Credentialing for accountable care organizations

Regardless of where you stand on the political spectrum, the Patient Protection and Affordable Care Act (better known as healthcare reform) is now the law of the land. Although challenges to the law are expected both in the courts and in Congress after the next election, for now, accountable care organizations (ACOs) are scheduled to come online in 2012. The problem is that nobody knows what they are supposed to look like. On June 7, CMS Office of Legislation posted the first of what are likely to be multiple guideline announcements regarding ACO implementation.

These first guidelines define an ACO as: "An organization of healthcare 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."

In response to the question, “What forms of organizations may become ACOs?” CMS identified the following types of organizations:

• Physicians and other professionals in group practices
• Physicians and other professionals in networks of practices
• Partnerships or joint venture arrangements between hospitals and physicians/professionals
• Hospitals employing physicians/professionals 
• Other forms that the Secretary of Health and Human Services may determine appropriate

Among the requirements for ACOs are the following:

• Have a sufficient number of primary care professionals for the number of assigned beneficiaries (to be 5,000 beneficiaries at a minimum)
• Have sufficient information regarding participating ACO healthcare professionals as the Secretary [of Health and Human Services] determines necessary to support beneficiary assignment and for the determination of payments for shared savings

As most of you have already recognized, these preliminary guidelines make it clear that physicians participating in an ACO (and likely not just the primary care physicians) must be credentialed to participate in an ACO. But what will this credentialing process look like? Nobody knows at this time, yet many organizations are rushing headlong into building ACOs. It’s a good thing to get a head start in determining what will and will not work for your organization as you seek to become a successful ACO. However, at this early stage, you should ask some basic credentialing questions that will eventually become the foundation of the credentialing process for your ACO. Some suggested questions include the following:

1. Will all physicians on your hospital’s medical staff initially be eligible to participate in the ACO? Why or why not?

Note that if all physicians with membership and/or privileges on the medical staff can be a provider within the ACO, there is no basis for establishing quality or cost effectiveness criteria for initial participation in the ACO. Allowing physicians to participate who don’t control their utilization or have quality problems will make it more difficult for your ACO to meet the goals of improving quality and cost effectiveness for the Medicare beneficiaries for which the ACO will be responsible. However, saying that only some physicians on your medical staff will be eligible to join the ACO may create strategic and political problems for the hospital in its relationships with physicians who are excluded from joining the ACO.

2. Once physicians join the ACO, will there be performance criteria regarding quality and cost effectiveness to maintain this eligibility?

The same challenges apply as those regarding initial eligibility for the ACO.

3. If criteria for initial or ongoing eligibility for ACO participation are established, who determines these criteria?

Will the organized medical staff have a role to play in determining these criteria or will a separate entity be established to carry out these and other leadership functions for the ACO? If the leadership of the ACO is tied in with the medical staff, all the current structural, self-governance, and political challenges currently faced by medical staffs will be carried over to the ACO, impeding its ability to function as an efficient and responsive business entity. Excluding the medical staff leadership will appear to be an end run around the medical staff. In addition, physicians may perceive the exclusion to be a power play by the hospital or whatever entity ends up making these decisions.

4. How will you ensure the quality and cost effectiveness data used to determine eligibility is valid and accurate given the challenges our field already has with accurate peer review data?

We do not yet know the specific indicators that will drive the rewards and penalties to be paid to ACOs. Whatever they are, physicians are likely to push back on the validity and accuracy of the data, especially when their compensation will be at least partially determined by the data.

5. Who will do all the work of credentialing, gathering the data, reporting it, and dealing with the inevitable pushback physicians will give to the data?

Every ACO will need enough infrastructure to carry out these functions. Will the current medical staff services department personnel be drawn into these functions or will a different structure be established? Will extra staffing be provided to the medical staff services department to help take on some of these functions?

These are only the preliminary questions that arise while the details of ACOs are yet to be determined. Once CMS establishes more guidelines for ACOs it is likely that additional credentialing questions will arise. One thing is certain: Credentialing specialists will play a role in ACOs. Just what that role will be is what we must wait to find out.

Rick Sheff, MD, is chairman and executive director of The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.