Rachael Addicott: Accountable Care Organizations: What are they 'accountable' for?
Accountable Care Organizations:What are they ‘accountable’ for?Dr Rachael Addicott2011-12 Harkness Fellow7 March 2013
Origins of ACO development Why was reform necessary? 2010 Patient Protection and Affordable Care Act – Payment and provision reform to encourage cost savings and high quality care – Care management for Medicare and Medicaid populations
What is an ACO (in theory)? Coordination of care across a network of providers Interdependency: cost savings are more likely if partners work together Defined patient population Shared governance structure (ie. ACO Board) Shared accountability for quality and cost of care Shared risk and savings: on condition of meeting quality metrics
ACOs for Medicare patients Centers for Medicare and Medicaid Innovation (CMMI) testing the efficacy of the model – SHARED SAVINGS PROGRAM: ACO develops from a one- sided to a two-sided risk model – PIONEER: providers with more experience move to an accelerated population-based payment – ADVANCE PAYMENT: additional upfront support to developing ACOs, which is then recovered from any future savings
What is an ACO (in practice)? Origins in contracts for commercial populations History of risk sharing with health plans Driven by medical groups Challenges in engaging hospital partners Care management Payment models What do ACOs do with the savings?
Accountability for what? Finance, mostly through process measures Increasing focus on patient satisfaction Quality measures as they relate to process Measures “negotiated” with payer – Medicare: single set of 33 quality measures – More variation / overlap on commercial side – ACO has variable influence in negotiations
Monitoring performance Thresholds or targets are more contentious than the measures themselves – eg. keeping patients in the network Collaborative accountability – eg. patient satisfaction Risk modelling
Sanctions and consequences Reliance on informal influence Appeals to professional competitiveness Credibility of data Development and coaching – “learning opportunity” Financial penalties Removal from ACO network
Conclusion: Culture of collaboration Shared goals and incentives – Reliance on data transparency and peer influence Align measures and thresholds across payers – Compatible matrix of accountabilities Credibility and transparency of data – Investment in IT infrastructure