Call Yourself an ACO? Prove It

Healthcare providers that boast they're accountable care organizations may now have their services vetted by the National Committee for Quality Assurance, which on Monday announced a three-tiered accreditation program to verify and score those claims.

"There's lots of organizations who are going to call themselves an ACO," Raena Grant Akin-Deko, the NCQA's Assistant Vice President for Product Development tells HealthLeaders Media. "But we think that from a patient or purchaser perspective, it might be hard to tell which organizations really are going to take accountability."

So the committee is rolling out a set of seven overarching criteria that it expects ACOs to master, and will confirm their ability to provide that quality of care with onsite surveys starting in March. Organizations can apply starting Nov. 21.

"Part of the rationale of why we developed this program was to give folks out there who will be using the services of these entities a level playing field," Akin-Deko says. "We want to be able to tell an organization that has the capabilities of being an ACO from one that might just be putting the label on their organization."

ACOs that submit to inspection would agree to have their status, and level of accountable care provided, posted on the NCQA website, much like quality data that can now be seen on the Centers for Medicare & Medicaid Services' HospitalCompare.

For example, organizations will have to demonstrate that they have a sufficient number and appropriate selection of types of practitioners for the community they purport to serve. They may, for example, demonstrate that they have the ability to arrange for a patient to see a provider within a certain number of hours to avoid a trip to the emergency room, Akin-Deko says.

Additionally, the ACO would have to have a method for patients to submit complaints.

Elliott Fisher: some reservations

Elliott Fisher, MD, director of the Center for Population Health at Dartmouth Medical School, tells HealthLeaders that he is "completely supportive of the goal (the NCQA) is trying to achieve, but has some reservations.

"I'm concerned that it's early in the development of this to set in place a set of rigid structural requirements that may or may not be predictive of high performance.  It may lock out some of the most creative innovative organizations and institutions from participating in this program."

For the time being, Fisher says, there are between 60 and 100, "actually closer to 100," organizations that are going forward with some model of an ACO, either just with private payers or through one of the pilots within the Medicare Shared Savings Program whose final rules were just announced late last month.

"We have to be conscious that there may be people trying to take advantage of this model to play an old game and continue business as usual," Fisher says.  But so far, of the ones organized by private payers that he's seen, "I think an awful lot of the activity is trying to help them do the right thing for patients."

7 measures of ACO competence

The accreditation process measures the competence of an ACO in these seven areas.

1. It has the infrastructure to coordinate providers and collaborates with stakeholders to improve quality of care, patient experience and manage financial resources. This includes the ability to arrange "payment for ACO professionals and working with payers to determine reimbursement."
2. It has sufficient numbers and types of practitioners to provide timely access and monitors its effectiveness in meeting needs and preferences of its patients.
3. It provides patients access to patient-centered medical homes and evaluates the ability of primary care practices to deliver that care.
4. It collects, integrates and uses data for care management and performance reporting, focusing on the capture of information in electronic systems and assuring that practitioners can access it.
5. It can assure that providers can share information about a patient in a timely way, ensuring rapid identification of "patients at risk of transitioning."
6. It respects the rights and privacy of patients, restricts access to data, and has a method for patients to submit complaints.
7. It strives to improve services by evaluating its performance using valid measures and making results available to the public and ACO providers.

3 levels of accreditation

The NCQA's accreditation program offers three levels, to allow those organizations with varying levels of compliance some framework, based on a scoring system with 100 points.

1. Organizations in the earliest part of their process, for example, those who have not reached full capabilities, might be designated Level 1, in which they would achieve 50 out of 100 points. Certain "must pass" thresholds, such as assuring clinical data and patient information is captured in structured electronic systems with meaningful use, would not be required.

2. Those achieving Level 2 would demonstrate compliance with 70 points and meet four "must pass" measures.

3. Level 3 is reserved for organizations that, in addition to complying with all metrics in Level 2, show significant improvement in measures that assess the triple aim, better quality, better patient experience and lower cost. Level 3, which lasts three years, requires annual performance reporting and evaluation to maintain the status.

Many of the ACOs approved under CMS' various models would not necessarily be accredited under the NCQA's standards, some of which go beyond what CMS requires, Akin-Deko says.

In a fact sheet distributed this week, the NCQA says that "in some communities, health plans are already contracting with integrated delivery systems that they know well. However, we expect that larger plans covering multiple communities, and large employers, will be challenged to understand if organizations are capable of participating in these initiatives."