A closer look at the proposed Medicare Shared Savings Program and Accountable Care Notice of Proposed Rulemaking (NPRM) and how it impacts the future of healthcare delivery in the U.S. By Justin Barnes, former vice president of marketing, corporate development and government affairs, Greenway Medical Technologies, Inc.
By 2020, accountable care organizations (ACOs) are expected to provide care for at least 105 million patients, up from 23 million in December 2015. With ACOs assuming more responsibility for the quality and cost of care, this rapid patient growth is driving the need for new, more intelligent clinical decision support tools at the point of care. These tools can help ACOs deliver consistent, evidence-based care so patients can return to health safely and quickly.
The movement to enhance and streamline healthcare through accountable care organizations (ACOs) is well underway in the wake of the issuance of final rules by the Centers for Medicare and Medicaid Services (CMS) in October 2011. Designed as patient-centered initiatives that help doctors, hospitals and other healthcare organizations better coordinate patient care, ACOs are fundamentally structured to incentivize participating healthcare groups for achieving an aggressive set of cost and quality measures built upon improved communication, data sharing and decision making.
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An Accountable Care Organization (ACO) utilizes a payment and care delivery system that bases payments to providers on quality metrics and seeks to reduce the total cost of care for a certain population of patients. ACOs use a range of payment models and consist of groups of coordinated healthcare providers that provide care to groups of patients. ACOs are accountable to a third-party payer and the group of patients for the appropriateness, quality, and efficiency of the health services they provide.
In 2011, the Department of Health and Human Services (DHHS) set forth initial guidelines for ACOs to be created under the Medicare Shared Savings Program. These guidelines contained all necessary steps required for a physician, health care provider, or hospital to voluntarily participate in ACOs.
The quality measures used to evaluate an ACO's performance as defined by the Center for Medicare and Medicaid Services (CMS) fall into five domains. These domains are patient/caregiver experience, care coordination, patient safety, preventative health, and at-risk population/frail elderly health.
The three stakeholders in an ACO are the providers, payers, and patients. Providers are a network of hospitals, physicians, and other healthcare professionals. The primary payer is the federal government, Medicare, but also includes other payers such as private insurances or employee-purchased insurance. The patient population of an ACO will primarily consist of Medicare beneficiaries, but in larger ACOs can also include those who are homeless and uninsured.
According to a new report, a lack of out-of-network interoperability is the biggest obstacle facing ACOs today. By Katie Wike, contributing writer