About an ACO

An ACO:

  • Promotes seamless coordinated care
  • Puts the beneficiary and family at the center
  • Remembers patients over time and place
  • Attends carefully to care transitions
  • Coordinates resources carefully and respectfully
  • Proactively coordinates the Medicare Fee-for-Service beneficiaries’ care
  • Evaluates data to improve care and patient outcomes
  • Innovation around improved health, improved care and lower growth in costs
  • Invests in team-based care and workforce

Key Terms

ACO (Accountable Care Organization)

A collection of health care providers and care coordination professionals working together to coordinate care for a defined population. The goal is to reduce overall costs and improve quality and outcomes. CMS adopted the ACO model as a way to increase care coordination, reduce unnecessary medical care, improve health outcomes, prevent medical errors, and decrease utilization of health care services for its Medicare Fee-for-Service beneficiaries who are enrolled in the traditional fee-for-service program assigned to the ACO. If the ACO is successful, participants receive a percentage of shared savings or bonus payments based on savings benchmarks and quality measures.

ACO Participant

An individual or a group of ACO providers/ suppliers identified by a Medicare–enrolled tax identification number (TIN) that alone or together with one or more other ACO participants comprises the ACO. An ACO participant may be a solo practice, group practice, acute-care hospital, federally qualified health center (FQHC) critical access hospital, rural health center, pharmacy, and other entities that are Medicare-enrolled.

ACO Provider/Supplier

A provider or supplier enrolled in Medicare that bills for items and services furnished to Medicare Fee-for-Service beneficiaries under a Medicare billing number assigned to the TIN of an ACO participant. (A large group practice may qualify as an ACO participant. A Medicare-enrolled physician who is billing under the practice’s TIN would be an ACO provider/supplier.)

Medicare Shared Savings Program (MSSP)

CMS has created financial incentives for ACO health care providers to work together when treating individual Medicare Fee-for-Service patients across care settings. ACO providers share—with Medicare—and savings generated from lowering health care costs while meeting standards for quality of care and providing Medicare Fee-for-Service patient-centered care. (Healthy Communities  ACO will participate in Track 1 of the MSSP, also known as the one-sided model. This model is designed for less experienced ACOs who will share in savings but not in losses).

ACO Components: High Level Summary

Governance and Organizational/Legal

  • Legal entity with a Board representing ACO participants and Medicare Fee-for-Service beneficiaries
  • Organizational considerations including: Stark, Anti-Kickback, Antitrust, and Tax

Care Coordination

  • Evidence-based medicine: adoption and use of protocols
  • Care coordination, care transitions and access to services and providers typically supported by nurse care managers, navigators, etc.
  • Coordination with home and community-based services

 Health Information Technology (IT) 

  • Population-based clinical intelligence, decision support, registries, EHR
  • Care coordination, communication, and workflow technology
  • Secure clinical data exchange
  • Mobile consumer applications and personal health records

Analytics and Reporting 

  • Consume, process, and analyze administrative and clinical data
  • Identify trends in utilization, prevalence of disease, “hotspots”
  • MSSP quality measures focused primarily on care delivered in the ambulatory setting (NQP, PQRS)

Patient Engagement

  • Activating Medicare Fee-for-Service patients and providing culturally appropriate care and improving the Medicare Fee-for-Service patient experience
  • Patient self-coordination and shared decision-making

 

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