11 Things to Know About Accountable Care Organizations

1. Time to start is now. ACOs must be organized before 2012, when one ACO will be designated in each region, with each region having no less than 5,000 Medicare beneficiaries who have signed up for an ACO. The first organization up and running will have an advantage, because no hospital, physician or other provider can be involved in more than one ACO.

2. Goal is clinical integration. The ACO is expected to save money by integrating care. Providers will need to work closely with each other on the full spectrum of care for each patient.

3. Physicians are essential. According to the reform law, every ACO must include physicians and have enough primary care professionals to treat the Medicare beneficiaries assigned to the ACO.

4. Strong leadership needed. Hospitals or large group practices are expected to run ACOs, either alone or in partnership with each other and other providers. Partners will form a joint governing body that will define expectations and payment levels to participating providers and oversee negotiations with payors. The ACO may also contract with some providers who would not play an active role in governance.

5. IT connectedness is essential. Have a solid data infrastructure and sufficient IT "connectedness" to provide the necessary information for care assessment, coordination, and management

6. Payment is different from managed care. Rather than receiving a per-member, per-month capitation payment, providers continue to get fee-for-service rates plus extra payments reflecting savings from coordinating care. And rather than having an HMO gatekeeper, patients are given a "medical home" where providers work in teams and share the savings realized through a mutually agreed formula.

7. How payment would be made. Providers in the ACO would continue to receive fee-for-service payments for their services. If total payments for patients fall below a designated benchmark, the ACO would receive a reward, which it would parcel out among providers.

8. Special attention to quality. Implementation of evidence-based guidelines and measurement of outcomes will be two key ways ACOs will be assessed.

9. Details still to come. HHS will need to resolve a wide variety of issues not spelled out in the law, such as spending benchmarks to determine reimbursements.

10. Stark, kickback laws must be addressed. The prospect of hospitals sharing reimbursements with independent physicians raises potential violations of federal prohibitions, such as the Stark Law against self-referrals, the anti-kickback law and the antitrust laws.

11. State insurance laws must be addressed. State laws on scope of practice, fee splitting, insurance contracts and designation of business entities would apply.

Copyright © 2024 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.


Featured Webinars

Featured Whitepapers

Featured Podcast