Accountable Care Organization is a healthcare organization characterized by a payment and care delivery mode. lt seeks to tie provider reimbursements to a quality metrics and reductions in the total cost of care for an assigned population of patients. A group of coordinated health care providers form an ACO, which then provides care to a group of patients. The ACO may use a range of payment methods, (e.g. capitation, fee-or-service with an asymmetric or symmetric shared savings). The ACO is accountable to the patients and the 3rd party payer for quality, appropriateness, and efficiency of the health care provided. The Centers for Medicare and Medicaid Services (CMS), an ACO ...view middle of the document...
In discussions about health care reform, the concept of ACO’s has figured prominently as a potential means of stemming rising health care costs and improving the quality of health care delivery. This potential is recognized both within the Medicare program, and possibly among private and public insurers. ACO’s take up only seven pages of the new health care law. Hospitals, insurers and provider organizations are rushing to learn more about them and develop strategies to transform health care delivery within their organizations to models that enable them to participate in the next evolution of health care management.
“An ACO is a group of health care providers that agrees to be accountable for the quality and cost of health care delivered to a defined population” (Fisher, 2006). “ACO were launched in January 2012, under section 3022 of the Patient Protection And Affordable Care Act, which allows Medicare to promote accountability for a patient population and encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery” (Patient Protection and Affordable Care Act, 2010). Many different models of ACO’s have been proposed, but proponents understand that ACO concept as having three basic attributes:
• The capability to provide, and manage patients through the continuum of care across different institutional settings, including ambulatory care, inpatient hospital care and acute care
• The ability to link payments to improved care and cost reductions
• The capacity to support comprehensive, valid and reliable performance measurements (Deliotte, 2010).
Organizations or groups of health care providers that may qualify as ACO’s include the following:
• Physicians and other professionals in group practices
• Physicians and other professionals in networks of practices (e.g. IPAs & PPO’s)
• Partnership or joint venture arrangements between hospitals and physicians/professionals
• Hospital employing physicians/professionals
• Other groups that the Secretary of Health and Human Services may determine appropriate (Deliotte, 2010)
In order to qualify for as an ACO, organizations must demonstrate:
• A formal legal structure to receive and distribute shared savings
• A sufficient number of primary care professionals for the number of assigned beneficiaries (minimum to be 5000)
• Agreement to participate in the program for no less than 3 year period
• Sufficient information regarding participating ACO health care professionals as the Secretary determines necessary to support beneficiary assignment and for the determination of payments for shared savings.
• Leadership and management structure that includes clinical and administrative systems.
• Defined processes to a) promote evidence based medicine b) report necessary data to evaluate quality and cost measurement
• Compliance with patient-centeredness criteria as determined necessary (Deliotte, 2010).
In a simplified example of...