Medicare Introduces Shared Savings Program with New
Accountable Care Organizations
ACOs will be joint health care effort for better
patient care at lower costs, says CMS
April 2, 2011 – Senior
citizens have become pretty familiar with HMOs and PPOs as managed care
options in the Medicare Advantage Program. Now, meet the new ACOs. The
Centers for Medicare & Medicaid Services (CMS) last week introduced the
Accountable Care Organizations, which CMS says will help doctors,
hospital and other health care providers better coordinate care for
The ACOs are being established
as part of the Medicare Shared Savings Program, which Medicare says will
be a program "that promotes accountability for a patient population and
coordinates items and services under parts A and B, and encourages
investment in infrastructure and redesigned care processes for high
quality CMS-1345-P 15 and efficient service delivery."
The public notice by Medicare
says, “The Shared Savings Program is a key Medicare delivery system
reform initiatives that will be implemented under the Affordable Care
Act and is a new approach to the delivery of health care aimed at: (1)
better care for individuals; (2) better health for populations; and (3)
lower growth in expenditures.”
ACOs create incentives for
health care providers to work together to treat an individual patient
across care settings – including doctor’s offices, hospitals, and
long-term care facilities. The Medicare Shared Savings Program will
reward ACOs that lower growth in health care costs while meeting
performance standards on quality of care and putting patients first.
Patient and provider
participation in an ACO is purely voluntary.
By focusing on the needs of
patients and linking payment rewards to outcomes, this delivery system
reform, as part of the Affordable Care Act, will help improve the health
of individuals and communities while lowering the cost of the system –
up to an estimated $960 million over three years in Medicare savings,
CMS says in a fact sheet issued March 31..
ACOs to Deliver Improved
Care to Medicare Beneficiaries
The physicians, hospitals, and
other providers participating in an ACO would work together to
coordinate patient care and keep track of patients’ conditions and
treatments, regardless of where the patient seeks care. The goal of the
program is to prevent beneficiaries from retelling their story and
medical history to each provider that cares for them.
ACO providers also would
carefully coordinate their patients’ care as they move among physicians’
offices, hospitals, and lab and other facilities in an effort to
eliminate duplication, medication errors, and mismanagement. In doing
so, beneficiaries may save time and money when the ACO effectively
coordinates the beneficiary’s care because improved care coordination
would reduce duplication and waste.
ACOs would be required to have
in place processes to promote treatments and procedures based on the
best medical evidence available in order to promote patient health.
Beneficiaries would be able to obtain their regular Medicare fee-for
service benefits, such as the annual wellness visit and relevant
screening tests, from ACO providers.
ACOs to Provide Patients
with More Health Care Quality Information
An ACO will publicly provide
information about the quality of care the ACO providers deliver each
year. ACOs also would track and report patient outcomes and experiences
on over 60 different quality measures. In addition, beneficiaries
obtaining care from ACOs would be surveyed annually about their
experience with the ACO’s providers. ACOs in turn would report publicly
the different quality measures and survey results so that beneficiaries
can have the information to better manage their own health care.
ACO Providers would Notify
Beneficiaries of their Participation in an ACO
CMS is proposing to require
ACO providers to notify Medicare beneficiaries, at the time they seek
services, that the provider is participating in an ACO. The providers
would offer beneficiaries information about the ACO including how the
ACO would improve the care that they receive. Providers in an ACO also
would be required to post signs in their facilities indicating their
participation in an ACO and to make available written information about
the ACO to Medicare beneficiaries.
Even if a beneficiary seeks
care from a physician, hospital, or other facility that is a member of
an ACO, the beneficiary would still be able to see or visit any provider
they choose. An ACO would be prohibited from using managed care
techniques such as limiting the beneficiary to certain providers,
utilization management, or requiring prior authorization for services
for Medicare beneficiaries.
Beneficiaries Can Opt Out
of Sharing Personal Health Information
To better coordinate care
among ACO providers, an ACO would be able to request personal health
information about the patient from CMS claims data. Before doing so,
ACOs would be required to provide written notice to beneficiaries during
an office visit that it would request the beneficiary’s personal health
information from CMS. ACOs would be required to allow beneficiaries to
opt-out of having their personal health information shared with the
physician and the ACO.
The Shared Savings Program
NPRM will appear in the April 7, 2011 issue of the Federal Register.
CMS will accept comments on the proposed rule until June 6, 2011, and
will respond to them in a final rule to be issued later this year. The
Shared Savings Program will begin operating on January 1, 2012.
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