Accountable Care Organizations (ACOs) Overview
While the Shared Savings/Accountable Care Organizations initiative may sound like a newly constructed system for care coordination and cost control, the emphases on quality reporting and data exchange are not. Those factors were reiterated as foundational aspects of the Shared Savings Final Rule issued Oct. 21, 2011 driven by comprehensive EHR and health IT technologies.
Specific Goals of the Shared Savings initiative include:
- Harness growing healthcare costs annually approaching $2.5 trillion
- Targets America’s approximately 50 million Medicare patients to advance EHR-driven preventive medicine, care coordination and wellness focusing on each patient’s care continuum as a patient-centered medical home (PCMH) concept.
- The ability to collect and analyze clinical, claims and payer data to enable quality monitoring and reporting
- Promotes remote monitoring/telehealth to develop PCMH objectives and advance the communication of care plans to patients.
- Stresses the need for development of health information exchanges (HIEs)
Improving patient outcomes through care plans coordinated throughout physician practice, hospital and related healthcare settings is an achievable goal through quality electronic health record systems impacting clinical, financial and administrative ends.
Accountable care models are currently seen within institutions such as the Mayo and Cleveland clinics, where affiliated physicians and payers are also included. Similar pilot programs for accountable care organizations have been in existence since mid decade.
What are Your Goals for Joining an ACO?
The most important item to consider is how you can position your practice for the future of accountable care. Ask yourself several questions — what are the goals of my practice? Do I have a three- to five-year operating or growth plan? Consider the various financial and strategic incentives to joining an ACO. Will you have access to bi-directional data exchange and interoperability? Are the agreements binding or non-binding?
Begin by assessing the EHR, interoperability and overall technology infrastructure of your practice. Check specific Medicare beneficiary patient volume and be aware that patients can opt in or out of the accountable care organization on a voluntarily basis. Begin engaging peers, associations, payers, employers and health systems in your community to see what they are planning. There could be an ACO forming near your practice.
Identify CMS, private payer or combined care coordination/ACO opportunities as well. Remember private payers are empowered to form ACO entities as well. Most importantly, don’t wait; accountable care organizations, accountable care and "at-risk” communities are forming today around the country and it’s important to ensure you are on the bleeding edge.
Eligible ACO Membership
The Shared Savings Final Rule offers flexible start dates for ACO entities, either April 1 or July 1 of 2012. Participation within an ACO, as defined in the final rule, maintains a 5,000-patient minimum and allows providers to join more than one entity. Membership is available to a wide range of care providers in an effort to coordinate care among various settings.
The following are eligible to join an ACO:
- Primary care physicians, specialists, nurse practitioners and clinical nurse specialists in group practice arrangement
- Networks of individual practices of ACO professionals
- Partnership of joint-venture arrangements between hospitals and ACO providers
- Hospitals employing ACO providers
- FQHC, CHC RHC facilities, eligible critical access hospitals, and home health networks
Shared Savings models have been compared to former HMO models, but there are a few instances in which they differ. Providers, not payers will be responsible for quality care and accountability. Also, the accountable care organizations are structured to contract with provider organizations, not health plans. There is a more-flexible system of care models available in an ACO, including the fact that health plans are allowed as an entity within an ACO. Overall, the most major difference is the utilization of health IT as the foundation.
Quality Measure Point System
The final rule offers more flexibility than the proposed rule, as there are now only 33 quality measures to report, reduced from 65. This will remove some of the pressure from the ACO to be successful within the program. There are four reporting domains and the entity must achieve at least 70% within each of the four to meet benchmarks:
- Care coordination and patient safety
- Preventive health
- At-risk population
- Patient and caregiver experience
Quality Measure Graph
Within the first domain, care coordination and patient safety, there is a quality measure specifically for EHR adoption. This measure is double-weighted to express the necessity to build an ACO’s foundation on electronification. Without meeting this measure, it will be nearly impossible for accountable care organizations to pass with 70% quality score.
Within the fourth domain, patient and caregiver experience, CMS will administer and fund the initial patient satisfaction survey during the first two years of the organizations.
