CMS issues long-awaited ACO guidelines
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ACOs take a team-based approach to care and link payment directly to the quality of care provided. CMS guidelines for ACOs are among the provisions of section 3022 of the Patient Protection & Affordable Care Act (PPACA). As part of the act's Shared Savings Program, ACOs are intended to expand value-based purchasing, improve quality reporting and the level of performance feedback available to providers, as well as enhance quality, improve outcomes and increase the value of care, according to the 429-page proposed rule.
PPACA establishes the types of groups of providers of services and suppliers, with established mechanisms for shared governance, that are eligible to participate as ACOs. Among others, these groups include:
• Professionals in group practice arrangements.
• Networks of individual practices of professionals.
• Partnerships or joint venture arrangements between hospitals and professionals.
To participate in the Shared Savings Program as ACOs, eligible groups must meet multiple requirements, including the following:
• The ACO is accountable for the quality, cost and overall care of the Medicare fee-for-service (FFS) beneficiaries assigned to it.
• The ACO agrees to participate in the program for not less than a three-year period.
• The ACO includes a sufficient number of primary care ACO professionals for the number of assigned Medicare FFS beneficiaries. The ACO shall have a minimum of 5,000 such beneficiaries assigned to it.
• The ACO shall provide information regarding ACO professionals participating in the ACO as is deemed necessary to support assignment of FFS beneficiaries, the implementation of quality and other reporting requirements and the determination of payments for shared savings.
• The ACO has a leadership and management structure that includes clinical and administrative systems.
• The ACO defines processes to promote evidence-based medicine and patient engagement, report on quality and cost measures and coordinate care through the use of telehealth, remote patient monitoring and other technologies.
For purposes of quality reporting, the measures used to assess the quality of care furnished by ACOs may include measures of clinical processes and outcomes and patient and caregiver experience of care and utilization (such as rates of hospital admissions for ambulatory care-sensitive conditions), according to the proposed rule.
ACOs are required to submit data in a form and manner specified by the Secretary of the Department of Health and Human Services (HHS) on certain quality-of-care measures. Such data may include care transitions across healthcare settings, including hospital discharge planning and post-hospital discharge follow-up by ACO professionals, as deemed appropriate by the secretary.
The HHS secretary may incorporate reporting requirements and incentive payments related to the Physician Quality Reporting System, such as requirements and payments related to e-prescribing, EHRs and other similar initiatives, and may use alternative criteria than would otherwise apply for determining whether to make such payments.
In addition, the secretary is required to monitor ACOs for “avoidance of at-risk patients.” If an ACO is found to be avoiding patients at risk in order to reduce the likelihood of increasing costs to the ACO, the secretary may impose an appropriate sanction on the ACO, including termination from the program, the guidelines state.
Under the Shared Savings Program, subject to the requirements concerning monitoring avoidance of at-risk patients, Medicare will continue to reimburse providers of services and suppliers participating in an ACO under the original Medicare FFS program under Parts A and B in the same manner as they would otherwise be made, except that a participating ACO is eligible to receive payment for shared savings if:
• The ACO meets quality performance standards established by the secretary; and
• The ACO meets the requirements for realizing savings.
Under the Shared Savings Program, ACOs will only share in savings if they first generate shareable savings and then meet the quality standards.
Consistent with section 3022 of the PPACA, the Shared Savings Program must be established by Jan. 1, 2012, according to CMS. Healthcare organizations of all kinds have begun implementing their own versions of an ACO framework, and even in the absence of formal CMS guidelines, ACO costs and benefits have been widely studied and debated. (Click here to see commentary on today's announcement by CMS Administrator Donald M. Berwick, MD, MPP.)
Comments must be received 60 days after date of publication, and may be submitted electronically or via conventional and priority mail. Click here to see the Proposed Rule.