NATIONAL REPORTS—Accountable care organizations (ACOs) have become a hot commodity since the Patient Protection and Affordable Care Act opened
the door for health plans to contract through an ACO for commercial enrollees. With federal money becoming available as soon
as 2012, and the promise of better quality healthcare via vertical integration, the momentum of ACOs will likely increase.
For example, in May, the Detroit-based Henry Ford Health System began a recruiting campaign to tempt private practice doctors
to join the ACO it founded in April. According to The Detroit News, the health system sent 2,000 letters to private practice doctors who have admitting privileges at its hospitals, hoping
to recruit them.
Premier, a healthcare performance-improvement alliance, is working on an even larger scale. It's organizing a nationwide collaborative
to share best practices for creating ACOs. It already includes 19 health system members with more than 70 hospitals in 15
states.
"ACOs will aid in improving the cost and quality of healthcare by the coordination of care among providers assigned to a Medicare
beneficiary," says Anthea R. Daniels, partner and co-chair of the Health Care Life Sciences practice group of Calfee, Halter
& Griswold LLP. "Unlike the [physician hospital organizations] that were created in the 1990s as joint ventures between hospitals
and physicians on staff where all doctors were included, an ACO will cover a broader sweep of providers. And the financial
incentives will be dictated by the government based on outcomes." Pilot programs will be critical to finding practical ACO models because there are such a broad range of variables to test
before best practices emerge. Chief among them: Different groups will arrive at ACO systems in different ways.
"The key attribute for ACOs is clinical integration, which might be achievable in several forms," says Paul Keckley, executive
director of the Deloitte Center for Health Solutions.
Specifically, he sees the clinical-integration options as: a medical group practice; networks of individual practices; partnerships
or joint ventures between a hospital and practicing physicians; hospitals with an employed group of physicians; and other
arrangements deemed appropriate by the Secretary of Health and Human Services.
"The law does not limit an ACO to Medicare enrollees nor does it stipulate that plans may not use a similar contracting arrangement
with a provider organization," he says.
WORK YOUR WAY UP TO ACOS
While the law's wide net provides the freedom to experiment with many different structures of ACOs, it could cause confusion
as various groups try to build the infrastructure needed to create an effective ACO. Health plans should take care not to
be caught up in the wave of ACOs without first doing their homework.
Starting small and working with strong partners will allow health plans to determine whether ACOs can improve the quality
of care and save costs. From there, plans can decide whether to expand their work with ACOs.
- A plan should independently assess the degree to which an ACO is clinically integrated and structured to accommodate risk
sharing and performance-based payments to providers, Keckley says.
- A plan should consider a subset of conditions (i.e. heart disease, type 2 diabetes, community acquired pneumonia, hip replacement,
heart failure, etc.) for its initial contracting that are supported by strong evidence so that providers are not likely to
challenge the clinical efficacy and effectiveness of the treatment recommendations.
- A plan should consider a set of short- and long-term measures of the ACO's performance using process and outcome measures
to balance cost savings and patient quality in a reasonable period of time.
Requirements of a Medicare Accountable Care Organization
- Formal legal structure to receive and distribute shared savings
- Sufficient number of primary care professionals for the assigned beneficiaries
- Minimum of 5,000 assigned beneficiaries
- Agree to participate for no less than three years
- Document information regarding participating health professionals to support beneficiary assignment
- Leadership and management structure must include clinical and administrative systems
- Defined processes must: promote evidence-based medicine; report data for quality and cost measures; and coordinate care
- Demonstrate model of patient-centeredness
Source: Centers for Medicare and Medicaid Services
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