Scenario: Medicare and private payers have expanded reimbursement
under Accountable care organizations (ACO). You are the chief financial officer
(CFO) of a hospital system that is forming an ACO to participate in these
payment models. The ACO seeks to improve care coordination for its patients
with chronic conditions. To provide better care management, the ACO is
interested in investing in primary care physicians and physician’s assistants
to provide more intensive care management services. After formation, the ACO
will enter contracts with Medicare and private insurers under alternative payment
models, including shared savings, bundled payments, and global capitation. The
ACO will need to determine how to set up reimbursement payments to ACO
providers and consider whether financial incentives are required to ensure ACO
providers deliver efficient care.
As the CFO of
the ACO in the provided scenario, recommend strategies for reimbursement and
utilization management. Defend your recommendations.
o How might you
set up the reimbursement payments to ACO providers, considering the alternative
payment models (i.e., fee for service, shared savings, bundled payments, or
utilization management controls might you add to align the interests of ACO
Zelman, W. N., McCue, M. J., Glick, N. D., & Thomas, M. S. (2014). Financial management of health
care organizations: An introduction to fundamental tools, concepts and applications (4th ed.). San
Francisco, CA: JosseyBass.
McClellan, M. (2015). Accountable care organizations and evidencebased
payment reform. Journal of the American Medical Association, 313(21), 2128–2130.