The country's top primary care medical associations -- the AAFP, the American Academy of Pediatrics, the America College of Physicians and the American Osteopathic Association -- have just released their Joint Principles for Accountable Care Organizations(www.acponline.org), which the organizations wrote together. The move comes in response to language in the recently enacted Patient Protection and Affordable Care Act that encourages physicians and other health care professionals to organize as accountable care organizations, or ACOs.
According to AAFP Board Chair Lori Heim, M.D., of Vass, N.C., it is important that the four primary care organizations articulate a shared vision of ACOs, much like they did with the Joint Principles of the Patient-Centered Medical Home.(3 page PDF) "You have all four organizations coming together to develop policy, and that sends a very strong message to the government and to other payers about what they need to be aware of as they roll out these accountable care organizations," said Heim.
"ACOs will not be successful if they are not based on primary care and the patient-centered medical home, because that's where we're going to get the care coordination, cost savings and quality of care that we're all interested in."
Indeed, according to the document, an ACO should provide accessible, effective, team-based care based on the Joint Principles of the Patient-Centered Medical Home. In addition, the ACO principles say an ACO should deliver culturally proficient and patient- or family-centered health care.
The four organizations also agree that structurally an ACO should, among other things,
- demonstrate strong physician leadership that includes equitable representation from primary care and subspecialist physicians;
- strive for clearly defined and transparent organizational relations -- including payment methodologies -- between physicians, other health care professionals and consumers;
The AAFP has reviewed and responded to draft accountable care organization, or ACO, standards and measures released by the National Committee for Quality Assurance, or NCQA, in October.
The NCQA invitation for public comment on its draft 2011 ACO criteria closes on Nov. 19. The committee plans to use the final criteria -- scheduled for release in mid-2011 -- to support a recognition program similar to its patient-centered medical home recognition program.
The Academy generally agrees with much of NCQA's proposed criteria, including the positioning of primary care as the foundation of any successful ACO. However, the AAFP does object to the NCQA's terminology "primary care practioners" in the section of its proposal dealing with stakeholder groups involved in oversight of ACO functions.
The Academy suggests that the NCQA use the term "primary care physicians" instead. "If the stated goal of NCQA is to have primary care as the foundation of the ACO, then primary care physicians must be part of the oversight body," says the AAFP.
- include patient and family input in policy development;
- commit to interfacing with programs that improve the health of the public,
- provide incentives for patients and families to pursue personal health and wellness activities;
- encourage patient selection of a primary care physician if the patient is assigned to an ACO or otherwise ensure voluntary ACO participation by all participants;
- use nationally accepted and validated clinical measures to gauge performance and efficiency and to evaluate patient experience;
- implement clinically integrated information systems;
- include monitoring to prevent unintended consequences;
- allow physician participation in multiple ACOs;
- address and eliminate barriers to small practice participation;
- protect physicians and other health care professionals from existing antitrust and similar laws that restrict collaboration on payment models; and
- promote processes that reduce administrative burdens on practices and their patients.
Heim said the Academy wanted to ensure that the ACO design was not driven by other organizations that may not have the same awareness of the primary care and the family medicine perspective. "One of the big fears we have is that the big players in the field -- the folks who are really ready to 'rock and roll' with this -- are the large health systems and the hospitals," she said.
Heim also noted that CMS is stepping up its efforts to test medical home projects and, as part of that process, the agency also will test ACOs. "It's critical for our members to be involved with this at the ground level," said Heim,
The joint principles for ACOs also lay out guidelines on payment models and incentives, which must, among other things,
- align mutual accountability at all levels;
- reflect the relative contributions of participating physicians and other health care professionals as they seek to increase health care quality, efficiency and value;
- recognize the effort required to involve multiple parties in the care management and care coordination process;
- base rewards for performance on target levels of performance, achievement and improvement that have been developed with significant input from physicians and other health care professionals;
- allow for the provision of additional financial incentives to ACO-participating practices that have achieved other related certification and recognition; and
- protect physicians and other health care professionals from insurance risk unless otherwise stated in the participation agreement.
Finally, ACOs should be allowed to employ a variety of payment approaches, including blended fee-for-service/prospective payment, shared savings, episodic or case rate methodologies, and partial capitation.
Heim said that as quality improvement and cost savings to the system are realized, primary care practices that are at the heart of the ACO model must be recognized. "Primary care practices will need to make sure that they are receiving the benefits of the shared savings," said Heim.