ACO Discussions Begin; Pediatricians Will Play a Role

ACOs may also end up being part of testing performed by the Center for Medicare and Medicaid Innovation, a new office created under the law. The innovation center has broad authority to test new payment ideas and will launch in January 2011.

Finally, the Affordable Care Act includes a pediatric ACO demonstration project that allows states to recognize pediatric medical providers as ACOs and to award incentive payments through Medicaid. That project is also expected to launch in January 2012.

Since the passage of the Affordable Care Act, there’s been a “flurry of activity” going on around the country, similar to what happened in the early 1990s around the growth of HMOs and capitation, said Dr. Crosson of the Kaiser Permanente Institute, who is also a pediatrician. “All over the country, hospital boards are going off with their medical staffs and asking the question, ‘Do we want to become an ACO?’?”

In the near term, there is likely to be a range of ACO models, Dr. Crosson predicted. Some will be tightly constructed around integrated delivery systems in which physicians and hospitals are part of the same economic entity. Other will be looser models that bring together a group of physicians and hospitals that are financially separate from one another, he said. The real question, Dr. Crosson noted, is not whether various models can be designed, but which ones will work best. And for that, he said, only time will tell.

But he added that pediatricians will have a role, especially if they have had success in transitioning to a patient-centered medical home practice. The type of care coordination that happens at the individual practice level is the same type of capability a physician will need to be successful within an ACO, he said.

“I think there’s room in this for virtually everyone to be in the game and try to get it to work,” Dr. Crosson said.

As the ACO concept develops, pediatricians may find that they are getting a lot more attention from hospitals that are interested in developing closer, more collaborative relationships with them, said Dr. Allen of Nationwide Children’s Hospital.

“I think [pediatricians] are going to find themselves to be incredibly popular,” Dr. Allen said.

The NCQA has convened a task force to study the concept of ACOs, and this month it plans to release its recommendations for what qualifying criteria these organizations should meet.

The task force includes representatives from organizations that consider themselves to be ACOs or that are developing plans to launch one. The diverse group has been working on setting out specific criteria – from governance structures to the ability to manage financial risk – that will help ACOs to succeed in the coming years.

“The idea [of ACOs] is mom and apple pie, and it’s terrific to talk about in its generalities,” said Tricia Barrett, vice president of product development at the NCQA. “But as soon as you start talking about specifics, you realize that nobody’s talking about the same thing.”

Over the past few months, task force members have delved into the details and found some common ground, she said, recognizing that there will be a variety of ways to run an ACO. For example, there is consensus within the task force that primary care and the principles of the patient-centered medical home need to be at the foundation of the ACO. The extent to which specialists and hospitals are part of the same legal entity, rather than contracted with primary care physicians, will depend on the dynamics in individual marketplaces, she said.

The task force is also making headway on the specific qualifying criteria that ACOs should meet to demonstrate that they are set up for success. For example, task force members generally agree that there should be rules around the composition of provider networks within ACOs. This would ensure that patients have a certain level of access to both primary care and specialist physicians, and that the ACO is able to support the full spectrum of patient needs.

Performance measurement will also be a critical way to evaluate ACOs. However, getting to reliable, comparable performance results related to these organizations will take some time, Ms. Barrett said.

The NCQA task force members are also focused on ensuring that there are consumer protections built into the ACO structure. Consumers need to be considered in the design and policies of an ACO so that they have a full understanding of what their obligations and rights are, Ms. Barrett said.