We’re used to seeing a doctor when we’re sick. What if your doctor and your insurance company were also striving to keep you healthy in between office visits?
First introduced in 2012, Accountable Care Organizations (ACOs) modeled a new way of caring for patients. When your employer offers you this type of plan during open enrollment, they’re expecting your doctors and insurance company to work together to keep you well – and can usually offer you a lower cost plan as a result.
“We can promote patients’ health more effectively in an ACO plan than we can if our relationship with a patient is visit-by-visit,” says Val Overton, Vice President of Quality and Innovation for Fairview Medical Group. “Accountability is about being accountable for your overall health all year long, not just when you're in the doctor’s office.”
In 2018, more than 30 million Americans were covered by an ACO. What’s it like to be in one?
With an ACO, patients enter into a new type of relationship with their insurers and providers, asking them to be more active in managing their overall health. After an introductory call with you, the insurer and providers both regularly monitor your health information.
Take, for example, if you visit a clinic for a case of bronchitis. You’ll get the same great care any patient would. But in a traditional health plan, if you don’t come into the clinic again, no matter what other health needs arise, that’s the extent of it. Your doctor and your clinic don’t have a way of knowing how you’re doing.
If you’re in an ACO and come in for bronchitis, then your insurer notices you later visit an ER for breathing problems while visiting another state, something new happens. When the care you need raises concerns about an ongoing problem, the insurer will contact your primary care provider, who will in turn follow up with you to determine what may be causing your bronchitis and how to prevent it from coming back.
“It's a different relationship than you've had with your insurer and provider than before,” Val says. “We have more proactive ways to find out when you need us, even if you are not in the clinic. If you need us, we're going to help more rapidly. This doesn't happen in traditional plans.”
Today, sharing general information electronically is fairly easy. Sharing medical information isn’t always so. Why?
Not every doctor has access to each other’s electronic health records or even the same record system. This means your medical history may be scattered among doctors, clinics, and hospitals, and it may require you to do some of the work of getting it to people who need it to help you. Your insurance company may also have a different system than your doctors.
ACO providers, on the other hand, have partnered with your insurance company to share information. This improved communication between your insurance company and your doctors can reduce your paperwork and improve your medical care. When doctors have access to more of your medical information, it can lead to faster diagnosis, fewer repetitive tests, and a better plan for staying healthy.
While all patients with chronic or high-risk conditions like high blood pressure or diabetes can count on Fairview to help manage that condition, patients in an ACO also get their insurance company as part of their care team.
Having two groups of people looking out for your health helps make sure you get the right care, right when you need it. This may come in the form of extra follow-up calls when you’re overdue for procedures, better coordination among all of your doctors, or even a designated care coordinator to give individual attention to your health.
“In an ACO, you're more likely to get that extra help early on, rather than later,” Val says. “When you’re in an ACO, your providers and your insurance company are both actively watching when you go to the hospital or when you're overdue for things like mammograms or colonoscopies and reaching out when things don’t look right.”
Health plans differ in terms of the deductibles (what you pay for medical expenses before the plan starts to cover your costs) and premiums (your price to purchase a health plan, typically paid out of your paycheck). Usually, high-deductible plans have low premiums, while low-deductible plans have high premiums.
With ACO plans, insurance companies and providers are working together to reduce costs for all parties. Employers often pass the savings on to their employees in the form of lower premiums, copays, and/or deductibles.
“The emphasis is on giving patients great results as a way of both saving money and producing better health,” Val says. “There is a myth out there that ACOs would give cheap care, but we treat all patients well, regardless of their health plan.”
ACO networks have another advantage: established quality standards.
The foundation of these plans is a commitment to quality care. Providers in an ACO network have intentionally come together to coordinate your care and work toward better results. Providers are monitored regularly and held to high standards. This means you can be sure that every provider in an ACO network is providing quality care.
“Patients can have confidence that any referral they get within the ACO is going to be a high-value referral,” Val says.
One myth about ACO plans is that they are a way to revive managed care plans from the 1990s.
Like most health plans today, ACOs strive to control unnecessary costs. ACOs do not, however, rely on aggressively restricting access to providers to save money, like some plans once did.
“The experience for the patient in a managed care plan back then was incredibly unsatisfying,” Val says. Though managed care has evolved since then, “with ACOs, it feels better for the patient, and it feels better for the clinician as well.”
Another key difference between ACOs and managed care plans of the past is the size of the networks. Managed care networks could be small, making it hard to get referred to a specialist.
Today, ACOs tend to be formed by large, integrated health systems. ACO plans with Fairview, for instance, provide a comprehensive range of primary and specialty services from more than 5,000 providers at locations throughout the Twin Cities region.
“I can get almost anything I am going to need within the Fairview system,” says Val. “And if I’m referred within the Fairview system, it’s going to be in the ACO’s network.”To choose a Fairview Accountable Care plan as your health plan for 2019, review this list to find your insurance provider and the plan names.