Accountable Care Organizations (ACOs) are one of the most important models of medical care implemented by the US federal government to provide enhanced and streamlined care for medicare beneficiaries. In 2011, the Centre for Medicare and Medicaid Services (CMS) announced its final provisions rule for ACOs, under the Medicare Shared Savings Plan (MSSP). The MSSP was implemented as a part of the Patient Protection and Affordable Care Act (PPACA) and pledged to promote enhanced quality care, accountability of care and sustainable infrastructure that could impart efficient healthcare services to all patients.

ACOs are primarily a network of healthcare providers that work in coordination to provide efficient and flexible services to patients while reducing costs. An ACO, which is a culmination of different hospitals, providers, suppliers and physicians, must service at least 5,000 beneficiaries to be eligible for the MSSP. Currently, there are two types of Accountable Care Organization models in existence. The first type doesn’t include inpatient facilities and has revenues less than $50 million. The other has inpatient facilities and includes rural and critical access hospitals, with revenues of less than $80 million per year.

Governance Measures to be Adopted by ACOs

According to the CMS, an ACO must meet the 33 quality measures related to structure, quality and governance to be eligible for bonuses under the MSSP. Here are some of the requirements that an ACO should meet:

  • Separate legal entity: An ACO must have a separate governing body that should be capable of receiving and distributing performance data, savings and losses. An ACO must also lease or purchase an office under its own name but employ workers under a separate identification number.
  • Delivery model: The CMS wants ACOs to promote evidence based medicine in their practice. The CMS also requires ACOs to publish public reports regarding their quality, performance and operations.
  • Privacy protection:  ACO’s must be compliant with the HIPAA and must have procedures in place for patient data privacy that can eliminate identity thefts. All ACOs must have privacy protection programs and provide cyber liability insurance.
  • Electronic health records: One of the foremost criteria for receiving bonuses under the MSSP is the implementation of electronic health records. The concept of electronic records is essential for consistent and flexible sharing of patient data that could translate into improved patient safety with time.

Apart from these requirements, ACOs would be required to develop care plans for high risk individuals and maintain detailed documentation regarding different processes and procedures employed.

Viability of the ACO Model

Although an ACO is designed to provide quality care by integrating discipline specific functionalities of different physicians and providers, there are some questions being raised regarding its viability. Some of the concerns that the medical fraternity has include:

  • Profit sharing: There are two reimbursement models for ACOs, one in which physicians get paid for meeting quality standards and keeping costs under check and the other where they get paid a certain fee for their services. Not only are these models confusing regarding the incentives that physicians will receive, but they may also lead to the demise of private practices.
  • Investments: The huge investments required for the infrastructure makeover for ACOs is also a cause for concern. With millions being spent on EMR, hardware, training and support, experts question the viability of the model. Also, the transition to automation from a manual framework may lead to initial inefficiencies and wastage of many human hours while the organization becomes adept at using the technology.
  • Medical billing: Revenue cycle management associated with medical billing and its implementation appears to pose a gigantic hurdle in terms of understanding it and its operation. It is essential that the providers be given adequate training on these reforms before they are implemented in healthcare organizations.

The ACO model might seem an expensive and exhaustive option towards quality care initially but taking care of these aspects would make sure that the model not only imparts long lasting revenues but forms the much needed processes required for improved patient care.