Tonya,

The Kaiser Permanente group is not the only organization that operates in this way. Many private physicians who hire PMHNPs prefer to do assessments in their private practice because of the billing. Physicians or Psychiatrists make more when they did the admission or initial psychic evaluation (they are supposed to as they do the diagnosis). Rural areas or underserved felt more of these barriers. Researchers have posed several barriers or drawbacks to ACO participation for rural healthcare providers. These relate to the distinctive cultures of rural healthcare providers, their infrastructure needs, and meeting the requirements of ACOs as established by the Federal Government.  The unique mission of RHCs Rural Health Clinics is dedicated to providing cost-effective health care to rural underserved areas. RHCs may perceive that partnering with other providers that serve geographic areas outside their vicinity would detract from their dedication to immediate communities. Anticipation of losing autonomy. Many rural providers, including RHCs, have operated independently for years or often decades. Over time, these providers have become accustomed to operating in relative autonomy and have developed distinct cultures reflecting their owners, administrators, and communities. The merging of cultures necessary for ACO development would require not only time but a fundamental change in approach to conducting business for many RHCs.

Inadequate capital for information technology improvements Although RHCs qualify to participate in SSP ACOs, either independently or along with other providers, many do not have adequate financial resources to develop the information technology systems necessary for coordinating care – one of the primary goals of ACOs. Care coordination is a basic tenant of ACOs and requires teamwork and information infrastructure systems that support data sharing. Shortell and Casolino stress that ACOs that are comprised of small practices, as well as most Independent Practice Associations (IPAs) and many Physician-Hospital Organizations (PHOs), would need technical assistance to restructure their practices in order to be successful (Shortell & Casalino, 2010). Nationwide, the mean size of RHCs (as measured by physicians + nurse practitioners + physician assistants) was 2.95 (Ortiz; Bushy; Zhou, & Zhang, 2013).

Thus, many Rural Health Clinics exemplify the small practices that would need technical assistance in order to successfully participate in ACOs. Rural providers that participate in Medicare ACOs have the opportunity to share in cost savings. However, in that many rural providers are small, they may not feel they have the adequate negotiating power to compete for an appropriate share in the savings of an ACO that is led by a large, integrated system. RHCs may perceive that there are regulatory barriers to their participation in ACOs. However, the final rule on the Medicare SSP does allow for RHCs to form ACOs independently or with other healthcare providers. An additional ‘de-motivator’ is that ACOs require contractual and/or legal agreements between hospitals and other providers that align incentives – a difficult goal, particularly for rural providers that are less accustomed to collaborations between multiple providers (MacKinney, Mueller, & McBride, 2011). The population base is not large enough RHCs serve non-urbanized areas that are designated as Health Professional Shortage Areas or Medically Underserved Areas. One requirement of Medicare ACOs is that they serve a minimum of 5000 Medicare beneficiaries. The population density of many RHCs’ service areas is simply too low to meet this minimum threshold. Other barriers MacKinney et al identified several additional constraints or ‘de-motivators’ to ACO participation for rural providers (MacKinney, Mueller, & McBride, 2011). Among these are rural efficiency and rural leadership inexperience. Many rural providers, they explain, are already efficient in managing expenses because they are accustomed to ‘doing more with less. Thus, they are less likely to be improving on efficiency by participating in ACOs. In addition, providing healthcare in rural areas reinforces independence and autonomy and does not offer providers many opportunities to cultivate leadership skills in settings with multiple collaborators (MacKinney, Mueller, & McBride, 2011).

References

MacKinney AC, Mueller KJ, & McBride TD. (2011). The march to Accountable Care Organizations-How will rural fare? Journal of rural health; 27(1): 131-137

Ortiz J.; Bushy A.; Zhou, Y. & Zhang, H. (2013). Accountable care organizations: benefits and barriers as perceived by Rural Health Clinic management. Rural & Remote Health, Vol. 13 Issue 2, p1-13

Shortell SM & Casalino LP. (2010). Implementing qualifications criteria and technical assistance for Accountable Care Organizations. JAMA; 303(17): 1747-1748.