expenditure) trend
analysis
 Tracking referrals across ACO practices
and outside the delivery system * Payer support role
 Capability for secure internet patient
contact and counseling
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9. Contact Us
Eagle Run MCC has the expertise and capability to:
• Construct and expand provider ACO networks for commercial and
government requirements.
• Negotiate contracts on behalf of providers and the ACO entity and
monitor contractual performance measures between providers and
payers.
• Provide medical and patient management techniques to improve
performance and produce desired clinical and cost outcomes.
• Provide access to low cost, leading-edge, cloud-based EMR, practice
management and revenue cycle management services to increase
productivity, profitability and health information exchange capability
among provider practices and the ACO network.
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