establishment and regulation of accountable care organizations acos section 1

1. Establishment and Regulation of Accountable Care Organizations (ACOs) Section 1 October 6, 2010 Julia Feldman, Esq. Principal Associate Center for Health Law and Economics Commonwealth Medicine University of Massachusetts Medical School

3. Organizations Likely to be Ready to Operate as ACO Provider organizations that are highly integrated clinically as well as financially, with the ability to manage and coordinate patient care, report on performance in a measurable way, and distribute savings. Special Commission Report of July 2009 recommended flexibility regarding types of organizations that may operate as ACOs. Most health policy experts agree that the highest level ACO reflects a high level of integration, ability to measure and report on quality performance, contractual/financial management capacity, and ability to accept some risk.

4. Federal Approach in PPACA Mainly establishes ACO models on a voluntary basis through pilot programs, demonstration projects, and the Medicare shared savings program Attribution of individuals to set of physicians the basis of voluntary model Incremental (rather than across-the-board) approach

5. What should be the Role of the State be in Promoting and Regulating ACO Formation? Legislation vs. Regulation: Should any legislation regarding ACOs set forth principles within which an oversight entity should develop qualifying criteria, or should it set some criteria, and if so which and how? What should be delegated to an oversight entity and left to regulation? Should government regulate the right of and hold accountable any provider group calling itself an ACO? Federal Requirements: what should the relationship be between state and federal requirements or definitions?

6. ACO Capacities Should ACOs be required to possess at least the following functional capacities: patient management functions (patient specific/management data); clinical service coordination, management and delivery functions; financial management capabilities; contract management capabilities; quality competence; and patient and provider communications functions? Is there a minimal array of services an ACO must be able to provide?

7. Level of Integration Should there be tiers of integration of ACOs? If so, how should that work? (For example, should there be three or four tiers ranging in integration?)

8. ACO Provider Composition Minimal Number: Should all ACOs include primary care medical homes as a minimum requirement? Specialty Providers: Should specialty providers be permitted to be a member of more than one ACO? Should there be a prohibition on limiting the ability of specialty providers from participating in more than one ACO? Primary Care Providers: Should Primary Care providers be limited to be a member of only one ACO?

9. ACO Members Assignment vs. Attribution: Should ACO members be assigned or attributed, and if so, how? Out of ACO Services: Should ACO members be permitted to go out of the ACO to obtain services? If so, which entity should be responsible for those costs: the assigned ACO or the out � of � network ACO? Consumer Protection/Appeals: What consumer protections should be provided to ACO members? Should existing governmental appeals processes be utilized, and if so which one/ones? Proposal is to afford process through the Department of Public Health Office of Patient Protection; is this adequate/acceptable? Should there be additional process(es) afforded ACO members, and if so, what?

10. What should the governance requirements be for ACOs? Should they vary depending on whether or not the ACO is fully integrated (if such variation is permitted)? Should ACO boards or other governance authorities be required to include a primary care physician? Must ACO boards/governance authorities be separate from any hospital providers that are part of such ACO? What level of overlap should be permitted? Should these decisions be established by legislation or left for determination by the oversight entity setting forth parameters? What should those parameters be?

11. Additional Questions and Points for Consideration What additional safeguards should be included for ACO formation, to protect against underutilization and inappropriate patient selection by ACOs? What kinds of disclosure obligations should be required of ACOs, and what entities/who should have access to such disclosures?

12. Questions