Coordinated care: which organizations can form ACOs?

One of the overall goals of any quality-focused program is to realize the ease and efficiencies that can occur when coordinated care is well-managed across providers. Currently, the specifications that define an Accountable Care Organization (ACO) are flexible enough to accommodate and include a wide range of provider organizations, including fully integrated health care systems, multi-specialty group practices, physician hospital organizations and independent physician associations.

The Medicare Shared Savings Program Fact Sheet explains that any of the following providers and suppliers of Medicare-covered services can participate in a Medicare Shared Savings Program ACO:

• ACO professionals (i.e., physicians, physician assistants, nurse practitioners or clinical nurse specialists) 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 Medicare providers and suppliers as determined by the Secretary.

Despite the growing interest in coordinated care across providers and groups of providers, there is little guidance about the types of caregivers who should participate in an ACO or the organizational structure under which they should operate. At minimum, to become or join an ACO, an organization should evaluate its ability to improve outcomes—that is, to control costs, improve quality, and provide patient-centered, coordinated care.

In the ACO model, the heart of coordinated care is effective primary care. That’s because some of the most important mechanisms for reducing and slowing the growth in health care spending are delivered through primary care: disease prevention, early diagnosis, chronic disease management and coordinated care.

Within an ACO, specialists play an important role in patient care. But relative to primary care, in an ACO, specialists will need to be better coordinated, and the overall volume of referrals to specialists will need to decrease in most regions to make the model work. Although an ACO will need to have effective working relationships with specialists, those specialists do not necessarily need to be part of the ACO itself.

^{1Miller, H.D. (September 7, 2009). How to Create Accountable Care Organizations. Center for Quality and Healthcare Reform. Available at: http://www.chqpr.org/downloads/HowtoCreateAccountableCareOrganizationsExecutiveSummary.pdf.}