As the industry keeps changing, it's important to know a company's "pedigree."
Jan. 15--Arlington-based Texas Health Resources has teamed with Blue Cross Blue Shield of Texas for what the organizations are calling the area's largest accountable care organization and one of the largest in the country.
ACOs, a part of the federal Affordable Care Act, are groups of medical providers and related companies that together work to save money while improving patient health. They were originally designed to apply to the federal Medicare program.
However, commercial ACOs like the THR-Blue Cross effort also exist, usually with participants who have health insurance through an employer.
Ron Long, THR's chief financial officer, said the as-yet-unnamed ACO is expected to have about 50,000 participants, and the number is expected to grow. THR also expects to form commercial ACOs with other big private insurers this year, Long said Monday.
THR has 25 area hospitals and says it admits more patients annually than any other hospital system in North Texas. Blue Cross Blue Shield is Texas' largest health insurer, with 4.8 million customers.
Commercial ACOs resemble managed-care organizations of the 1990s that aimed to control costs by requiring doctors and hospitals to share in the risk of rising medical costs. Those "capitated" models -- so named because they put a per capita budget on spending -- quickly faded as consumers and physicians found them too restrictive, regulators trimmed their powers, and savings failed to materialize.
Dr. Eduardo Sanchez, chief medical officer at Blue Cross Blue Shield of Texas, said one reason capitated plans were unsuccessful was that doctors and insurers lacked good information to work with.
Sanchez said all parties are now much more committed to sharing data. Physicians, hospitals and other medical providers "have not been connected electronically to the degree we will be for the near-real-time exchange of information," Sanchez said.
He said the improved data will also allow it to more accurately predict medical costs for patients, whether young or old.
"The reimbursement model is much more sophisticated" in adjusting for risk, he said. "That's very different than 15 or 20 years ago."
Long said the new ACO also differs from a capitated plan because THR does not fully share in the risk of higher medical costs, although the precise details are still being developed. Instead, the ultimate financial risk stays with Blue Cross or its self-insured customers, who must agree to participate in the program.
He said THR will approach other insurers to create similar ACOs with them.
Sanchez said Blue Cross "is engaged in active discussions with large employers," which the insurer hopes will adopt the ACO model.
All ACOs, whether Medicare or commercial, aim to control costs and improve quality by actively managing the health of patients, especially those with chronic conditions like diabetes or heart disease.
"Texas Health has been advancing the concept of putting more emphasis on keeping people healthy and out of the hospital and developing new programs like this ACO to help employers keep their employees healthy," CEO Doug Hawthorne said in a statement.
Bert Marshall, president of BCBS Texas, said the ACO is an extension of the insurer's other initiatives "designed to reward physicians for managing costs and quality of whole patient care and moving from the traditional fee-for-service approach to a fee-for-value payment model."
The ACO covers 12 North Texas counties, including Tarrant and Dallas.
Jim Fuquay, 817-390-7552
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