Regional ACO networks for self-insured employers

by Frank Tiedemann on March 5, 2012

If you are ready to embrace Medicare ACO implementation, have you also considered organizing to serve the self-insured employer market? Self-insured employers represent a 3rd of private companies and organizations who provide two thirds of employees with private health insurance. The opportunity is to help those employers maintain healthcare benefits for their employees at affordable cost with improving clinical quality. In other words, to create a private ACO–like relationship with employers in your service area.

It’s important to note that such relationships build on the earlier concept of direct hospital–employer contracting. Today it’s possible to offer the employer more predictable and stable pricing for health care services because of clinical data that allows for risk analysis and stratification, identification of chronic health issues among the employee population, and the identification and management of high-risk populations and individual high dollar cases. These activities generally fit under the rubric of population health management.

Often dismissed as wellness and health promotion, population management has come into its own in recent years with the creation of massive comparative clinical databases. Big data allows employers to identify those conditions and individuals who generate the greatest cost to the self-insured plan and to take steps to help those individuals manage their health.

Groups of hospitals and physician organizations can come together under the new accountable care regulations to be recognized as clinically integrated networks. This legal concept, enunciated by the Department of Justice and the Federal Trade Commission, allows organizations that do not share the same economic parent to act as if they are under common ownership. This permits them to contract as a single entity and set common prices making them, in my opinion, a regional ACO designed to serve the self-insured employer market.

I address these and other issues in my new “PlayBook for the Accountable Care Strategist”. You may download a free copy of the PlayBook at .

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