The Patient Protection and Affordable Care Act (ACA)
Accountable Care Organizations (ACOs)
Patient Protection and Affordable Care Act
What They Are
The ACA includes policies to reward providers for offering better coordination of care to Medicare beneficiaries. ACOs are designed to be patient-centered and to network physicians, hospitals, and other health care professionals, such as audiologists and speech-language pathologists (SLPs), with the patients and each other for partnering in making care decisions.
The ACO model is not limited to Medicare; the private sector adopted an ACO-style of reimbursement, where providers are eligible for bonuses based on savings and outcomes. Many state Medicaid programs are also incorporating ACO models into their Section 1115 Research and Demonstration projects. The key elements of the ACO model include an integrated system of health care delivery, performance measurements, distribution of shared savings, and a governing board with member and practitioner input.
Reimbursement can be fee-for-service through the Medicare Shared Savings Program (MSSP), including the distribution to organizations of additional payments based on meeting or exceeding pre-determined benchmarks for quality standards. An alternative, the Pioneer ACO Model, is designed for organizations already experienced with an ACO model; higher levels of reward and risk are involved for the first 2 years of the project and, during the 3rd year, a population-based reimbursement system is piloted—as opposed to beneficiary-based fee for service. In December 2011, 32 organizations were selected to participate in the Pioneer ACO model. Another alternative offered is the Advanced Payment Model, where the ACO will receive either one up-front fixed payment—a variable payment based on the number of beneficiaries historically assigned—or a monthly variable payment based on the number of beneficiaries.
Qualifications for participation as a Medicare ACOs include
- recognition under state law, which can include legal partnerships or profit/non-for profit corporations with a single Taxpayer Identification Number to distribute the shared savings;
- a governing board 75% of whose membership must be chosen by the ACO providers, a beneficiary, and management;
- an established process to engage patients in shared decision making, including giving patients access to their records;
- an established process to engage specialists and to coordinate care with the primary physician, specialists, and acute care and post-acute care providers.
Organizations interested in developing ACOs complete the Medicare Shared Savings Program Application, including a sample agreement to be used with other providers and a list of the ACOs participating providers. Many Medicare ACOs will require start-up funds of approximately $3 million. For this reason, hospitals will usually be ACO partners.
What This Means for SLPs and Audiologists
SLPs and audiologists will have opportunities to join ACOs as ancillary service providers and, if interested, should start gathering information about their local ACOs now.
Implementation Time Line
This is an ongoing process, as new initiatives and demonstrations projects are introduced by the Center for Medicare and Medicaid Innovation (CMMI) and private health plans.
Certain Advance Payment Models began operation in July 2012. A new round of applications for Advance Payment Model ACOs began August 2012, with implementation in January 2013.
ASHA will continue to monitor initiatives and demonstrations related to the ACO model.