Succeeding with quality-based health care programs

Under the Affordable Care Act (ACA), the Centers for Medicare & Medicaid Innovation (aka the Innovation Center) was created to develop and test new models of quality-based healthcare payment and service, designed to reward providers for efficient, high-quality outcomes. The emergence of ACOs (Accountable Care Organizations) has been a significant trend in quality-based healthcare reform; private payers are following suit, developing their own versions of ACO-type contracts.

Independent practices should regard these efforts as an inevitable, if very gradual, shift from the traditional fee-for-service payment model to quality-based healthcare. To succeed in these newer initiatives, some independent physicians decide to sell their practice, merge with a hospital-led ACO, or join a physician-led ACO.

But there is an increasingly strong case for being able to thrive independently and succeed under quality-based healthcare reform. First, initial reports have shown that the Centers for Medicare & Medicaid Services (CMS) ACO programs have had mixed results.1 And private payers are creating an expanding array of quality-based healthcare reimbursement contracts outside of the formal ACO program. For example, the Massachusetts Blue Cross Blue Shield Alternative Quality Contract (AQC) has been improving the quality of patient care while simultaneously slowing the growth in health care spending.2

Winning at risk-based reimbursement does not necessarily require an independent practice to formally join an ACO or other quality-based healthcare program. Regardless, practices must focus on improving quality and efficiency simply to continue being competitive with, and receive referrals from, ACOs and other risk-based entities in their region.

Primary care physicians who want to thrive as an independent will need the right tools for:

  • tracking patient outcomes and provider performance
  • coordinating care
  • managing payments from quality-based healthcare contracts

Independent specialists will need to become quality-focused, low-cost providers in order to attract others operating in a quality-based healthcare environment.

To succeed under any value-based payment reform, independent practices need to have:

  • An EHR that streamlines practice workflow, gives providers access to evidence-based guidelines, and offers intelligent work delegation to maximize practice efficiency
  • Secure communication and interoperability with multiple clinical partners, including seamless, secure data exchange with local ACOs, to meet care coordination requirements
  • Health information technology that facilitates the tracking and monitoring of patients both inside and outside the practice, in order to measure and report on quality-based healthcare outcomes

1 CMS Data Show Mixed Results From Medicare ACO Programs. (January 31, 2014) California HealthOnline. Available at:

2 Song et al. (July 11, 2012) “The ‘Alternative Quality Contract,’ Based on a Global Budget, Lowered Medical Spending and Improved Quality.” Health Affairs.

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