On October 20, 2011the US Department of Health and Human Services released the final rule implementing the ACO Shared Savings Program and the complementary regulations and guidance from CMS/OIG as well as the DOJ/FTC. It should be noted that the final rules are materially different from the proposed rules of March, 2010.
ACOs were created by the Affordable Care Act (ACA) signed into law March 2010. The dual purpose, of this network provider model, is to reduce the increasing cost of healthcare and to include incentives to create this new way of providing care for individuals. Coupled with the ACO rules, CMS had unveiled the Shared Savings Program (SSP), a program created by Congress to allow the ACOs to share in the savings and potentially share the costs of care to Medicare beneficiaries.
The final regulations were released. The proposed rules did not stimulate the interest expected. CMS has since changed the final rule to focus on the themes of flexibility, accountability, and innovation. It also provides clear guidance aimed at encouraging the development of the ACO participation in the Shared Savings Program. The purpose of ACOs is to realize savings and quality care through the coordination of services among the various providers, including hospitals, individual physicians, group practices, hospitals, home health agencies, and community health centers, or any combination of the above. Applications for the implementation of ACOs are currently being accepted through January 1, 2012, and the first ACOs will begin April, 2012.
The three goals of the ACOs stressed under the Shared Savings program will be to promote: 1) effective, patient-centered care for individuals; 2) preventive oriented and education oriented care for specific populations; and 3) cost savings (and profit) for the ACOs and CMS in general as well as decreasing waste in the system.
To be eligible to participate in the Shared Savings Program, ACOs must be accountable for at least 5000 beneficiaries a year for each of the three years of the agreement. To be eligible to share the savings, ACOs will be required to report on four quality measure domains.
It is apparent that this new healthcare model will be very patient-centered, not only addressing the medical needs of its participants, but also the social, nutritional and community needs as well. The cost sharing for the ACOs is determined by not-yet established benchmarks for 33 quality measures (QMs) broken down into the four domains:
- Care Coordination/Patient Safety (6 measures)
- Preventive Health (8 measures)
- At-Risk Populations/frail elderly health (12 measures)
- Patient/Caregiver Quality Standards (7 measures).
The QMs include population focused areas that are approached in a patient-centered manner. These indicators include timeliness of physician appointments, effective communication, tobacco use, diabetes and other comorbidity control, as well as preventive screenings. Depending on the success of the outcome-driven education and approach to the care as well as patient ratings and surveys, specific provider scores could garner up to 60% of the savings realized by the organization. It is anticipated that the new system will save over $960 million over the next three years for the Medicare program, per CMS.
This new form of healthcare organization will utilize technology to link providers. “An ACO will be rewarded for providing better care and investing in the health and lives of patients,” said Donald M. Berwick, M.D., CMS Administrator. “ACOs are not just a new way to pay for care but a new model for the organization and delivery of care.”