ACO GLOSSARY
With no regulation on use of the term “accountable care organiza- tion” (ACO), Medicare, private payers, and accrediting organiza- tions each have their own definitions. Here’s a glossary of some of the more recognized ACO programs under way.
Pioneer ACO An ACO initiative the Centers for Medicare & Medicaid Services (CMS) Innovation Center (CCMI) created for health care organiza- tions and health care professionals already experienced in coor- dinating patient care across various settings. The model starts out using a hybrid fee-for-service (FFS)/shared savings payment structure. It then moves to fixed, per-member, per-month popula- tion-based payments, all based on performance metrics similar to those in the Medicare Shared Savings Program.
Medicare Shared Savings Program (MSSP) An initiative the Patient Protection and Affordable Care Act cre- ated. Its goal is improving coordination and cooperation among physicians, hospitals, and other providers to enhance quality and reduce costs. Participants share in the financial savings they gen- erate by meeting established quality and cost targets, but take on less risk than they would in a Pioneer ACO.
Advance Payment ACO A CMMI initiative that provides additional support to physician- owned and rural health care organizations in the MSSP that would benefit from additional start-up resources to build the necessary infrastructure.
National Committee for Quality Assurance ACO An ACO accredited by the National Committee for Quality Assur- ance (NCQA). The designation allows aspiring ACOs to demon- strate they have met recognized standards. Some of the NCQA standards overlap with Medicare standards. An NCQA ACO, how- ever, is not restricted to Medicare fee-for-service patients.
Commercial ACO A nongovernment ACO serving privately insured patients. Com- mercial ACOs are distinct from Medicare ACOs in that the com- mercial payer, such as a private health insurance company, is the entity driving the financial incentives for providers to improve quality and costs.
24 TEXAS MEDICINE July 2013
“We’re looking at ancillary services. Case management. Transitional coordi- nation. Those are pieces we are missing. What can [an ACO] do to provide better care to my patients? That’s the key.” He, too, wants assurance that primary care won’t be undervalued the way it is in the current fee-for-service system. Those pay- ment issues raise additional concerns be- cause it may be difficult for primary care physicians to participate in more than one ACO, if the goal is to streamline patient care, he added.
While some physicians may be restrict- ed, patients are not, if the ACO uses an open-network structure. The Medicare program is one example, and physicians in those models acknowledge that patient freedom could undermine efforts to im- prove and rate the quality and value of care physicians are accountable for. Dr. Sheff says non-Medicare ACOs can adopt a closed, capitated model, but “if we have to rely on forcing the patient to stay in our network, then we are not meeting the patient’s needs. So part of the issue is spending the time to figure out why patients leave.” As for payment, Dr. Knight cautioned that while there are short-term profits for physicians who get in the ACO game early, “long-term, this is about practicing medicine for reasonable reimbursement, not the straight fee cuts and treadmill of having to see more patients faster.” Even those physician leaders involved
in ACOs acknowledge that the distant fu- ture remains cloudy. But for the next few years, some things are clear as health care delivery drifts away from a fragmented, fee-for-service system. “It’s going to be a more organized sys- tem of care, it’s going to be consumer- driven, and there’s going to be more transparency around quality outcomes and efficiency. Doctors have to be part of a system that helps them practice coordi- nated care, and there are lots of way to accomplish that while maintaining inde- pendence,” Dr. Sheff said.
Choices to make As they scan the ACO landscape, physi- cians do have options in how they go about creating or joining one. Physicians don’t have to be employed,
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60