Accountable Care
& Care Coordination
& Care Coordination
A
foundation for improved population health
As a proposed pillar of community health merging ambulatory
primary care with multi-specialty, hospital, rehabilitation and other
healthcare entities and needs, accountable care organizations (ACOs) will be
linked through innovative electronic health record (EHR) and related health IT
platforms to achieve seamless and comprehensive medicine.
Major
accountable care goals
·
Harness growing healthcare costs
annually approaching $3 trillion
·
Advance EHR-driven preventive
medicine, care coordination and wellness focusing on each patient’s care
continuum under a patient-centered medical home (PCMH) concept
·
The ability to collect and analyze
clinical, claims and payer data to enable quality monitoring and reporting
·
Promote remote monitoring/telehealth
to advance the communication of care plans to patients
An accountable care organization is comprised of a group of
healthcare providers who work collaboratively to deliver coordinated care and
chronic disease management, improving the quality of care patients receive.
A
participating organization’s payment is tied to achieving healthcare quality
goals and outcomes that result in cost savings. Medicare ACOs were formed by
the Patient Protection and Affordable Care Act of
2010 (PPACA), with Medicaid and commercial accountable care organizations
following suit.
How is an ACO Formed?
Medicare ACOs
To form a Medicare ACO and participate in the Medicare Shared Savings Program
(MSSP), participants must agree to the following:
o
Agree to be accountable for the care of Medicare fee-for-service (FFS)
beneficiaries
o
Agree to three-year participation in the ACO program
o
Create a formal legal structure that allows the organization to receive and
distribute bonuses to participating providers
o
Include at least 5,000 beneficiaries
o
Create and institute a specific management structure
o
Promote evidence-based medicine, report on quality and cost measures, and
coordinate care
o
Demonstrate that the ACO meets patient-centered criteria
A Medicare ACO must have a governing body, such as a board of directors or
managers who are responsible for:
o
The operational and strategic aspects of the organization, which includes
holding management accountable for meeting the goals of the ACO
o
The Centers for Medicare & Medicaid Services (CMS) requires that ACOs must
have a transparent governance process and board members who have fiduciary
duties to the stakeholders
Must evaluate inventory, resources, human capital, data systems, leadership,
and clinical organization
Key component of ACO formulation and execution is coordinated care that relies
on health information technology for informational tracking
Eligible Medicare ACOs must follow the instructions in the Notice of Intent
(NOI) to Apply Memo and submit the application and accompanying required
documents
Questions about the Medicare program can be directed to the local CMS regional
office
Commercial
ACOs
Commercial ACOs vary in structure from a Medicare ACO in the following ways
o
Payers, hospitals, and physician groups can form coalitions under a contract to
provide coordinated care management where payment is determined by metric sets,
possible expanded from those of a Medicare ACO
o
Payers provide the financial incentives to the provider organization allowing
flexibility among various Commercial ACOs
The patient-centered medical home (PCMH) is an inventive
program that focuses on improving primary care. The recognition program is
outlined by a clear set of standards, empowering providers with information
needed to personalize care to their patients and enabling providers to work in
teams to better coordinate care.
ACO
and PCMH programs share quality measures both in structure and approach, and
also align with those of the meaningful use program.
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