Organizational structure

  • How many ACO contracts does the provider hold?
  • How does the ACO differentiate services for different health plans (including those outside the ACO)?
  •  What does the provider do differently for the ACO (compared to its traditional health plan contracts)?
  •  What is the provider’s road map for performance improvement and managing the cost of care?

Patients and providers

  • Do the members know they are part of an ACO if it’s an attributed relationship?
  • Does the provider know when it is seeing patients in the ACO?
  • Is the provider aware it’s part of an ACO?
  • What is the provider required to commit to?
  • How does the provider gain access to needed metrics?
  •  Is improvement monitored?

Care management

  • Are ACO-attributed patients getting different care management from those who are not part of an ACO seen by the same providers?
  • How are complex patients identified? Are their needs addressed differently from others?
  •  If behavioral health services are offered, how is that information coordinated?

Quality

  •  What performance metrics are measured?
  •  Are the metrics reported to physicians and other providers? If so, how often?
  •  Are systematic improvement approaches in place to support needed redesign and monitor progress?

Payment models

  • Are provider payments based on quality or fee for service?
  •  What kind of alternative payment models are part of the ACO (e.g., bundled payments or capitation)?

Prescriptions

  •  Is information on claims and authorization coordinated if a provider uses a pharmacy benefit manager?
  • What portion of doctors have EMR access that supports medication management services?
  • Do protocols exist to optimize efforts like generic prescribing, step therapy or utilization management?

Data

  • What information does the plan provide the ACO, and how often is it given?
  •  Does it have a common EMR platform for providers? How many use it? For those that don’t, how is information exchanged between the provider and the ACO?
  •  Do providers and care coordinators exchange information in real time?
  •  Do care coordinators and physicians access the same information?