Accountable Care Organization

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If the patient-physician relationship is at the center of primary care in the new system of healthcare, then the primary care can be considered the center of an ACO. An ACO can be defined as:

“An Accountable Care Organization (ACO) is a network of physicians and other health care providers who accept overall responsibility to provide health care services for a defined population and are responsible for improving the quality and reducing the costs of care.”

In order to ensure these goals, the Centers for Medicare and Medicaid Services (CMS) ties the organization’s payment to achieving health care quality goals and outcomes in an effort to achieve cost savings. While there are no specific requirements for how an ACO is structured, the Department of Health and Human Services proposed a set of guidelines for the establishment of ACOs under the three-year Medicare Shared Savings Program (MSSP). Those choosing to enroll their organization as an ACO agree to accept the responsibility for a minimum of 5000 beneficiaries in return for a capitated payment per patient. Savings that the ACO achieves through efficiency and increased quality will be eligible to be kept by the ACO; however, if the cost of care exceeds the capitated payment, then the ACO is responsible for the cost. Furthermore, the ACO is then responsible for any out-of-network care for that patient, so it is in the best interest of the organization to provide all the services necessary in a timely fashion. By agreeing to the program the ACO network effectively shifts the financial risk away from the insurance providers to the ACO. With such a risk and lack of infrastructure, many networks large enough to support an ACO are partnering with insurance provides in new partnerships. It is yet to be seen how many of these relationships will play out after the current trial run is over.

HIT is so critical to the success of ACOs that CMS has outlined six key responsibilities of HIT in an ACO:

Cross Continuum Medical Management (CCMM) Member Engagement Clinical Information Exchange Quality and Performance Reporting Predictive Modeling and Analytics Administrative and Financial Risk Management Systems