This past spring, the Centers for Medicare & Medicaid Services finally released the proposed rules for accountable care organizations (ACOs), which would provide a way for various healthcare providers to share in healthcare savings by coordinating care better. The first ACOs could start popping up in 2012, and the new rules beg the question: Will renal care get involved in ACOs in any meaningful way?
A quick Google search may shed some light with the DaVita website www.accountablekidneycare.com popping up. "As nephrologists, we are keenly aware of the need to deliver higher-value care," Robert Provenzano, MD, FACP, chair of the Accountable Kidney Care Collaborative, and vice president of medical affairs for DaVita, wrote on the site's homepage. "We now have the opportunity to be innovative and utilize our skills, processes, and integrated provider relationships to provide more efficient, coordinated care. To that end, we created the Accountable Kidney Care Collaborative (AKCC). This voluntary group will explore how nephrologists can succeed in the world of accountable healthcare delivery."
ACOs are voluntary and do not have the immediacy of other large shifts, such as the bundling rule or even 2008's update to the ESRD Conditions for Coverage. Still, there is interest in the renal community in ACOs and the possibilities they could bring.
Renal Foundation
The first iteration of ACOs is primary care focused, and that is likely due to the basic need of getting a large program like this off the ground. However, there is an argument within the renal community that nephrologists should be able to play a more central role in ACOs, especially when it comes to kidney disease patients.
"The most important thing, the basic building block that leads to success, is trying to figure out a way to take this massively fragmented system and bring it under control meaning that one, the nephrologists really are the principle care providers," DaVita chief medical officer Allen Nissenson, MD, said. "They know what’s going on and what other specialists the patients are seeing. They’re working closely with a primary care doctor if there is one. The importance of all of this care being coordinated is so that patients don’t go off and see a doctor whose it not familiar with dialysis patients, orders some kind of test that isn’t indicated, has side effects or orders a medication that’s inappropriate. It’s making sure that everyone is part of the same team. Care managers can really coordinate the care. And third, this is where either of us are at the place we want to be, is a very important component of this is having some sort of electronic health record, which really facilitates the ability to keep track of everything that’s happening to an individual patient."
Perhaps the biggest test of whether a renal-centered ACO came from a disease management demonstration project conducted through the Arbor Research Collaborative for Health. It looked at whether three disease management organizations could improve clinical outcomes and reduce Medicare spending. The report found there were improvements in diabetes care, cardiovascular disease, nutrition and vaccinations. In addition, on of the groups saw a small improvement in advanced care planning. More importantly, the report found that an "analysis combining all DMOs demonstrated significant reduction in mortality when compared to FFS (fee-for-service) at both one and two year time points."
Inside the Rule
In essence, ACOs create incentives for healthcare 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 healthcare costs while meeting performance standards on quality of care and putting patients first. In addition, patient and provider participation in an ACO is purely voluntary.
To coincide with the release of the rule, CMS Administrator Donald Berwick, MD, MPP, wrote a perspective piece for the New England Journal of Medicine. "The financial opportunity for an ACO to achieve shared savings will vary according to its initial tolerance for risk," he wrote. "Two different models are proposed. In the first model, ACOs earlier in their evolution can elect to assume a smaller share of upside gains but no risk of loss for 2 years and then transition in year 3 to accepting risk. In the second model, organizations that are willing to take on both upside gains and downside risk can qualify for a higher proportion of shared savings from the start."
For beneficiaries, there would be significant differences between ACOs, as described in the proposed rule and the private managed care plans offered under the Medicare Advantage program. Beneficiaries would not enroll in a specific ACO. Instead the proposed rule calls for Medicare to take a retrospective look at the beneficiary’s use of services to determine whether a particular ACO should be credited with improving care and reducing expenditures. This means that an ACO would have an incentive to improve the quality of care for all patients seen by its member providers and suppliers.
The proposed rule would require providers participating in an ACO to notify the beneficiary that they are participating in an ACO, and that the provider will be eligible for additional Medicare payments for improving the quality of care the beneficiary receives while reducing overall costs or may be financially responsible to Medicare for failing to provide efficient, cost-effective care. The beneficiary may then choose to receive services from the provider or seek care from another provider that is not part of the ACO.
The proposed rule would also require each provider in an ACO to notify the beneficiary that the beneficiary’s claims data may be shared with the ACO. This data sharing is intended to make it easier to coordinate the beneficiary’s care; however, the provider may not require a beneficiary to obtain services from another provider or supplier in the same ACO. The provider must give the beneficiary the opportunity to opt-out of those data sharing arrangements. For Medicare beneficiaries who choose not to opt-out of the data sharing arrangements, the proposed rule would limit data sharing to the purposes of the Shared Savings Program and would require compliance with applicable privacy rules and regulations, including the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Eligibility Requirements for an ACO
Under the proposed rule, an ACO refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the Medicare fee-for-service beneficiaries they serve. The Affordable Care Act specifies that an ACO may include the following types of groups of providers and suppliers of Medicare-covered services:
- ACO professionals (i.e., physicians and hospitals meeting the statutory definition) in group practice arrangements,
- Networks of individual practices of ACO professionals,
- Partnerships or joint ventures arrangements between hospitals and ACO professionals, or
- Hospitals employing ACO professionals.
- Other Medicare providers and suppliers as determined by the Secretary
The statute also requires each ACO to establish a governing body representing ACO providers of services and suppliers and Medicare beneficiaries. The proposed rule would make each ACO responsible for routine self-assessment, monitoring and reporting of the care it delivers.
