Health Care Reform and Your Relationship with Your Medical Doctors

By now you are all probably tired of hearing about Heath Care Reform or the Accountable Care Act as it is most often called.  This legislation has made some important contributions but you really need to understand what is still to come, specifically Accountable Care Organizations (ACOs) and the impact of ACOs on your ability to see the healthcare providers that you want to continue to see.  All of the providers at North Suburban Eye Associates, including Dr. Doug Evans, Dr. Kimberly McNulty, Dr. Omah Singh, Dr. Renell Sinha, Dr. Rita Cherian and Dr.  Maura Trail, want to assure you that we will continue to service as your eye care providers no matter the changes in this market wrought by the creation of such ACOs.

This legislation has provided some important improvements to our health care system; things like getting rid of the ability of insurance carriers to deny you coverage based on pre-existing conditions, allowing children to stay on their parent’s health insurance plan until they are 26 and eliminating annual or lifetime limits on payments from your health insurance.  And there are more good things to come through the next two years.

But one of the things in this legislation that are actively being worked on in many markets is the approval, and the implementation, of Accountable Care Organizations.  These are organizations, generally made up of a large hospital system and the physicians affiliated with that system, being established to take part in the Medicare Shared Savings Plan (MSSP).  Under this program, if the ACO can take care of Medicare patients effectively and, in doing so, save money, the ACO will share in some of those savings.  The Federal Government, including Medicare, are convinced that there is a lot of money to be saved by having these ACOs do a better job of coordinating care and, in the process, reducing costs.

In the Greater Boston market area there are currently 6 organizations approved to set up ACOs and at least two others who are planning to apply for approval yet this year.  So it is going to be next to impossible to avoid getting caught up in one of these ACOs if you have Medicare insurance.  And many commercial health insurers, such as Blue Cross Blue Shield of Mass, Harvard Pilgrim, Tufts Health Plan, Fallon and others,  are actively negotiating with the ACOs to set up something similar for the non-Medicare members in their plans.

One of the ways that the ACOs contemplate doing what they were set up to do, treat patients more effectively and thereby saving costs, is to try to provide all services to all Medicare beneficiaries assigned to their ACO within and among the providers who are part of the ACO.  So if one of your specialty medical providers, say your cardiologist or ophthalmologist, is not part of the ACO to which you are assigned, there will be lots of attempts made by your PCP and other ACO providers to convince you to see a cardiologist or ophthalmologist who is in the ACO instead of your preferred provider.  You need to know that they CANNOT REQIUIRE you to see those providers within the ACO.  You are, under the ACO regulations, freely able to choose any provider you wish to see without any ramifications to your care from the ACO’s providers.  But you will, we are sure, be bombarded with requests and information designed to hopefully convince you to see an ACO provider for all of your care.

And yes you will be “Assigned” to an ACO based on the PCP from whom you received the majority of your primary care services during the previous year prior to the assignment date.  So if you saw one or more PCP (that is a physician who is an internal medicine, family medicine, or geriatric medicine physician), you will be “assigned” to the ACO to which the provider belongs who provided you with the plurality of those service.  You cannot “opt out” of this assignment.  Your only option will be to prevent your data from being shared with the ACO which will really have no effect except to complicate the process of the government being able to evaluate the success of the ACO in achieving its goals.

So what do you do?  We suggest that you accept the fact that you have been assigned to an ACO when you are provided notice of this fact by your PCP’s office.  But we strongly recommend that you resist the efforts of the ACO, and it affiliated providers, to convince you to stay within the ACO for all of your care if any of your preferred providers are not a part of the that ACO.  See the PROVIDER YOU CHOOSE TO SEE, not who the ACO wants you to see.  And remember that all of us here at North Suburban Eye Associates want to continue to provide you with your eye care services at any of our three offices in Wakefield, Winchester or Waltham, MA.

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