According to the Centers for Medicare and Medicaid Services (CMS) an Accountable Care Organization (ACO) is defined as:
…groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.
While the goal of such broadly cast and some may say overly ambitious agenda onto the backs of [under-powered or ‘HMO-lite] entities is to:
…ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.
On the ‘upside’ of participation, CMS notes:
When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.
And finally, the regulatory framework and market context in which these entities are organized (at least at the Federal level) is via the ‘three legged (wobbly?) stool’ of:
- Medicare Shared Savings Program—a program that helps a Medicare fee-for-service program providers become an ACO. Apply Now.
- Advance Payment ACO Model—a supplementary incentive program for selected participants in the Shared Savings Program.
- Pioneer ACO Model—a program designed for early adopters of coordinated care. No longer accepting applications.
Yet there is quite a bit more to the ‘ACO Story‘. As noted in ‘More or Less Confusion in ACO World: Who Really ‘Certifies’ ACOs?’, the portfolio of Federally certified ACOs omit the financing and service delivery innovation in the commercial or private pay space. To fully grasp the range and complexity of innovation in the accountable care industry, one must also look outside the limited albeit large purview of CMS.
Reports from the Front
For recent insights and a comparative view checkout ‘ACO Contracting With Private and Public Payers: A Baseline Comparative Analysis‘. The report summary is noted below:
And for both strategic and tactical guidance on the road-map towards implementation of an ACO, ‘Adopting Accountable Care: An Implementation Guide for Physician Practices‘ offers real world guidance via case studies from innovators walking the talk of the ‘triple aim’.
At the end of the day, the mission of the accountable care industry and the challenge presented to healthcare leadership is perhaps best framed as a v3.0 version of the vision and genius of the ‘under-celebrated’ Sidney Garfield, MD.
While the ‘triple aim’ expression had yet to be coined, his vision of coordinated, high quality healthcare at affordable price points was the source DNA of the then emerging Kaiser Permanente (culture of health) HMO model, and a consistent theme entrusted to the stewards of the predominantly non-profit healthcare sector in the United States.
Yes, it’s deja vu all over again. The names and faces of the stewards at the controls of the ‘healthcare borg’ change, but the challenges remain the same (see: The Committee on the Costs of Medical Care and the History of Health Insurance in the United States circa 1920s) while both scale and complexity of the ecosystem grow.
Previously the cost of employer sponsored healthcare benefit plans or Government funded healthcare programs (Medicare, Medicaid, etc.) threatened only companies (or Government budgets) and considered remedies contained often behind the closed doors of healthcare enterprise Board rooms (or on Capital Hill), today absent the value based paradigm shift whole countries and Governments are at risk of insolvency.
Perhaps this time former CMS Administrator Don Berwick’s ‘all hands on deck..’and ‘…full court press’ nature of the change (re-invention) imperative will be taken to heart and truly guide the actions of a volume fueled industry into the brave new world of value based medicine.
Again, only time will tell….