More or Less Confusion in ACO World: Who Really ‘Certifies’ ACOs?

By Gregg A. Masters, MPH

The ‘signal to noise’ discernment premium went up a notch recently with the following tweet:

@NCQA Read more about newly recognized ACO @KelseySeybold and their commitment to quality and value in the Houston Chronicle http://ow.ly/g6vzl 7:39 AM – 14 Dec 12

And with that breaking news announcement (Kelsey Seybold is the first ACO to be recognized by NCQA) another piece of the ACO puzzle has been laid before American public as well as industry stakeholders. Unfortunately one cannot simply graft the information on top of an expanding but orderly base of journalistic reporting and therefore public assimilation of how their healthcare experience can be expected to change. The fast developing (i.e., ‘bottoms up’, vs. alleged ‘top down’ dictates of an overreaching Federal overlord) world of ACOs are just not that simple to grasp due to the underlying absence of operating standards, the best intentions of Government and the private sector notwithstanding.

A closer look reveals some of the unintentional misdirect or potential for market confusion. The referenced Houston Chronicle article (aka @HoustonChron) erroneously identifies the NCQA as:

…the entity that certifies ACOs.

Yet, NCQA (the National Committee on Quality Assurance) is a ‘private non-profit healthcare measurement group’ based in Washington, D.C. that has organized a voluntary, fee based ‘ACO accreditation program.’ NCQA’s ‘ACO standards’ focus on the following seven core competencies:

ACO Structure and Operations
Access to Needed Providers
Patient-Centered Primary Care
Care Management
Care Coordination and Transitions
Patient Rights and Responsibilities
Performance Reporting and Quality Improvement

For context, private, nongovernmental entities typically recognize submitting applicants via a certification or ‘accreditation’ consideration process that approximates a ‘good housekeeping’ or ‘JD Power’ like ‘seal of approval’. They do not license nor legally certify ACOs per se, unless that authority is delegated to them by some governmental entity.

The authority that officially ‘certifies’ ACOs as legal entities for participation in the Medicare Shared Saving Program (MSSP) is the Center for Medicare and Medicaid Services (CMS), aka @CMSgov. ACOs are codified in Section 3022 of the Affordable Care Act and serve as the principal market based vehicles to fulfill the goals of the Medicare Shared Savings Program.

Even here though, the story is not that straightforward, as CMS certifies entities for participation in the MSSP, while its innovation arm, a division within CMS, the Center for Medicare and Medicaid Innovation (CMMI) aka @CMSinnovates, both admits and ‘certifies’ participation in the ‘Pioneer Program’.

Splitting hairs? Maybe. But there are structural differences of what constitutes an ACO to the Feds vs. NCQA vs. those effectively deemed an ACO via contractual agreements with one of more payers under the terms of an ‘accountable care collaboration’ or derivative arrangement.

So perhaps the correct narrative is that NCQA is ‘an’ entity that certifies some ACOs, not ‘the’ entity per se. More accurately though and per terms of their program, NCQA ‘accredits’ ACOs (as defined by NCQA) via a seal that signifies:

Organizations that earn accreditation may have extra credibility and first-mover advantages in their local markets. Being an early adopter of ACO accreditation may also help an organization become eligible to participate in demonstration projects or pilot programs that public and private health plans sponsor.

Finally, it’s interesting to note, that Kelsey Seybold Clinic though now recognized by NCQA is neither participating in MSSP, nor as a risk savvy medical group, perhaps even integrated delivery system, in the Pioneer Program designed and administered by CMMI for more advanced risk bearing participants.

So you be the judge. The slog continues?