The Accountable Care Organization NPRM

Since the Affordable Care Act passed, many senior healthcare executives have told me - "I do not know what an Accountable Care Organization is, but I know we need to be one!"

On March 31, HHS released the Accountable Care Organization Notice of Proposed Rulemaking, so now we know what an Accountable Care Organization must be.  From the Introduction:

"This proposed rule would implement section 3022 of the Affordable Care Act which contains provisions relating to Medicare payments to providers of services and suppliers participating in Accountable Care Organizations (ACOs). Under these provisions, providers of services and suppliers can continue to receive traditional Medicare fee-for-service payments under Parts A and B, and be eligible for additional payments based on meeting specified quality and savings requirements."

Here's a bookmarked copy of the 429 page Notice of Proposed Rulemaking signed by Don Berwick and Kathleen Sebelius.

There are numerous summaries online from various stakeholders

Don Berwick's NEJM Perspective

Kaiser's excellent list of resources

The Healthcare.gov overview

I've read the regulation and there are few items to highlight from an IT perspective:

Electronic Health Records appear on 39 pages

Health Information Exchange appears on 12 pages

To be an ACO, you must first achieve meaningful use, embrace interoperability, and gather the data to pool clinical data for quality measurement.

From Page 404:

"Electronic health records technology. 

(1) At least 50 percent of an ACO's primary care physicians must be meaningful EHR users, using certified EHR technology as defined in §495.4, in the HITECH Act and subsequent Medicare regulations by the start of the second performance year in order to continue participating in the Shared Savings Program.

(2) CMS may terminate an ACO agreement under § 425.14 of this part if fewer than 50 percent of an ACO's primary care physicians are not meaningfully EHR users, using certified EHR technology as defined in §495.4, the HITECH Act and subsequent Medicare regulations by the start of the ACO's second performance year."

Pages 174-194 outline 65 quality metrics than can only be accomplished with a cross organizational quality registry.  Claims analyses are not enough.  From page 170 and 173:

"We propose that ACOs will submit data on these measures using the process described later in this proposed rule and meet defined quality performance thresholds.

Better Care for Individuals:
* Patient/Caregiver Experience
* Care Coordination
* Patient Safety

Better Health for Populations:
*Preventive Health
*At-Risk Population/Frail Elderly Health"

The NPRM is well aligned with Meaningful Use (which appears on 27 pages).  The rule notes that all the CMS programs - Meaningful Use,  Medicare Improvements for Patients and Providers Act (e-prescribing incentives), and Accountable care organizations require separate but aligned IT efforts

"Page 220
 We note that including metrics based on EHR Incentive Program and eRx Incentive Program data does not in any way duplicate or replace specific program measures within each of the two respective programs or allow eligible professionals to satisfy the requirements of either of the two programs through the Shared Savings Program. To receive incentive payments under the EHR incentive or eRx programs (or to avoid payment adjustments), eligible professionals will be required to meet all the requirements of the respective EHR and eRx programs."

So what it an ACO?

It's a group of healthcare providers who have implemented electronic health records, health information exchange, and quality data warehouses to coordinate care and measure population health.  

Our marching orders are clear.   We must implement Meaningful Use Stage 1/2/3, Medicare e-Prescribing incentives, and Healthcare Reform in parallel.

The words ICD-10 and 5010 do not appear in the NPRM.  I continue to hope that ICD-10 is deferred until 2016 to free up the resources we need to create the EHRs, HIEs, and Registries in support  of Accountable Care Organizations.