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Monday, April 4, 2011

A sumary of a summary: What is an ACO and how does HealthIT matter?

This is in response to a request from a colleague that I simplify my summary of the proposed ACO rule from Friday. This summary is based on that post, and vastly simplifies the 427-page rule. Read the post from Friday, or better yet, the rule and various commentary on it for full details (see the Friday post for links).

What is an ACO?
An ACO is an organization that contracts with CMS to take responsibility for care of patients, agreeing to terms that include providing high quality, patient-centered, evidenced-based care.  In so doing, the ACO hopes to reduce costs of care incurred by those patients. When those patients are Medicare eligible, and the ACO provides most of the primary care for that patient, the ACO can receive incentive payments from Medicare. If it fails to reduce costs, it would share (eventually) in the increased expense by paying Medicare back. In order to receive incentive payments, an ACO must report quality measures, exceed certain thresholds in quality and patient experience, and generate a savings over baseline costs as established by Medicare. If it "wins" (meets all quality and cost goals set by CMS), it can get a significant chunk (more than half) of that savings back.

An ACO can be formed by doctors, nurse practitioners, clinical nurse specialists and physician assistants, and hospitals that employ them. It can also include Federally qualified Health Centers and Rural Health Centers. CMS has some additional incentives for an ACO if they do. It can also include Skilled Nursing Facilities, Nursing Homes, Long Term Care Hospitals and Critical Access Hospitals.

An ACO must be a legal entity, and might be an existing legal entity if appropriately structured and governed. Governance requirements include a certain percentage of physician control, existence of physician directed quality programs, and patient involvement.

As a patient, if your primary care provider becomes part of an ACO, your rights don't change. You still have the option to get care anywhere you want, just as you have today. However, a couple of things will be different. CMS and your provider will tell you about the ACO. You will be given the option to opt-out of sharing certain data that CMS has on you with the ACO. The ACO will communicate with you clearly about your care options, and will make it easy to get access to your records, and transfer them to other care providers.

If you aren't a Medicare patient, how could this rule effect you? Well, CMS seems to be encouraging other payers to take advantage of the rule. I presume payers other than CMS could make agreements with the ACO for their own members as well.

How does all of this effect Health IT?
There are several requirements in the rules regarding support for Meaningful Use (e.g., 50% of providers would have to be meaningful users), the quality reporting requirements are rather detailed and require health IT support, and the need to exchange summary data on patients, and to utilize individually and aggregated data from CMS on patient populations will all require Health information technology to support these capabilities. There are a lot of other opportunities for Health IT to make ACOs better able to support their mission.

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