Pharmacists in ACOs, Part 1: Accountable Care Basics Every Pharmacist Should Know
While trying to explain his work on quantum mechanics, physicist Richard Feynman famously quipped, If anybody says they understand it, they don't understand it." The same could be said about the speed-of-light changes occurring within our nation's health care system.
While trying to explain his work on quantum mechanics, physicist Richard Feynman famously quipped, “If anybody says they understand it, they don’t understand it.” The same could be said about the speed-of-light changes occurring within our nation’s health care system. In an effort to bring us all up to speed on these current changes, and share some pretty amazing opportunities ahead, this series, Pharmacists in ACOs, will give you a history, background, and implications of accountable care as it pertains to our profession.
Q: Start at the beginning: What is accountable care, and where did it come from?
A: The term accountable care refers to language within the Patient Protection and Affordable Care Act, commonly known as the ACA or Obamacare. More than 20,000 pages of related regulations have sprung from the original 974-page federal statute, covering everything from improving health care access to Medicare spending to revenue provisions. Accountable care is the idea that providers and health care systems should be rewarded or punished based on how well they provide their services (ie, that health care systems are financially incentivized to take into account their patients' outcomes. Accountable care’s goal is coined the “triple aim” and formally includes (1) improving patients’ experience, (2) improving the health of populations, and (3) reducing overall cost. Accountable care is often countered against the traditional fee-for-service model in which providers are paid for their volume of services, rather than for their services’ quality.
Q. If health care is being held accountable, how do we get graded?
A: The ACA's passage created several cost-containment methods called alternative payment models (APMs) that CMS can now use to incentivize health systems to produce better patient outcomes. You are probably familiar with the effects of the Hospital Readmission Reduction Program, which penalizes hospitals that have excessive readmission rates for certain conditions, such as congestive heart failure and chronic obstructive pulmonary disease. (Pharmacists have already shown that we can improve outcomes in this model, but that is a story for another time.) Or maybe you have heard of things called Bundled Payments or Patient-Centered Medical Homes. But, one of the major ways CMS "grades" health care systems is through an APM called an accountable care organization, or ACO.
An ACO is a group of providers, systems, and health care entities that partner to ensure delivery of quality care to a specifically defined population. Although some private sector ACOs also exist, most ACOs are highly associated with Medicare; however, all ACOs are graded against quality measures. These quality-improvement standards, of which 34 exist, adjust slightly from year to year, cover 4 domains related to patients’ satisfaction, safety, preventive health, and care for high-risk populations.
Each ACO’s standards are compared to national benchmarks established by CMS based on prior to the year to which they apply. Benchmarks are the performance standards ACOs must achieve in order to earn points. Each ACO’s final quality score is then used to determine the amount of savings it shares or amount of penalties it will owe to CMS.
Q: So who is being held accountable?
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