More Clarity on Accountable Care Organizations

In late October, the Centers for Medicare & Medicaid Services (CMS) announced it was significantly cutting back the criteria it required for organizations to be certified as an accountable care organization (ACO). The long-awaited final rule for ACOs (http://www.ofr.gov/OFRUpload/OFRData/2011-27461_PI.pdf) contained just more than half (33) of the quality measures originally proposed, making it easier for providers and their partners to qualify.

The National Committee for Quality Assurance’s (NCQA) recent announcement that it will roll out its ACO standards and guidelines may add some confusion to exactly what entities (and which practitioners) are eligible to participate as an ACO.

More than just a means to access the Medicare Shared Risk Program, an ACO should demonstrate a level of integration that can result in improved quality and lower costs of care. In addition, NCQA is trying to ensure that ACOs develop a level of transparency in performance that is reportable and therefore may benefit patients, payers, and the public.

According to NCQA, the ACO accreditation program forms a “roadmap for provider-led organizations to demonstrate their ability to reach the triple aim: reduce costs, improve quality, and enhance the patient experience.” (www.hcbd.biz/story.aspx?id=29302)

HealthPartners of Minneapolis, an integrated health plan, is one of the first organizations that will undergo full accreditation as an ACO in 2012.

Using 7 domains of standards (program operations, access and availability, primary care, care management, care coordination and transitions, patient rights and responsibilities, and performance reporting), NCQA will grade prospective ACOs according to one of 3 levels:

• Level 1 accreditation means that an organization is not ready for prime time as an ACO—it meets some standards, it may have some of the necessary infrastructure in place, but is in a “transformative” stage.

• Level 2 accreditation applies to entities that have ACO structures in place that offer an excellent chance of attaining reduced costs, better quality, and patient satisfaction. This label expires after 3 years.

• Level 3 organizations are ACOs that have already met with some success in attaining this triple goal.

According to NCQA, a provider-based entity seeking ACO status can be eligible if it serves a minimum of 5,000 individuals. Examples of eligible entities include group practices, individual practice networks, physician—hospital organizations or other joint ventures between providers and hospitals, hospitals and their internal salaried or contracted clinicians, and provider–health plan partnerships.

The NCQA ACO accreditation program will require plans to meet specific structural or process standards and have the ability to measure performance in up to 40 clinical quality and cost areas.

However, NCQA believes that the newness of the program and general questions about ACO eligibility may discourage some provider organizations interested in becoming an effective ACO (not that any guarantees exist that gaining a Level 3 designation will mean one is improving care delivery). The organization has unveiled a program that helps entities unsure about its positioning to tap into the NCQA Educational Assessment. This option allows an organization to receive an in-depth review from NCQA and offers an assessment of its performance against the standards with recommended areas for improvement.

Most assume that highly integrated provider organizations like Kaiser Permanente in California, Group Health of Puget Sound in Washington, or the Geisinger Health System in Pennsylvania already will meet NCQA’s standards. It is highly likely that if they underwent the accreditation process, they would indeed meet the standards for required infrastructure. However, whether they meet the other measures for performance and costs is an open question.

It will be interesting to see whether NCQA’s product will drive the ACO creation process or be a “nice-to-have” option that many Medicare-qualified ACOs will forego.