Solid coverage – if I do say so myself – appears in the January issue of ACO Market News concerning the involvement of Tufts Medical Center and the New England Quality Care Alliance in a global risk-sharing contract serving 95,000 Blue Cross Blue Shield of Massachusetts HMO members.
NEQCA is a five-year-old network of 1500 academic and community physicians founded by Tufts. What stands out in comments from Jeff Lasker, M.D., chief executive of NEQCA, is just how messy global risk-sharing arrangements are – and how much care is outside the control of the provider organization at risk.
NEQCA doesn’t set or negotiate pricing at community hospitals involved in the arrangement or at third-party lab and radiology facilities. It has no say over benefit design, such as copay levels. It doesn’t control drug formularies, but is at risk for drug costs. It has no input into employee wellness programs. It has no say over premium dollars the insurer might devote to care and disease management programs. And it has nowhere near the level of reserves of an insurance company like BCBS-MA.
Another big challenge: while NEQCA can exert some influence over Tufts physicians – who are employees of the medical center – its influence over community physicians is mixed at best. At some community hospitals, both specialties and PCPs are affiliated with NEQCA and are at risk under the BCBS-MA contract. In other cases, only the PCPs are at risk – suggesting little incentive for specialists to fall in line.