What is an Accountable Care Organization and What is the Role of the Physician?
(April 2011) - An ACO (accountable care organization) is an organization of health care providers that agrees to be accountable for the quality, cost and overall care of Medicare beneficiaries. The accountable care organization concept is a program administered by CMS (Centers for Medicare & Medicaid Services) under the 2010 Patient Protection and Affordable Care Act. The act creates incentives for hospitals, health systems, physician groups, and independent practice associations (IPAs) to more closely integrate the delivery of health care to Medicare beneficiaries and ultimately to share in the savings created by such integration.
To participate in the Medicare Shared Savings Program, an ACO must be willing to be accountable for the quality, cost and overall health care of the Medicare fee for service beneficiaries assigned to it. An ACO must enter into an agreement with CMS for a period of not less than three years, and the ACO must have a legal structure in place to receive payments and distribute shared savings to participating providers. Additionally, an ACO must include primary care professionals sufficient for the minimum number of beneficiaries assigned to it. Presently, that number is 5,000. An ACO must meet quality and other reporting requirements, and must have a leadership and management structure. Further, to participate in the Medicare Shared Savings Program, an ACO must promote evidence-based medicine, coordination of care, and must utilize enabling technologies while doing so. An ACO should be able to demonstrate patient-centered criteria as specified by the Secretary of Health and Human Services. On March 31, 2011, CMS proposed regulations setting forth the details of the implementation of ACOs. The proposed rules will be published on April 7, 2011, and CMS will accept comments until June 6, 2011.
The role of physicians as active participants in ACOs is critical to increasing Medicare operational efficiencies and outcomes which, theoretically, are supposed to lead to shared savings. Essentially, the physician is looking at what is called health care “integration.” Although participation in ACOs is scheduled to begin in January, 2012 (exclusively in the Medicare program) it is anticipated that this move from the fee-for-service payments to a more comprehensive payment structure will carry over to the third-party payor system in the future.
ACO participants will have leeway and discretion in their formation and operation. The ACO must fit the needs of the community of beneficiaries assigned to it. So, while participation of primary care physicians is clear and essential under the program, the role of the specialty physician may be limited. Although specialists will continue to play a vital and important part in patient care, ACOs may more carefully coordinate the volume of referrals to specialties. The new guidance from the federal government addresses ACO cost, formation and governance. Most importantly, because collaboration of physicians and other providers has previously led to antitrust and Stark County law violations, it is unclear how the enforcement agencies for these laws and others will approach technical violations as the move towards the ACO model progresses. For more information, Attorney Kristin Zemis can be reached at(330) 456-8341 or at .
