Figuring out what the long-awaited accountable care organization (ACO) guidelines really mean may require some study.
The federal government finally delivered its much- anticipated guidelines for ACOs. Even though the program is voluntary and will be limited to only about five million Medicare beneficiaries when it opens next year, many healthcare experts have a sense that things have changed forever.
The guideline document is huge – 429 pages and 116,000 words, accompanied by an 8,700-word statement on the proposed ACO anti-trust enforcement policy.
Even for people who’ve been anticipating and researching ACOs for a while now, this could be overwhelming. It seems we all need to familiarize ourselves with a host of new terminology and acronyms. I came across a great article in HealthLeaders Media that outlines “13 Hot ACO Buzzwords” we should all know. Here’s a quick summary, but read the article for full definitions.
- The Paperwork Reduction Act of 1980 (PRA) – Bottom line, it won’t apply to ACOs because of more patient “opt-in” provisions vs. “opt-out” and the resulting new paperwork that will follow.
- Safety Zone – This is promise that federal anti-trust agencies won’t challenge ACOs if provider participants have a combined share of 30 percent or less of each common service in an ACO participant’s primary service area. Of course, exceptions apply.
- Primary Service Area (PSA) – the lowest number of contiguous postal zip codes from which the ACO participant draws at least 75 percent of its patients for that service.
- Retrospective Assignment – Each ACO will retrospectively be assigned groups of 5,000 beneficiaries to prevent them from picking only the healthiest, easiest-to-manage patients.
- Procompetitive – The Department of Justice and Federal Trace Commission are more likely to approve, and less likely to scrutinize, ACOs deemed to be “procompetitive” vs. “anticompetitive.”
- Rule of Reason – The guidelines that will be used to ensure procompetitiveness. Pure price-fixing is clearly out, but joint price agreements among competing health providers that are deemed “reasonably necessary to accomplish the procompetitive benefits of integration” may be okay.
- Taxpayer Identification Number (TIN) – Each ACO will use this number to signify who would be paid shared savings.
- Dominant Provider Limitation – This would apply “to any ACO that includes a participant with a greater than 50 percent share in its PSA of any service that no other ACO participant provides to patients in that PSA. Under these conditions, the ACO participant (a “dominant provider”) must be non-exclusive to the ACO to fall within the safety zone.
- Mandatory Antitrust Review – Most ACOs will be subjected to mandatory federal scrutiny if its share exceeds 50 percent for any common service that two or more independent ACO participants provide to patients in the same PSA. Of course, again, exceptions apply.
- Group Practice Reporting Option (GPRO) – the proposed method to calculate results for the first year of the program. Beneficiaries’ lab results and other clinical information will be reported using this tool to determine shared savings.
- Domain – categories for the 65 quality metrics that will be the basis for determining shared savings. There are five domains: patient or caregiver experience, care coordination, patient safety, preventive health and at-risk population/frail elderly health.
- ACO Professional – Physicians, osteopaths, physician assistants, nurse practitioners and clinical nurse specialists, not limited to primary care.
- Eligibility – The proposed rule says that the following groups are eligible to participate in an ACO:
- ACO professionals in group practice arrangements.
- Networks of individual practices of ACO professionals.
- Partnerships or joint venture arrangements between hospitals and ACO professionals.
- Hospitals employing ACO professionals.
- Other groups of providers determined to be appropriate by the Secretary of Health and Human Services.
Wow. I’m definitely not ready for the quiz yet, but you can bet I’ll be figuring out how to use GPRO in a sentence soon. Good luck.