To successfully manage the 40 to 60 percent of costs of care driven by specialty physicians, your ACO must overcome one major obstacle when you begin to address specialty costs: the lack of information to guide your actions.
Although ACOs have claims data to calculate total costs per ACO patient and totals for specialty services, you can’t compare those costs. Why? Claims are not organized into cases or “episodes of care” that include all providers and services so that it is easier to compare case costs between patients or providers. More importantly, the small number of Medicare patients seeing any given specialist is not representative enough to evaluate that provider’s average cost per episode, because the Medicare patients could be more or less sick.
The small number problem is why CMS moved MIPS quality measurement to an all-patient basis, in order to more accurately indicate how a particular provider performs against quality standards. That accuracy benefits providers—and ACOs under the proposed new rules—by providing actionable comparative data.