Report: Primary care, robust reporting power ACOs
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In the report, authors Stuart Guterman and colleagues at the Commonwealth Fund identify promising organizational and payment models for ACOs and offers recommendations for their implementation and expansion.
The Medicare Shared Savings Program, which provides incentives for improved quality and efficiency to a new category of provider, the ACO, “has generated a groundswell of interest and activity,” according to the authors. However, many issues need to be addressed, including the methods of determining how accountability is to be achieved, assessed and rewarded, they wrote.
“Whether the promise of this new payment and delivery model is realized will depend both on the implementation decisions made over time by [the Centers for Medicare & Medicaid Services] and the willingness and ability of healthcare providers, payors and the general public to respond to this opportunity to improve the performance of the healthcare system,” wrote Guterman and colleagues.
Organization and payment
The Commonwealth Fund report cited three promising organizational models for ACOs:
1. Advanced primary care practice networks with infrastructure support and associated specialist referral networks;
2. Multispecialty physician group practices with hospital affiliation; and
3. Healthcare organizations with functionally integrated ambulatory, inpatient and post-acute care services.
Medicare could pay the ACO for the services it provides while continuing to pay for “out-of-organization” services directly as it does now, with any savings distributed to the ACO as an incentive for proper stewardship of the total resources required in the provision of care, either directly, as under a global fee; through shared savings, as in a fee-for-service model; or as a combination of the two, as under partial capitation, the report stated.
Policy recommendations
“The objective is to achieve a high-performance health system that is organized to attain better health, better care and lower costs,” stated Guterman et al. To facilitate the process, the report made the following recommendations for ACOs:
1. Strong primary care foundation. CMS should ensure that all ACOs have a strong primary care foundation that builds on the concept of the patient-centered medical home. The availability and accessibility to patients of a regular source of care and the ability of that provider to coordinate care received from all sources should be paramount.
2. Mandatory reporting of outcomes and total costs. ACOs should be required to report measures of quality of care, patient care experiences and outcomes or have arrangements in place to enable such reporting. Shared savings should be distributed contingent on high quality and positive patient experiences.
3. Informed, engaged patients. Providers should notify all patients that the providers belong to a given ACO, along with its characteristics and what that will mean for patients’ care. “CMS should test different approaches for encouraging patients to designate an ACO as the principal source of their care by providing positive incentives to do so (such as enhanced benefits or lower cost-sharing responsibility),” the authors wrote.
4. Commitment to serve the community. An explicit CMS commitment to serving its community, including low-income and uninsured patients, should be an integral part of qualifying as an ACO.
5. Criteria for entry and participation that emphasize accountability and performance. Entry criteria for ACOs should include, at a minimum, the availability of primary care and the capacity of the organization to ensure that patients have access to needed services across the continuum of care, as well as the ability to provide meaningful evidence of quality (including patient experiences and outcomes) and cost performance. Continued participation and rewards should be contingent on performance and accountability.
6. Multipayor alignment for appropriate, consistent incentives. CMS should actively work with providers and payors in each major market to develop multipayor ACO arrangements—including Medicare, Medicaid and private payors—whenever possible.
7. Payment that rewards high performance. Shared savings should be paid out so that the reward for reducing costs and improving quality is received promptly. CMS and other payors should make up-front support available to organizations that, because of certain circumstances, need it to offset the infrastructure investment expense required to redesign care processes and make other changes so they can become successful ACOs.
8. Innovative payment methods and organizational models. CMS should be prepared to apply different payment approaches that are suitable for different organizational configurations of ACOs in different geographic areas and different circumstances, as appropriate. All approaches should make payments contingent on reaching quality benchmarks.
9. Balanced physician compensation incentives. For ACOs receiving payment for direct care as well as shared savings, compensation of clinicians within the ACO should include incentives to deliver evidence-based care but ensure that appropriate care is not withheld.
“Much work needs to be done to establish and spread ACOs and learn from innovative care systems,” the authors concluded. “Success requires the development of trust among all the parties, as well as a willingness to test multiple approaches, measure results and adapt rapidly to improve performance. Government leadership and flexibility are essential, as are activated and engaged clinicians and patients who embrace accountability for better care and health outcomes.
“If all this occurs, moving ACOs from concept to action can play an instrumental role in achieving a high performance U.S. health system over the coming decade.”