ACO final rule cuts provider burden

Quality measures reduced from 65 to 33

In response to comments from healthcare professionals, the Centers for Medicare and Medicaid Services (CMS) made significant changes to the final rule for the creation of accountable care organizations (ACOs), which encourage providers to better coordinate care across all settings.

ACOs are intended to encourage providers of services and supplies to better coordinate care for Medicare patients by rewarding the ACOs that lower healthcare costs and meet quality standards. Participants in an ACO might include group practices, networks of practices, partnerships between hospitals and practices, or hospitals employing physicians. The organization shares savings by better coordinating patient care, providing high quality care, and using healthcare dollars wisely.

The final rule makes changes in the way participants will be rewarded for better coordinating care and extends the deadline for applying to become an ACO through the end of 2012.

When CMS announced its proposed rule for ACOs, many healthcare organizations and industry trade associations expressed disappointment, arguing that the burdens were too high and the potential return too low.

"We commend CMS for listening to the concerns of America's hospitals. The hospital field is actively working on ways to improve care delivery and the final accountable care organization rule provides hospitals a better path to do so," says Rich Umbdenstock, president and chief executive officer of the American Hospital Association, with headquarters in Chicago.

ACOs mean opportunities for case managers as providers coordinate care across healthcare settings, says Joanna Malcolm, RN, CCM, BSN, consulting manager, clinical advisory services for Pershing, Yoakley & Associates in Atlanta. "Case managers are now being recognized as important players in the healthcare field. We are able to affect both the financial and the clinical side of patient care and see the big picture as patients move through the continuum of care," Malcolm says.

Case managers will become the glue that hold ACOs together and make them work, by making sure that the patients clinical needs are being met in a timely manner while keeping the financial piece in mind, she adds. "Improving transitions as patients move from one level of care to another is essential in an accountable care organization and this is where case managers have expertise," she says.

In addition to making changes to the Medicare Shared Savings Program to make it more appealing to providers, the final rule reduces the number of quality measures to be reported from 33 to 65. (To view the 33 measures, see resources on right) Under the final rule, providers will report quality measures in four domains: patient experience; care coordination and patient safety; preventive health; and caring for at-risk populations.

Participants in an ACO continue to receive payments under Medicare fee-for-services but will share in savings if they meet quality and performance standards. CMS will aggregate an ACO's spending across all individuals and compare it to the national healthcare spending trend. The higher quality of care the providers deliver and the greater effectiveness of their care coordination, the more savings they share.

Resources/Sources

A list of quality measures is on pages 324-326.

For more information contact:

  • Joanna Malcolm, RN, CCM, BSN, Senior Consultant, Pershing, Yoakley & Associates, Atlanta. E-mail: JMalcolm@pyapc.com.