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Playing the ACO Symphony
Playing the ACO Symphony |
 | Alan Cudney Executive Consultant |
There’s a great line in the 1995 movie, Mr. Holland’s Opus. At the end of his career, Mr. Holland, a music teacher, feels dissatisfied that he was never able to complete his life’s dream of being a composer. One of his students tells him, “There is not a life in this room that you have not touched, and each of us is a better person because of you. We are your symphony, Mr. Holland. We are the melodies and the notes of your opus. We are the music of your life.” Done well, an ACO is like a symphony played for an audience of patients. All the moving parts come together to create something bigger than each individual piece.
The Instruments
The instruments of an ACO include government regulations and pay structures. Section 3022 of the Affordable Care Act requires the Centers for Medicare & Medicaid Services (CMS) to establish a shared savings program to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs. The Shared Savings Program is designed to improve beneficiary outcomes and increase value of care by promoting accountability for the care of Medicare FFS beneficiaries, requiring coordinated care for all services provided under Medicare FFS, and encouraging investment in infrastructure and redesigned care processes.
The instruments of an ACO include government regulations and pay structures. Section 3022 of the Affordable Care Act requires the Centers for Medicare & Medicaid Services (CMS) to establish a shared savings program to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs. The Shared Savings Program is designed to improve beneficiary outcomes and increase value of care by promoting accountability for the care of Medicare FFS beneficiaries, requiring coordinated care for all services provided under Medicare FFS, and encouraging investment in infrastructure and redesigned care processes.
The rules specify that an ACO must have a governing board that is responsible for its oversight and strategic direction. The rules also specify that ACO management must be held accountable for the ACO’s activities described in the ACO regulations. It must have a transparent governance process and demonstrate a fiduciary duty to the ACO, and hence, the patients served. The board must be separate and unique to the ACO, since participants likely come from multiple, disparate entities. In addition, the governing body must include a Medicare beneficiary representative served by the ACO who does not have a conflict of interest with the organization. Interestingly, ACO participants must control at least 75% of the ACO’s governing body. If this is not the case, the ACO must give a reason why, and describe how it plans to involve participants in governance, or provide meaningful representation by Medicare beneficiaries.
The Players
There are many actual players in an ACO, listed here:
The Players
There are many actual players in an ACO, listed here:
- ACO professionals in group practice arrangements
- Networks of individual practices of ACO professionals
- Partnerships or joint venture arrangements between hospitals and ACO professionals
- Hospitals employing ACO professionals
- Critical access hospitals
- Rural health clinics (RHCs)
- Federally Qualified Health Centers (FQHCs)
Furthermore, an ACO does not necessarily need to be a newly formed entity. Participants can use an existing entity, as long as it meets all the eligibility requirements specified in the legislation. However, it must be a legal entity, which is separate from the entities represented by the participants. The ACO must “have a leadership and management structure that includes clinical and administrative systems that align with and support the goals of Shared Savings Program” (42 C.F.R. §425.108). The ACO must be managed by an individual whose election and removal is controlled by the governing body. Clinical management must be controlled by a senior-level medical director who is a board-certified and licensed physician of one of the ACO providers or suppliers. The clinical manager must be physically present on a regular basis at an ACO participant’s location.
As this diagram shows, participants in an ACO run the gamut of healthcare professionals:
As this diagram shows, participants in an ACO run the gamut of healthcare professionals:
Click here for full-size diagram
The Audience
From the patient perspective, the enrollment process is not like insurance. It is essentially invisible to the Medicare FFS beneficiary. Patients are not required to see providers within the ACO but they must be notified that their provider or supplier is participating in the ACO. The ACO must also inform beneficiaries of its ability to request claims data about them and give them opportunity to object.
From the patient perspective, the enrollment process is not like insurance. It is essentially invisible to the Medicare FFS beneficiary. Patients are not required to see providers within the ACO but they must be notified that their provider or supplier is participating in the ACO. The ACO must also inform beneficiaries of its ability to request claims data about them and give them opportunity to object.
Beneficiaries will be assigned to an ACO, in a two-step process, if they receive at least one primary care service from a physician within the ACO:
- In the first step, a beneficiary is assigned to an ACO if the beneficiary receives the plurality of his or her primary care services from primary care physicians within the ACO. (Primary care physicians are defined as those with one of four specialty designations: Internal medicine, general practice, family practice, and geriatric medicine, or for services furnished in a federally qualified health center (FQHC) or rural health clinic (RHC), a physician included in the attestation provided by the ACO as part of its application.)
- In the second step, beneficiaries are only considered who have not had a primary care service furnished by any primary care physician either inside or outside the ACO. Under this second step, a beneficiary is assigned to an ACO if the beneficiary receives a plurality of his or her primary care services from specialist physicians and certain non-physician practitioners (nurse practitioners, clinical nurse specialists, and physician assistants) within the ACO. A plurality means the ACO participants provided a greater proportion of primary care services, measured in terms of allowed charges, than the ACO participants in any other ACO or Medicare-enrolled provider TIN, but can be less than a majority of services.
Patients should enjoy benefits under ACOs. ACOs will be held accountable for the quality, cost, and overall care of assigned Medicare FFS beneficiaries. CMS has proposed 33 measures under four domains to determine an ACO’s success in promoting the Three-Part aim:
- Patient/caregiver experience
- Care coordination/patient safety
- Preventative health
- At-risk populations
CMS will establish a method to calculate the ACO’s “quality performance score”, which will evaluate the ACO’s meeting of CMS’ established quality performance standards.
Learn more about how ACOs are changing the landscape of healthcare as we know it.  |
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