NCQA Draft Standards for Accountable Care Organizations Outline a Pathway to Integrated Care

by Ropes & Gray LLP
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The concept of Accountable Care Organizations (“ACOs”) began to take a more defined shape last week as the National Committee for Quality Assurance (“NCQA”) released for public comment draft ACO standards and guidelines. This guidance has implications not only for providers interested in participating in the upcoming Medicare Shared Savings program or forming ACOs for the commercial payer or Medicaid markets, but also for all other providers looking to improve coordination and quality in order to succeed in a reformed health care delivery system.

NCQA’s goal in these draft criteria is to identify core capabilities that increase an ACO’s likelihood of success in achieving the “Triple Aim” of improving health, improving patient experience, and reducing per capita costs. These core criteria fall into the following seven defined categories:

• Program Structure and Operations

• Access and Availability

• Primary Care

• Care Management

• Care Coordination and Transitions

• Patient Rights and Responsibilities

• Performance Reporting

Recognizing that ACOs will seek continuous assessment and improvement, NCQA also furnishes guidance on how organizations can continue to enhance their performance even after meeting the threshold criteria for recognition as an ACO by Medicare. To this end, NCQA proposes to implement four scoring levels that apply regardless of organization structure, with Level 1 ACOs meeting core quality criteria, and Level 4 ACOs meeting advanced criteria and demonstrating excellence or improvement in outcomes. At a minimum, to qualify as an ACO, an organization must be the legal entity that accepts contracts to deliver health care to a defined population and must include primary care physicians. Beyond these requirements, NCQA leaves flexibility for providers to organize themselves in ways that best address the needs of their communities, including but not limited to group practice arrangements, networks of individual practices, partnerships or joint ventures between hospitals and providers, or hospitals and their employed providers. ACOs are also free to develop various reimbursement mechanisms.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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