ERISA: The New Kid on the ACO Block

The CMS-Medicare Accountable Care (ACO) program has received so much administrative and clinical attention recently that another large and important segment of the health care population is being all but ignored.  Employer-based ERISA health plans include most of our working population, and these younger patients face many of the same clinical problems that their older parents face.  In fact, employers, who finance the health care for their employees, are seeing annual increases of 5-10 percent.  Many companies already work through Independent Practice Associations (IPA) or Clinically Integrated Networks (CIN); however, it makes increasing sense for practicing doctors to work through a single organization managing all the populations in the community.

Most physicians would agree that they do not treat patients differently due to their insurance type.  Of course, there are differences based on formulary or benefit package, but it is clearly more efficient to consider clinical matters first.  Nonetheless, expanding the ACO patient base to include ERISA-based patients is a logical next step.

Employers not only want to see lower costs for the health benefit, they also want to see better outcomes.  Employee absenteeism and workplace inefficiency due to health reasons are also a major concern. Jed Constantz, DBA from Employer Advantage, works with companies to select “featured and favored” primary care physician groups to medically manage the company’s population.  These medical groups are paid well to tightly manage the specific population, not only by reducing cost, but also by introducing and monitoring useful preventative measures.

Employers may see increased pharmacy and outpatient visit costs as they measure lower emergency room and inpatient expenses.  Additionally, as their employees feel better, absenteeism is reduced, and personal productivity invariably rises. In the employer’s view “primary care is an investment and the rest of healthcare is a payment.”

The community-based, primary care ACO that is committed to better care for their population is well suited for an expanded role with ERISA-based patients.  The ACO can then be considered the “featured and favored” group to manage this new population. Their data visualization, analytic, and performance management systems must be able to expand to include the obstetrical and pediatric groups.  Additionally, it is essential that one performance management system efficiently guides the doctors toward current and sustainable success with consistent data across all managed populations.

ERISA is actually a long-term member of the health care neighborhood.  The ACO is just a welcoming organization that can integrate “her” along with the other kids on the block.  Medicare MSSP, NextGen, Medicare Advantage, Medicaid, and now ERISA are all members of the health care community better described as “us.”


Craigan Gray

About the Author

Craigan Gray, MD, MBA, JD

Dr. Craigan Gray, Salient Healthcare’s Chief Medical Officer, brings rich experience from private practice, hospital leadership, and governmental health-benefit programs. Prior to joining Salient, Dr. Gray was director of North Carolina’s $12 billion Medicaid program. His time as VPMA at Bon Secours Our Lady of Bellefonte Hospital in Kentucky was distinguished by moving the facility into the top-quality performance tier for Health Grades and CMS health quality indicators. Dr. Gray is a Stanford University trained Obstetrician/Gynecologist. In addition to an MD degree, Dr. Gray holds an MBA degree and a JD degree. He is a Certified Physician Executive and is published in various medical journals.

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