The Medicare Shared Savings Program, commonly known as an Accountable Care Organization (ACO), redesigns healthcare delivery by offering healthcare providers a share of the savings generated through an “integration” model. An ACO requires providers to join one legal organization and achieve high-quality outcomes that should reduce patient visits; thus, lowering costs to Medicare. Lowering costs and redesigning the Medicare reimbursement to be based upon quality outcomes instead of volume is an underlying tenet of the Patient Protection and Affordable Care Act of 2010 (“Healthcare Reform”).
The definition of an ACO
Specifically, an ACO is one legal organization, with a separate governing body and corporate infrastructure, which provides healthcare services to at least 5,000 Medicare beneficiaries. The participating providers deliver care through patient-centered protocols and each patient is assigned to an ACO based upon which ACO his or her primary care physician (“PCP”) participates. The PCP is the patient’s medical home to control the patient’s treatment plans and the patient referrals to specialists, even though the patient is not required to only see providers in the ACO.
Characteristics of a successful
To be successful an ACO must deliver the care to the patient population at a lower cost than what Medicare historically paid for such services. In addition to lower costs, the ACO will be scored on the participating providers’ quality metrics. ACOs will receive a percentage of the savings based upon the ACO’s quality score. Accordingly, if the ACO providers do not offer high-quality care at a low price or in an efficient manner, the providers will not receive a financial benefit. Therefore, an ACO should include high-quality providers that are willing to discount his or her rates or deliver care efficiently to participate in the ACO.
State of ACOs today
Even though there are over 100 Medicare ACOs being formed, integrating independent physicians has been a slower process than expected for some ACOs. Some organizations are signing up healthcare providers through written contracts instead of purchasing or merging organizations. The providers are contractually required to report on specific clinical indicators to enable the ACO to report on its quality outcomes. Other ACOs launched uniform EHRs for the providers to adopt while others have used interfaces to exchange data.
IT and informatics’ role in ACOs
Without an IT infrastructure, ACOs are hampered in efficiently delivering care, tracking outcomes and reporting on quality metrics. The costs to electronically integrate are an impediment to many ACOs. On the other hand, there are providers that already electronically exchange patient data. These providers utilize the previous IT structure and engaged programmers to address the reporting requirements necessary to measure the quality metrics.
In order to expand ACOs, the underlying corporate and technology infrastructure requirements will need to be addressed. Over time reimbursement changes will drive further integration of providers and likely expand ACO models. Currently, the health information exchanges and mobile devices engaging patients are key components for successful ACO expansion.
This article originally appeared in the December 2012 issue of HIMMS News.