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What is an Accountable Care Organization? . A Presentation by Michealle Gady Families USA June 13, 2011. ACOs Defined . Generally – ACOs are a group of providers who are held accountable for improving health care quality while lowering the rate of growth in health care spending

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What is an accountable care organization

What is an Accountable Care Organization?

A Presentation by

MichealleGady

Families USA

June 13, 2011


Acos defined
ACOs Defined

Generally – ACOs are a group of providers who are held accountable for improving health care quality while lowering the rate of growth in health care spending

Medicare Shared Savings Program ACO – a legal entity that is recognized and authorized under applicable State law…comprised of an eligible group of ACO participants that work together to manage and coordinate care for Medicare fee-for-service beneficiaries…established a mechanism of shared governance that provides all ACO participants with an appropriate proportionate control over the ACOs decision-making process


Who is eligible to form a mssp aco
Who is Eligible to Form a MSSP ACO?

Group practices

Individual practices

Hospital-physician partnerships or joint ventures

Hospitals employing physicians

Certain critical access hospitals


Mssp aco models
MSSP ACO Models

  • One-sided model:

    • Regular FFS payment

    • Eligible for shared savings in years 1 & 2

    • Become at risk for losses in year 3

    • Only available for the first agreement period

  • Two-sided model:

    • Regular FFS payment

    • Shared savings and losses in all 3 years


  • Mssp aco requirements
    MSSP ACO Requirements

    • Become accountable for the care delivered

    • Meet antitrust and other federal law requirements

    • Commit to a 3-year agreement

    • Formal legal structure

    • Establish and maintain a shared governance structure

    • Leadership and management structure

    • Sufficient number of primary care providers to ensure that at least 5,000 beneficiaries will be assigned to the ACO

    • Have in place processes that promote patient-centered care, evidence-based medicine, care coordination, and quality and cost measures


    Mssp aco quality measurement
    MSSP ACO Quality Measurement

    • 65 measures grouped in 5 domains (weighted equally) 

      • Patient/caregiver experience of care (7 measures)

      • Care coordination (16 measures)

      • Patient safety (2 measures)

      • Preventive health (9 measures)

      • At-risk population/frail elderly health (31 measures)

    • Must meet performance standards to share in savings

    • Year 1 reporting only, future years minimum requirements


    Mssp aco beneficiary assignment
    MSSP ACO Beneficiary Assignment

    Assignment is for determining savings only

    Beneficiaries maintain freedom of choice of providers

    Retrospective assignment

    Based on where the beneficiary receives a plurality of primary care services


    Any other acos out there
    Any other ACOs out there?

    Center for Medicare and Medicaid Innovation

    Medicaid waivers and state plan amendments

    Private Insurance


    What are the potential benefits
    What are the potential benefits?

    Lower cost

    High quality, patient-centered care

    Better patient outcomes

    Improved population health


    What are the potential problems
    What are the potential problems?

    History repeating itself

    Culture

    Infrastructure

    Complexity

    Consolidation

    Financial conflicts

    Patient involvement

    Achieving accountability


    What beneficiary protections are we advocating
    What beneficiary protections are we advocating?

    Advance notice to beneficiaries, including explanation of provider financial incentives

    Beneficiary and community-based organization participation in ACO governance

    Robust patient-centeredness criteria

    Strong protections to prevent ACOs from avoiding and/or dumping high risk patients

    Beneficiary grievance and appeals process

    Strong quality and performance measurements that evolve over time

    Public reporting