The ACO Specialist Manual

By Julian D. "Bo" Bobbitt, Jr. and Shawn P. Parker
Published by North Carolina Medical Society

"A Guide To Getting The Optimum Value-Add Contributions From Each Medical Specialty In Integrated Care"

The ACO Specialist Manual is a strategic guide to getting the optimum value-add contributions from each medical specialty in integrated health care. For purposes of this Manual, the teams are generally termed accountable care organizations (“ACOs”) or clinically integrated networks (“CINs”), but can embrace any grouping of providers working jointly under value-based payment models, including single tax ID multi-specialty entities, Independent Physician Associations, and virtual networks.

The New Health Care Is a Team Game – Building upon the momentum of other growing trends toward changing payments to incentivize better population health and lower costs such as the Medicare Shared Savings Program,  commercial payors moving to value-based contracts and “MACRA,” the Medicare Access and CHIP Reauthorization Act of 2015, on April 22, 2019, the U.S. Department of Health and Human Services unveiled 5 new value-based care models, all intent on having providers work collaboratively to lower overall healthcare costs while improving patient satisfaction and quality. The transformation of the delivery model has been progressing in recent years from fee-for-service (which has had the unfortunate unintended consequence of paying more money for more, not better care) to pay-for-value (which rewards better outcomes at lower cost). A fundamental premise of value-based care is to achieve better health status and reduced avoidable overall costs for patient populations. This, in turn, is almost impossible to achieve if providers continue practicing in silos, within a fragmented and uncoordinated “non-system.” Put another way, practicing in integrated care teams is the proverbial low-hanging fruit in the new health care to drive “value,” defined for purposes of this Manual simply as achieving the highest quality at the lowest costs. 

Change Is Hard – We are moving inexorably to a team-oriented value-based payment model for integrated population health. This will require a disruptive transformation of health care delivery. Such a fundamental change is extremely difficult, and there is a natural tendency to resort back to fee-for-service business practices even once in an integrated or alternative arrangement. Additionally change is difficult even when there is universal support, which this movement has never purported to have. 

As of this writing, it may be said that CINs, ACOs, and other value-based care teams are starting to emerge from primary-care only prevention and wellness activities—ACO 1.0, as it were—to ACO 2.0, of strategically utilizing value-adding specialties to address the diagnoses and process flaws of their patient population.

This Manual Is a Compilation of Single-Specialty White Papers – In what some may look back on as remarkable prescience, beginning in 2011, different medical and health care facility professional associations and societies pooled resources to develop multiple white papers to provide practical insights for the members of each respective association to optimize their contributions to, and thus their rewards from, the then new value-based care. This group, called the "Toward Accountable Care Consortium"(TAC), now includes over 40 members. The white papers on each topic combined the “best of the best” national research on what is working elsewhere with actual examples from practicing providers and leaders for each paper assembled into “Accountable Care Workgroups” for their respective specialties. This Manual is a distillation of these more inclusive single-specialty efforts, and you may find resorting to them useful if you need more detail or context. Unlimited free downloads of all of the Toolkits are available at http://www.

How to Optimize the Role of Specialists In, and Thus the Success of, Your CIN/ACO – The pertinent substance of the compiled aforementioned white papers have been distilled into this Manual. It may represent the first-ever collection of such strategies for CINs and ACOs. It is recommended that you not just plunge into these, but follow a plan. You may consider the following approach:

  • A primary care core is essential. Not only is it the only group of specialties required under the Medicare Shared Savings Program (“MSSP”), but virtually all of the high-value initiatives identified by TAC’s research—prevention, wellness, complex patient management, reduced hospitalizations, etc.—are in primary care’s wheelhouse.
  • Do a gap analysis. A gap analysis, sometimes called a “patient stratification,” identifies the gaps in care and processes for your patient populations and the patients they impact. Where are care costs and processes less than ideal? Who are these patients? This is a huge benefit of value-based population health care versus fee-for-service where one was often relegated to reacting to individuals who self-present for care. Find out what diagnoses and which processes are amenable to improvement.
  • Be strategic about which specialties to add. The gaps will reveal game plans and ideal care teams to mitigate those gaps. Armed with that knowledge, you can then select which specialists you will need and how many.

The manual involved input through participation by many thought leaders and sponsoring organizations who have come together to form the Toward Accountable Care Consortium and Initiative (TAC). The core activity of the TAC since 2011 was the creation of specialty-specific guides addressing the best ways for each to contribute significantly in a value-based integrated care environment. This undertaking required hundreds of hours of research and input by professionals. 

This paper would not have been possible without the generous support of all TAC Consortium member organizations, including significant support from the North Carolina Medical Society, as well as a substantial grant from The Physicians Foundation. Special thanks to the North Carolina Academy of Family Physicians and North Carolina Society of Anesthesiologists, whose seminal ACO white papers are the underpinning of this Toolkit. Smith Anderson’s Julian D. “Bo” Bobbitt, Jr. served as head of research and drafting on all of the specialty guides and the Specialist Manual.

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