Understanding ACOs and Provider Integration

What is an ACO?

An ACO is a term defined in the Accountable Care Act (ACA) used to describe integrated groups of physicians, hospitals, and other providers who contract with the Centers for Medicare and Medicaid Services (CMS) and subcontracted Medicare Advantage plans. They negotiated to receive financial rewards for achieving patient-focused quality targets and demonstrating reductions in overall spending growth for their defined patient population.

As of January 2016, over 400 organizations across the country are participating in the Medicare Shared Savings Program (MSSP), which aims to promote accountability for the care of Medicare FFS beneficiaries, coordinate care for all services provided under Medicare FFS, and encourages investment in infrastructure and redesign care processes.  Beyond Medicare ACO initiatives, interest and participation in accountable care reforms has been growing both in states and in the private sector. Several states have developed programs to support the transition toward ACO-like models for either their Medicaid programs or state employees. In addition, over 300 private sector ACOs, IPAs, PHOs and Co-Ops contract with all of the major private health plans and many self-funded employers with health plans organized under ERISA have implemented payment reforms similar to the ACO model.

ACOs can be organized in a number of ways, ranging from fully integrated delivery systems to networked models within which physicians in small office practices can work together to improve quality, coordinate care, and reduce costs.  The term has also been loosely applied to the point where many provider-designed business models blur the lines that used to frame up independent practice associations (IPAs), physician hospital organizations (PHOs) and Management Services Organizations (MSOs) popular during the Clinton Administration healthcare reforms of the 1990s.

ACOs can also feature many creative and innovative reimbursement models and payment incentives, ranging from “one-sided” shared savings within a fee-for-service environment to a range of capitation arrangements with quality bonuses. Maria Todd is one of the few remaining consultants who was present in the 1990s and guided many IPAs, PHOs, MSOs and Clinics Without Walls who  still manages a busy consulting practice and that hasn't retired from the industry. As a result, she brings clients decades of lessons learned, practical tips, and insights about how capitation can be managed better than ever given the new data repositories to which we now have access.  "In the past, we had to make do and patch data together to make risk management decisions.", says Todd.

Today's ACOs are compatible with a range of other payment reforms, such as medical homes and bundled payments; they can help assure that these reforms lead to sustainable quality improvements and cost reductions. In sum, ACOs provide an ideal mechanism to transition from paying for volume and intensity to paying for value.  Don't build a cookie cutter ACO! Whatever your ACO wants to do, if your innovation makes sound business sense, Maria can help you achieve your goals and meet or exceed your operational and financial objectives.

The Outlook for ACOs

ACOs in both the public and private sector have continued to grow over the past several years, ushering in more experience and evidence on what is working and ways to continue evolving accountable care models. Maria Todd guides clients how to neutralize and work around challenges to widespread ACO implementation in the Medicare, Medicaid and Commercial population setting. She shares strategies to overcome these challenges, and designs policies, procedures, standards, metrics and workflows to encourage the continued growth and sustainability of the accountable care movement. Call on Maria Todd to share unique and in-depth insights on ACO implementation and disruptive innovation in health care reform. Shes able to help you with ideas, strategies and tactics for innovative contract and payment arrangements, individual provider and network performance measurement, clinical practice transformation, the impact of bundled care strategies, care for high-risk patients, care coordination for out of network and out of area challenges, challenges with attribution, specialty care and post acute integration, the development of pharmaceutical pricing and payment models, how to maximize data and technology, and how to develop strategies to work with community care providers. She can also help your organization prepare for the impact of the Medicare Access and CHIP Reauthorization Act (MACRA).

Physician Consolidators: Should You Merge or Sell Out?

Physician practices are rushing into the arms of physician consolidators such AmSurg, Envision, TeamHealth and Mednax to gain access to the capital and data needed to negotiate with payers and prove their quality under value-based reimbursement. In Physician Consolidators: Should You Merge or Sell Out?, a timely, one-day workshop, Maria Todd guides participants through many of the issues that arise in branding, contracting, risk sharing and more before making the decision to join up with a physician consolidator firm.

Healthcare acquisitions as a whole are happening at a steady rate. Companies like AmSurg and Envision offer a no-cash, all-stock transaction to keep the combined company's leverage low for more physician acquisitions. Physicians must determine their objectives for the merger, their need for cash and their future career path. Some may not be of the personality required to work in a corporate arrangement. Others may find it exactly what they need. These and other critical considerations and concerns are addressed what Maria Todd covers in Physician Consolidators: Should You Merge or Sell Out?

Rather than come at this decision with strictly financial facts and figures and spreadsheets, Maria Todd guides physicians through the many other considerations (managed care, growth, brand integrity, sustainability outlook of the prospective partner, assets of each partner and corporate culture) that must be weighed before making other decisions about the value of the deal. She brings additional options to the table that may not require giving up as much to meet physician business objectives. One way that many physicians are taken by surprise by consolidators is the practice of working with strategic buyers, where consolidator partners buy up rivals and complementary products. These deals may make total sense in business, but may raise serious concerns for compliance with Stark and other self referral relationships that are prohibited. Maria brings examples of several seemingly honest and appropriate deals that have transpired only to be quashed later on, after everyone is settled in place in the new arrangement, and have the rug pulled out from under them by regulators that disagree with the merger's legal counsel and force them to unravel the deal. Many physicians don't have the mettle to go through this a second time. Private equity firms are also far more emboldened when it comes to taking cash out of the acquisitions.

CEU Credit: 7 hours

Consolidators: The new PPMCs

Decades ago, PhyCor and PhyMatrix were early consolidators in the healthcare industry. "Consolidation" is a new term in the area of healthcare practitioner (medical, dental and psych) practice organization and management. Consolidation refers to the linking together, or networking, of separate independent practices. Typically, these arrangements are driven by non-practitioner entrepreneurs that have recognized a potential income source in uniting the growing managed-care market need for providers with practitioners who are disillusioned and stressed by private-practice problems.

One of the issues surrounding consolidators is that unlike IPAs, PHOs and ACOs that are physician owned, the consolidators are generally owned by non-physicians and include an employment model, which may be prohibited under the corporate practice of medicine (CPOM) laws in a state. Participants who attend Consolidators: The new PPMCs, a one day workshop for physicians, dentists and other healthcare practitioners, receive a handout that outlines the current CPOM restrictions, state-by-state.

About the instructor:
Maria Todd has organized more than 400 integrated practitioner groups around the USA and abroad. While the term "consolidator" may be the new bright shiny object, the concept of consolidating and integrating medical professionals recruited from practices which have been faced with the choice of avoiding managed care and losing patients or joining plans and losing money is not new. The primary purpose of a consolidated practitioner network is to provide convenient "one-stop shopping" for the managed-care industry and intensified market leverage (deal-making ability) for the consolidator.

So You Want to Build an ACO?

Many hopefuls wish to join the ranks of more than 700 integrated physician groups and more than 25 million people already served by them. In So You Want to Build an ACO?, Maria Todd leads workshop participants through a one-day discovery workshop for those interested in creating an ACO or other integrated health delivery system (IPA, PHO, MSO, Co-Op). She describes how groups can apply innovative tactics and strategies to demonstrate capacity for care coordination, outcomes measurement, physician leadership, peer monitoring and reporting and network design and management. These take time and money.

Maria Todd explains that unlike the integrated physician networks of the 1990s, we now how at our access, information technologies that facilitate patient-encounter tracking, utilization management and monitoring, predictive modeling, evidence-based outcome protocols, and many tools for patient-adherence monitoring and engagement. She explains how start-up costs for an ACO can exceed $5 million or more, and how the startup can take two years to commence seeing patients, all while burning cash without income.

Maria also discusses how business partners, sometimes a hospital, but just as often a private equity fund that takes on a "consolidator" role, or an independent management company or a health insurer or TPA, who are able to bring a bolt-on solution for the infrastructure and operating expertise and how to work with them to everyone's mutual advantage.

ACOMaria Todd is the author of two industry best seller books on physician integration and alignment business development, payer contracting, and operations management,  and has experience coming from working with over 400 integrated health delivery systems and startups, examining several as an expert witness in damages cases involving IPA and MSO organizers and advisers, and consulted to about a hundred more outside the USA since 1993.

CEU Credit: 7 hours


In most instances, physicians call Maria Todd because they are in one of two situations:

 The typical first calls come either early in the pre-startup strategic planning process or when things aren't going so well.

Chances are you've decided with a group of close confidantes to work on establishing a network of physicians, either independent of or in collaboration with one or more hospitals. you may have read Maria's industry best-seller book Physician Integration and Alignment: IPA, PHO, MSO, ACOs and Beyond and you are ready to call on an expert for help.  The reasons physicians are attracted to these integrated health systems are many. The primary reasons are a) input over destiny b) group leverage potential in contracting with health plans, and c) building an infrastructure that supports them in the delivery of the best care possible to patients. By sharing in the investment of technology, practice management systems and clinical reporting tools,  participating network physicians and extenders can coordinate care with specialists, hospitals and other healthcare providers. With these tools in place and a well-trained management team and navigator personnel, physicians are better able to manage their patients’ care, collaborate, achieve better outcomes and manage the total cost of care.


Working with Maria Todd

Brainstorming Sessions

Maria Todd facilitates brainstorming sessions with providers and hospitals that need a fresh pair of eyes and lessons learned from other assignments around the nation. She helps the group to flush out and refine a strategy or a tactical plan or solve problems that exist with workflows, patient engagement, physician leadership development, communications, contracting, and other problems that arise for ACOs, IPAs, PHOs, MSOs and Co-Ops.


She charges a flat fee to come to your location and spend a day or two in a strategic brainstorming retreat.  Clients who wish for her to remain for a second day are granted a 2nd-day discount. Her fully inclusive rate covers her pre-arrival conference time with retreat organizers, her preparation and research time to learn about your group and your issues, study your market, and then facilitate your brainstorming retreat.  The price quoted includes her travel costs (airfare, hotel, ground transfers, and incidentals).

If necessary, Maria's meeting and education planners can also plan the entire event including travel, venue, and team building activities coordination for your group at retreat locations anywhere in the world.

Brief Consultations

Maria Todd is available for brief consultations in person or by teleconference or web conference for one person or a whole team.


Her time is charged by the hour, paid in advance when you book your appointment. You decide how much time you may need, and there is no limit on the number of participants in the call or at the meeting. Any overtime charges are balance billed after the meeting, if applicable.  If you wish for her to travel to your location for the meeting, travel time is charged at 50% of her hourly rate, plus travel costs if she must fly to attend your meeting and book a hotel accommodation or incur ground transportation costs.

Once an appointment is booked, if a cancellation is requested by the client, the non-refundable fee paid applies to the rescheduled date, any travel costs or change fees are charged to the client at 100% of out of pocket costs.

Ongoing Projects and Assignments

Maria Todd accepts short-medium- and long-term projects and assignments when time permits. She usually reserves 8-10 hours per week to fit in short term engagements and assignments for established clients so arranging time on her "bench" on short notice can sometimes be quite difficult if her calendar is full.


Maria bills most ongoing projects on an hourly basis at her usual and customary rate. Volume discounts are given to clients that hire her for more than 100 hours in a year. To begin working with her, a fee agreement must be executed and initial deposit must be paid in advance. Generally initial deposits range from $3500 to $5000 and clients are requested to replenish the funds when the deposit retainer reaches a certain level $1000-$1500.

In the event you must break your agreement:

Sometimes cash flow gets tight. It happens.  It's not the end of the world. In the event that required funds deposited on account are not replenished, the client's work is removed from Maria's workflow to make room for other clients who need her personal attention.  Your work will be pended and there will be no further work performed once the deposit is completely exhausted until the funds are replenished. Work that has been completed up to that point is not held because it has been prepaid. Deliverable that is not complete at that point is held for completion once payment is received.  Placement back into Maria's project load and workflow is subject to time available at the time replenishment is paid. Maria will advise if the delay may be significant to your unique circumstances in order to set clear expectations.

Situation Assessments

After more than 30 years working as a consultant and strategist, Maria's mantra is "Prescription without Diagnosis is Malpractice." Maria opens new projects with an initial situation assessment. This includes gathering data, researching relevant facts and statistics, asking questions, conducting stakeholder interviews, and learning your symptoms and objectives. This may involve travel, purchase of data and special proprietary published research or reports, and other miscellaneous expenses. Once the situation assessment is complete, she analyzes what's been gathered and does a little "theoretical woodshedding" to test her fully develop her recommendations before defining the base problem and sharing her best recommendations on how to solve them. Armed with the recommendation, you are free to proceed without further assistance from Maria or you are welcome to create a new scope of work based on the recommendations and your desire for assistance to accomplish the planned implementation of your chosen solution. While situation assessments are often billed on a flat fee project basis, follow on engagements for implementation are not quoted or even estimated until the precise number of hours per month or per week have been determined, in addition to a better estimate of costs and a timeline.

Work Performed by Associates and Assistants

Maria Todd charges for her work at her usual and customary rates. Work performed by associate consultants are charged a their usual and customary expert rates. Work performed by research assistants and analysts is billed at a much lower rate per hour than a key expert. Generally these rates are $50 per hour, or less.

Requests for Proposal

Maria Todd will respond to a request for proposal as long as the RFP contains enough information to respond. Sole source proposals are given priority. RFPs must state the value of the award opportunity, scope of work, and terms of reference. They must state the nature of the problem or symptoms, time frame to complete the project, identification of the project manager, and identification of other experts who have already been appointed to the project. Maria Todd will not respond to an RFP that contains an undefined scope of work for a defined price other than to quote an hourly rate for services rendered.

Projects Paid "On Contingency"

By corporate policy, Maria Todd is not permitted to accept projects on contingency.

Projects compensation in the form of equity shares

Maria rarely accepts compensation in the form of equity shares. You are welcome to enquire, but please understand that decisions to accept such offers in lieu of payment for services rendered are subject to significant scrutiny and Board of Director and legal review and approval. The approval and vetting process can take as long as 90-120 days. Out of pocket expenses are expected to be paid by the client regardless of other arrangements for consultation and advisory services performed.

Since 1993, Maria Todd has built more than 400 IPAs, PHOs, MSOs and ACOs in the USA, along with the world's largest medical tourism "cluster" organization and the first and only Globally Integrated Health Delivery System®. 

The infrastructure you will build to operate the network may be very lean, or it could morph into a full service practice management MSO that allows physicians and extenders to focus solely on matters related to direct patient care. Maria can set up the MSO for your network and train the staff to manage:

  • Technology that connects your physicians to real-time patient information
  • Care management services for patients, coordinated by their PCPs and navigators, to improve quality and manage the total cost of care
  • Single point of service for claims for all network patients
  • Collaborative employee benefit programs for physicians and their employees
  • Partnerships with new health plans and delivery systems to expand patient access
  • Negotiation with health plans and to handle all contracting matters including contract review and renegotiations
  • Handle billing and claims payment mattes, appeals of denied claims and short paid claims recovery
  • Web-based credentialing and re-credentialing for all health plans
  • Support for your office and patients on nights and weekends through an After Hours Care Network and call coverage rotation by conscientious physicians, NPs and PAs of similarly aligned ilk

How to get started

The first step is to call or write and tell us where you want to locate your new practice, your area of specialization, your current employment situation, your time line, and your budget. We typically start with having you read and work through Maria's Physician Integration and Alignment book, and then schedule a face to face consult. Optimally, this meeting takes place at your location, but alternatively, we can meet with you at our office in Denver, which is set up with conference rooms and work tables, white boards, and lots of resources we maintain in the office.  Afterward, depending on your needs, we can support most everything else via telephone and web-conference at our usual and customary hourly rates.  When we travel to you, the fee is inclusive of travel expenses, travel time and consultation time. Maria will not perform any work without a fully-executed fee agreement and modest retainer deposit. As the retainer deposit account is depleted, Maria requests a modest replenishment to continue working on your project.

[RIGHT]  THE #1 BOOK IN THE INDUSTRY.  The Physician Integration and Alignment: IPA, PHO, ACOs and Beyond written by Maria Todd is like no other book on the market. It was originally designed as self-help workbook book to help physicians plan, launch and operate their integrated health delivery network to work with Medicare and/or commercial payors. Derive the greatest value from time spent with Maria during one-on-one consulting when you first read this book and begin your brainstorming and planning at a deeper level. It is now available for purchase at all major retail and online booksellers.

Denver-based consultant, award-winning speaker, trainer and author, Maria Todd, brings you her best insights and strategies from working on various healthcare, health tourism and international development projects in the USA, Europe, Asia, Latin America and Central America for over 30 years.

As part of her professional work as a consultant, speaker and author, Maria Todd reviews and advises clients on planning, launching and operating this new business model for groups of physicians independent of or in collaboration with health facilities. She provides training and coaching on what services to include in participation offer and infrastructure, how to operate your network and drive up patient engagement and medication compliance.

In addition to the USA, integrated health delivery models are also gaining traction on five continents for medical tourism business. Maria has worked on private and public-private partnership (PPP) startup projects in each of these countries and is considered a leading expert in the USA for those physicians that are ready to work together towards better patient care.



Maria Todd offers Master Classes and Workshops

Learn about IPAs, PHOs, MSOs, ACOs and Co-Op models from Maria Todd.

Maria Todd frequently presents workshops, Master Classes, webinars and seminars for hospitals, clinics, trade associations, professional societies and also gives guest lectures at medical staff meetings and university programs.  In addition, she often conducts focused, custom training programs onsite for clients including the Cleveland Clinic, Bangkok Dusit Medical Services, the Korean Health Industry Development Group, The Monterrey Health Tourism Cluster, The Republic of South Africa, Opus Dei Health Systems, Adventist Health, Trinity Health (formerly Catholic Healthcare East), Order of St Francis, Gundersen Health, Spectrum Health, Marshfield Clinic, Pediatrix®, Glaxo, Bristol Myers Squibb, Allergan, the Veterans Administration, KCI, Hill Rom, and hundreds of other leading brands in the healthcare industry.

Maria trains physicians and healthcare executives on the business and operational differences related to IPAs, PHOs, MSOs, ACOs and Co-Op models. Regardless of the model you choose, there are subtle differences in how you'll plan, budget and launch your new network, how you'll establish the network's competitive brand, your market position, and how you'll contract and promote your new business model. She also covers use of social media as a marketing strategy, reputation management for physicians, public appearances and public relations management, e-newsletter creation, your member services handbook for patients, brochures, flyers and your website.

Maria K Todd, MHA PhD

Chief Executive Officer
The Mercury Healthcare Companies
600 17th Street
Suite 2800- South Tower
Denver, Colorado USA 80202