Accountable Care Organizations (ACOs) -- A model that is emerging for the long-term but hard to implement in the short-run

CMS Announces New Options for ACOs
Last week, CMS announced several new options for implementing accountable care organizations (ACOs). These new options provide incentives for providers to develop or join ACOs earlier than the original start date (January 1, 2012) and to receive upfront bonus payments. ACOs were established as part of health care reform to incentivize the development of networks of providers to collaborate and coordinate services to deliver higher-quality care to Medicare beneficiaries. By delivering care that meets certain quality measurements, ACO-affiliated providers can receive CMS-issued bonus payments.

The new options to facilitate ACO development that were proposed are:
1. Pioneer ACO Model -- CMMI is now accepting applications for this new ACO model, which will provide a faster path for existing ACOs and integrated-care organizations than under the Medicare Shared Savings Program start date of January 1, 2012. Pioneer ACOs will be able to collaborate with private payers and achieve greater savings by transferring to a population-based model in the third performance year (given satisfactory performance during the first 2 years of operation). CMS will hold these organizations financially liable for delivered care and will publicly report their performance.
2. Advance Payment ACO Initiative -- CMMI proposes to allow ACOs to receive a portion of shared savings (ie, bonus payments) upfront before CMS begins contracting with ACOs in 2012. These upfront payments will help providers make necessary infrastructure and staffing investments that are the backbone of successful ACOs. CMS plans to recoup these advanced payments through ACOs' shared savings once they become operational. Comments for this initiative should be submitted to advpayACO@cms.hhs.gov by June 17, 2011.
3. Accelerated Development Learning Sessions -- CMS will offer educational sessions to inform providers about the necessary steps to becoming a successful ACO. These free sessions will provide information about actions providers can undertake to improve delivery of care and to achieve better-coordinated care. CMS will offer 4 sessions in 2011, each with a focused curriculum on ACO development. To attend the June Accelerated Development Learning Session in person, individuals may register at https://acoregister.rti.org.

Many healthcare stakeholders believe CMS released these new options in response to the strong criticism facing the ACO proposed rule. Provider reaction to these new options is still unclear and many providers remained fundamentally concerned about the ability of these models to positively impact the quality and outcome of care.

So what does an ACO mean to a physician, nurse or pharmacist in your community? At this point its not clear but many analysts are projecting these new care models will develop more locally through the expansion of existing integrated delivery systems. There is hope that eventually these models will allow very different models for care including expanded roles of physician assistants, nurse practitioners and pharmacists.

So as a patient, will I know if I am in an ACO? The answer is a "maybe". In fact we know that in Massachusetts, the ACO model has grown but patients often do not know they are part of an ACO. Its often "not obvious" that you are being served by an ACO which in many ways is a positive sign that care is not being inappropriately restricted -- but questions remain on how ACOs impact care for disease states like cancer.

Like many parts of health care reform implementation -- we are just beginning to see how this might work and what it might mean for patients.