Are Accountable Care Organizations (ACOs) only for Medicare beneficiaries?

At the present time, Medicare funds are supporting ACO formation around the country to serve Medicare beneficiaries.  In January 2013, CMS announced 106 new organizations will be participating in the Medicare-sponsored ACO programs, taking the participation numbers to over 250 nationwide.

Additionally, some states are looking at the ACO to service Medicaid patients in their attempt to improve quality and reduce costs.

Some commercial insurers are supporting ACO development for their own members as well.

Innovative physician-led organized groups have been following the ACO care model with all of their patients for decades and are participating in both Medicare and commercial ACO pilot programs.  

The intention of the Affordable Care Act is that ACOs will eventually be available to everyone.  Multispecialty medical groups, physician-hospital organizations (PHOs), integrated delivery systems (IDSs), and independent practice associations (IPAs) are likely candidates to become the ACOs of the future.

ACO Programs at CMS

Medicare offers several ACO programs, including:

• Medicare Shared Savings Program (cms.gov) - For fee-for-service beneficiaries
• Advance Payment ACO Model - For certain eligible providers already in or interested in the Medicare Shared Savings Program
• Pioneer ACO Model - Health care organizations and providers already experienced in coordinating care for patients across care settings
• ACO: Accelerated Development Learning Sessions - For existing or emerging Accountable Care Organizations (ACOs) to develop a broad and deep understanding of how to establish and implement core functions to improve care delivery and population health while reducing growth in costs.

General information on ACOs can also be found at cms.gov/aco and this HealthCare.gov ACO Fact Sheet.

What do Accountable Care Organizations (ACOs) mean to U.S. Patients?

No one would disagree that better quality of service for less cost is highly desirable in any industry.  It seems the Healthcare Delivery Industry has, for a long time, been “behind the times”.

Sparked by the incentives of the Affordable Care Act (ACA), a new and innovative approach to Healthcare Delivery, the Accountable Care Organization (ACO) has come into the forefront of patient care models.  ACOs are groups of primary care physicians, specialists, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the patients they serve.

The basis of the ACO model can be represented with this acronym: PEACE

·         Prevention of Illness and Disease

·         Evidence-based Treatment

·         Access to Care Resources

·         Coordinated Medical Care Team

·         Electronic Health Records 

We can look at each of these points and explore the how and why the ACO model may provide a great start towards improving the Healthcare Delivery System in America. 

Prevention of Illness and Disease - The best way to control health care costs is to stay healthy. Reducing readmissions and hospitalizations for preventable conditions alone could save the Medicare program at least $12 billion per year. It is estimated 50% of Americans don’t get the recommended preventive care and screening tests that science recommends.  ACOs believe in wellness and preventive care. You get reminders for the tests, screenings, and immunizations you need, and health information, classes, and advice are easily available.

Evidence-Based Treatment - Scientific advancements are so rapid that no single physician can stay on top of all the current and best treatment options. ACOs support their patients and doctors by providing information about up-to-date treatments based on research and evidence.

Access to Care Resources - Significant numbers of Americans don’t get the recommended health counseling and education for their conditions.  Providing the right care at the right time is the goal of ACOs. Patients of ACOs are able to get professional medical advice day or night, in offices, by phone, and even via e-mail. Quick treatment helps maintain health and reduces cost.

Coordinated Medical Care Team - It is estimated that unnecessary care or “overtreatment” kills 30,000 Americans a year.  Care teams and care coordination are very important when you need to see more than one doctor, or you need to be hospitalized. In the ACO model, coordinating your care among all your care providers ensures that each knows what the other is doing for you.

Electronic Health Records - The Institute of Medicine (IOM) has estimated that 44,000 to 99,000 patients die in hospitals each year due to medical errors and that there could be at least 1.5 million preventable adverse drug events in the U.S. every year.  A high percentage of U.S. patients have reported that medical records and test results were not available during a visit or that tests were duplicated unnecessarily.   Shared electronic medical records help both your primary care doctor and specialists know your entire health history, the drugs you have been prescribed, and your test results. This improves the cost, quality and safety of the care you receive.

These five principles are shared by Accountable Care providers who take responsibility for the cost and quality of the care they provide to their patients.   Patients receive better care at a lower cost and have a greater PEACE of mind.

NEW GOVERNMENT INITIATIVE: STRONG START FOR MOTHERS AND NEWBORNS

The Department of Health and Human Services initiative, Strong Start for Mothers and Newborns, aims to reduce preterm births and improve outcomes for newborns and pregnant women.  CMS recently announced the two strategies of this initiative to achieve these goals:

• A public-private partnership and awareness campaign to reduce the rate of early elective deliveries prior to 39 weeks for all populations.   
• A funding opportunity to test the effectiveness of specific enhanced prenatal care approaches to reduce the frequency of premature births among pregnant Medicaid or Children’s Health Insurance Program (CHIP) beneficiaries at high risk for preterm births. 

The Strong Start effort to test new approaches to prenatal care is a four-year initiative to test and evaluate enhanced prenatal care interventions for women enrolled in Medicaid or CHIP who are at risk for having a preterm birth.   

The goals are:

1.       Determine if these approaches to care can reduce the rate of preterm births

2.       Improve the health outcomes of pregnant women and newborns

3.       Decrease the anticipated total cost of medical care during pregnancy, delivery, and over the first year of life for children born to mothers in Medicaid or CHIP.

Three approaches to enhanced prenatal care

This initiative will test three evidence-based maternity care service approaches that enhance the current care delivery and address the medical, behavioral, and psychosocial factors that may be present during pregnancy and contribute to preterm-related poor birth outcomes.  Awardees will test one of the three following interventions but cannot use funds to supplement or supplant any funding sources, including Medicaid and CHIP reimbursement:

• Group prenatal care that incorporates peer-to-peer interaction in a facilitated setting for health             assessment, education, and psycho-social support.
•  Comprehensive prenatal care facilitated by teams of health professionals, including peer counselors.  Services include collaborative practice, intensive case management, counseling, and psycho-social support. 
• Enhanced prenatal care including psychosocial support, education, and health promotion in addition to traditional prenatal care.   Services provided will expand access to care, improve care coordination, and provide a broader array of health services. 

Awardees receiving Strong Start funds can administer more than one approach to enhanced prenatal care at multiple provider sites; however, individual provider sites can administer only one of the three enhanced approaches. 

Strong Start awardees will be serving women in the areas with the highest preterm birth rates in the country, including areas that are among the top ten prematurity and infant mortality counties according to the Centers for Disease Control and Prevention.  

Eligibility criteria

 To be eligible to participate in the Strong Start initiative, applicants had to be:

1.   Providers of obstetric care (for example, provider groups or affiliated providers and facilities);

2.   State Medicaid Agencies, in partnership with providers;

3.   Medicaid managed care organizations (MCOs), in partnership with providers; or

4.   Conveners in partnership with other applicants.  The convener could be a direct applicant or could convene and support other organizations to become applicants.  Examples of conveners include professional trade associations or other health service related organizations.

Program requirements

Strong Start awardees will participate in monitoring and evaluation activities to ensure that quality care is being delivered

• Participants will be expected to provide the CMS Innovation Center performance metrics consistent with the goals of the initiative on a quarterly basis.  
• Awardees will report information on gestational age and birth weight for the infants of the mothers participating in one of the three approaches to enhanced prenatal care.  
• Participants will also provide the gestational age and birth weight data on births from a historical baseline period that spans at least two years prior to the start of the intervention.          
• Participants also submit quarterly progress reports on the specific uses of the cooperative agreement funds, assessment of the overall project implementation, and other specific information.  
• They must also submit quarterly data reporting on operations, utilization, and outcomes.

CMS will provide technical assistance, analytic support, and coordination to help participants launch their interventions to reduce premature births.  As with all Innovation Center initiatives, participants will participate in opportunities for shared learning and dissemination with others.  

About the Innovation Center

The CMS Innovation Center was created by the Affordable Care Act to test new innovative payment and service delivery models.  The Center is committed to testing models to help the Medicare, Medicaid, and CHIP programs deliver better care for beneficiaries while reducing costs. 

For more information

Additional information on the Strong Start initiative is available on the Strong Start website at: innovation.cms.gov/initiatives/strong-start.