Frequently Asked Questions

How does an Accountable Care Organization differ from a PPO?

It is hypothesized that the traditional Fee-for-Service (FFS) model incentivizes physicians and facilities to perform services, but not to coordinate care and improve patients’ overall health.¹

In 2008, the Commonwealth Fund, a private foundation working toward a high-performance health system, polled over 200 opinion leaders in the healthcare industry and found that 70 percent of respondents believed that the current fee-for-service system leads to inefficiencies in care.²

¹Hackbarth GM MedPAC Medicare Payment Advisory Commission, Reforming American’s Health Care Delivery System, 2009. Senate Finance Committee Roundtable on Reforming America’s Health Care Delivery System. https://www.medpac.gov. Accessed February 4, 2010

²Stremekis K. Gutterman S. and Davi K. Health Care Opinion Leaders’ Views on Payment System Reform, 2008. The Commonwealth Fund. https://www.commonwealthfund.org. Accessed January 31, 2010

Are there local studies that show results of an ACO model when compared to others?

The AON Hewitt Associates Health Value Initiative™ is an annual independent benchmarking study of all health plans in major metropolitan areas. Kelsey-Seybold’s KelseyCare health benefits plan has been benchmarked in this major study in the Houston market for seven years.

According to the AON Hewitt Associates Health Value Initiative™ national benchmarking surveys, the KelseyCare accountable care delivery model was rated the “most financially efficient” health plan in the greater Houston area in 2004, 2005, 2007, 2008, 2009 and 2010. The survey also reports that the KelseyCare plan regularly scores above the market average on quality measures.

Within the greater Houston region, the 2010 annual benchmarking survey showed that KelseyCare’s cost-effectiveness is:

• 16% better than the average PPO plan.
• 21% better than the average POS plan.
• 12% better than the average HMO plan.

The ACO model is designed to treat the “whole patient” through development of the patient’s relationship with their selected primary care physician, and specialist colleagues. Value is delivered by strong emphasis on timely preventive care, effective follow-up, and identification and management of disease over time. In an ACO model, primary care physicians and multiple medical specialists share information, enhancing communication and emphasizing early identification of disease. Barriers to care are identified and removed, or reduced.

As an example, enrollees in Kelsey-Seybold’s KelseyCare health plan, based on the ACO model, receive ongoing outreach and contact from physicians and staff to encourage needed follow up and testing for disease monitoring after disease is identified. This is especially significant for chronic illnesses such as diabetes and hypertension, in which symptoms are often not present until late stages of the disease.

What are the disadvantages of an ACO system?

Because the model is not yet widespread, education is needed on the ACO model and how it works. Many patients already understand the value of having an ongoing relationship with a primary care physician.

How does the ACO model fit into the future of our nation’s healthcare needs?

Change in healthcare delivery and reimbursement in the United States is upon us. The significance of healthcare reform is that we are no longer thinking about what do about the problem, rather we now have something in place and can work on improving it over time.

Many experts foresee the advancement of payment models which reward provider performance on quality measures and patient satisfaction, with attention to managing the total cost of care are being recognized as a viable solution to our nation's escalating healthcare crisis.

Coordination of care across multiple medical specialties and care settings is key to the model. Currently, redundant paperwork, unnecessary tests, avoidable complications, hospital readmissions, lack of information technology and information sharing plague the system. There is widespread recognition that the current system of payment based on volume is unsustainable.

How does an ACO manage costs while delivering quality care?

The ACO model fosters teamwork across multiple medical specialties and care settings and focuses on the precepts of evidence-based medical care. This means that low-value or unnecessary testing and procedures are discouraged while early identification of disease, ongoing intervention and care management is emphasized through a ‘coordinated care’ approach. Best practices and standards of excellence are identified, encouraged, and rewarded.

Will Medicare patients be able to enter an ACO model?

Medicare enrollees in the greater Houston area now have the opportunity to participate in Kelsey-Seybold Clinic’s KelseyCare Advantage Medicare Advantage plan, which is based on the ACO model.

In addition, the current healthcare reform legislation, the Patient Protection and Affordable Care Act, H.R. 3590, creates an alternative payment model within Fee-for-Service Medicare to reward physician-led organizations which take responsibility for managing the quality of care and the cost received by their patient panel over time, starting January 1, 2012.

How does the ACO model help manage chronic and acute diseases?

ACOs can marshal resources for training and best-practices certification. As an example, Kelsey-Seybold has the largest number of physicians in the State of Texas who have achieved certification for excellence in diabetes care, a distinction awarded by the National Committee for Quality Assurance (NCQA) through a rigorous auditing process. Seventy-two Kelsey-Seybold physicians have achieved certification, representing 38 percent of all NCQA-certified physicians in the state of Texas.

Additionally, 58 Kelsey-Seybold Clinic physicians have been recognized for excellence in diabetes care by the NCQA and the American Heart Association/American Stroke Association through the Heart/Stroke Recognition Program. Five Kelsey-Seybold physicians have been recognized for excellence in back pain care by the NCQA through the Back Pain Recognition Program.

How can an ACO take care of me if I need emergency care or have to be hospitalized?

The ACO model encompasses the full spectrum of care, including emergency, in-patient and hospital-based care. For example, Kelsey-Seybold patients are admitted to local facilities, including St. Luke’s Episcopal Health System hospitals in the Texas Medical Center, The Woodlands and Sugar Land; Texas Children’s Hospital; the Woman’s Hospital of Texas; and many community facilities. Patients are able to access emergency care as needed.

In another example of coordinated care, Kelsey-Seybold employs 16 full-time hospitalists, specialists in Internal Medicine or Pediatrics, who are skilled in treating the unique needs of hospitalized patients. Kelsey-Seybold hospitalists coordinate the care of hospitalized patients and take a leading role in discharge planning and post-hospital care. They can access the secure Kelsey-Seybold Electronic Medical Record while onsite at local hospitals.

How do I know if an organization is really following an ACO model?

There are several distinguishing features of an ACO. An ACO is a local healthcare organization that is accountable for provision of care, quality of care, patient satisfaction and total medical cost of a defined population of patients. An ACO may include primary care physicians, specialists and hospitals that work together to provide evidence-based care through reliance on a coordinated care model. The model is highly focused on prevention, intervention and physician-directed disease and case management.

The NCQA named Kelsey-Seybold Clinic as the first U.S. healthcare organization to receive accreditation as an Accountable Care Organization (ACO) in the nation.