The Affordable Care Act provides many compelling reasons for safety-net providers—which serve uninsured, publicly insured, or underserved communities—to consider new ways of delivering care.
Under the Affordable Care Act’s accountable care organization (ACO) initiative, participating providers, including Federally Qualified Health Centers (FQHCs), join together in networks to care for a population of patients. They share in Medicare savings achieved by delivering more efficient and effective care—and share in losses if spending targets are not achieved. While Medicare is not a dominant payer for safety-net providers, the newly established Center for Medicare and Medicaid Innovation is developing ACO models to test through Medicaid that will likely include safety-net providers. In addition, 13 states have passed legislation to explore or implement organizations similar to ACOs, and Colorado Medicaid’s implementation of its version of the ACO, built specifically for safety-net providers, is in full swing.
Safety-net providers might want to form or participate in ACOs to capitalize on the potential to bolster primary care, to better serve their community, and to establish strong linkages to specialty care. But participating in ACOs presents several risks and challenges to safety-net providers. To examine how safety-net health systems might participate in ACOs and other innovative payment and delivery system reforms, the National Academy for State Health Policy, with support from The Commonwealth Fund, conducted 10 key informant interviews earlier this year. We spoke with leaders of rural and urban safety-net systems, state officials, and national organizations that represent safety-net providers or plans. Their responses are summarized below.
Is there interest in ACOs among safety-net providers?
All interviewees agreed that many safety-net and rural providers want to join or form ACOs. Safety nets’ mission to serve the community and coordinate care aligns well with the goals for ACOs. In addition, safety-net providers could benefit from better integration with specialty care providers through an ACO network.
What are the barriers to participation in ACOs?
Despite interest in the concept of ACOs and eagerness to participate under the right conditions, informants expressed concerns about the readiness of safety-net systems to join or form an ACO. Their top concerns included:
What’s needed to promote ACO formation among safety-net providers?
Despite such concerns, there was strong interest in advancing safety nets’ participation in ACOs or similar models. Federal and state governments can assist ACOs in reaching this goal by:
As the federal and state governments roll out ACOs and other integrated care models, the development of strong primary care systems will be fundamental to their success, particularly among safety-net providers. It will also be important to monitor the impact of ACOs on safety-net patients to ensure that our most vulnerable populations are not left behind.