accountable care organization (ACO)

Introduction

A formally organized entity of physicians & other health care professionals responsible through contracts with payers for providing a broad set of health care services to a specific population.

Organizations must demonstrate a sufficient number of providers within the network to manage the number of patients covered

Goals of an ACO include:

• control of health care costs*
• focus on prevention
• improve quality of healthcare for chronic conditions

* includes reducing hospitalizations & institutionalizations

Centers for Medicare & Medicaid (CMS) offer providers & hospitals financial incentives to meet quality markers for Medicare beneficiaries.

• reduce hospitalizations & institutionalizations
• to be eligible for shared savings, an organization must show improvement in quality measures in specific domains
• points have been assigned for 65 quality measures grouped into 5 domains
  • patient/caregiver satisfaction
  • care coordination
  • patient safety
  • preventive health
  • management of at risk populations (chonic conditions)
    • diabetes mellitus
    • heart failure
    • coronary artery disease
    • hypertension
    • COPD
    • frailty

ACOs are responsible for care that a Medicare beneficiary receives even if the care is provided outside of the ACO (i.e. out-of-state care ...)

ACOs are not responsible for Medicare part D benefits

Additional terms

• Medicare