Description of ACO Measures: Excerpts and Table from CMS "Accountable Care Organization 2013 Program Analysis--Quality Performance Standards Narrative Measure Specifications" Report
On November 2, 2011, the CMS finalized new rules under the Patient Protection and Affordable Care Act (Affordable Care Act) to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through ACOs. ACOs create incentives for health care providers to work together to treat an individual patient across care settings -- including doctor's offices, hospitals, and long-term care facilities. The Medicare Shared Savings Program (Shared Savings Program) will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first. Participation in an ACO is purely voluntary. (ACO Provider Fact sheet: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO_Summary_Factsheet_ICN907404.pdf.)
To participate in the Shared Savings Program, ACOs must meet all eligibility and program requirements, must serve at least 5,000 Medicare FFS patients and agree to participate in the program for at least 3 years. Providers and suppliers who are already participating in another shared savings program or demonstration under FFS Medicare, such as the Independence at Home Medical Practice pilot program, will not be eligible to participate in a Shared Savings Program ACO.
Medicare providers who participate in an ACO in the Shared Savings Program will continue to receive payment under Medicare FFS rules. That is, Medicare will continue to pay individual providers and suppliers for specific items and services as it currently does under the Medicare FFS payment systems. However, CMS will also develop a benchmark for each ACO against which ACO performance is measured to assess whether it qualifies to receive shared savings, or for ACO's that have elected to accept responsibility for losses, potentially be held accountable for losses. The benchmark is an estimate of what the total Medicare FFS Parts A and B expenditures for ACO beneficiaries would otherwise have been in the absence of the ACO, even if all of those services were not provided by providers in the ACO. The benchmark will take into account beneficiary characteristics and other factors that may affect the need for health care services. This benchmark will be updated for each performance year within the agreement period.
CMS is implementing both a one-sided model (sharing savings, but not losses, for the entire term of the first agreement) and a two-sided model (sharing both savings and losses for the entire term of the agreement), allowing the ACO to opt for one or the other model for their first agreement period. CMS believes this approach will have the advantage of providing an entry point for organizations with less experience with risk models, such as some physician-driven organizations or smaller ACOs, to gain experience with population management before transitioning to a shared losses model, while also providing an opportunity for more experienced ACOs that are ready to share in losses to enter a sharing arrangement that provides a greater share of savings, but with the responsibility of repaying Medicare a portion of any losses.
Under both models, if an ACO meets quality standards and achieves savings and also meets or exceeds a Minimum Savings Rate (MSR), the ACO will share in savings, based on the quality score of the ACO. ACOs will share in all savings, not just the amount of savings that exceeds the MSR, up to a performance payment limit. Similarly, ACOs with expenditures meeting or exceeding the Minimum Loss Rate (MLR) will share in all losses, up to a loss sharing limit. To provide a greater incentive for ACOs to adopt the two-sided approach, the maximum sharing percentage based on quality performance is higher for the two-sided model. ACOs adopting this model will be eligible for a sharing rate of up to 60%, while ACOs in the one-sided model will be eligible for a sharing rate of up to 50%. Under both models, CMS will base the actual savings percentage for the individual ACO (up to the maximum for that model) on its performance score for the quality measures. As with shared savings, the amount of shared losses will be based in part on the ACO's quality performance score.
Medicare offers several ACO initiatives including:
ACO Quality Measures
Under the CMS ACO initiatives, before an ACO can share in any savings created, it must demonstrate that it met the quality performance standard for that year. CMS will measure quality of care using nationally recognized measures in four key domains:
Patient/caregiver experience (7 measures).
Care coordination/patient safety (6 measures).
Preventive health (8 measures).
- At-risk population:
- Diabetes (1 measure and 1 composite consisting of five measures);
- Hypertension (1 measure);
- Ischemic Vascular Disease (2 measures);
- Heart Failure (1 measure); and
- Coronary Artery Disease (1 composite consisting of 2 measures).
The 33 quality measures are provided at-a-glance in Table J-10 below. For each measure, the table includes (1) the ACO measure number, (2) its domain of care, (3) the title of the measure, (4) its measure steward and NQF number (if applicable), (5) the method of data submission, and (6) when the measure is subject to pay for reporting versus pay for performance. Note that for the diabetes-related measures, five of the six measures are grouped into one "all-or-nothing" composite performance rate. Similarly, the two coronary artery disease measures are also grouped into one "all-or-nothing" composite rate for reporting purpose. In addition, six of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures are scored together as one measure and one of the CAHPS measures is treated separately.
The ACO quality measures align with those used in other CMS quality programs, such as the Physician Quality Reporting System (PQRS) and the EHR Incentive Programs. The ACO quality measures also align with the National Quality Strategy and other U.S. Department of Health and Human Services priorities, such as the Million Hearts Initiative. In developing the final rule, CMS listened to industry concerns about focusing more on outcomes and considered a broad array of measures that would help to assess an ACO's success in delivering high-quality health care at both the individual and population levels. CMS also sought to address comments that supported adopting fewer total measures that reflect processes and outcomes, and aligning the measures with those used in other quality reporting programs, such as the PQRS.
TABLE J-10. Measures for Use in Establishing Quality Performance Standards that ACOs Must Meet for Shared Savings
SOURCE: Accountable Care Organization 2013 Program Analysis -- Quality Performance Standards Narrative Measure Specifications, prepared for Quality Measurement and Health Assessment Group, Center for Clinical Standards and Quality, Centers for Medicare and Medicaid Services, by RTI International, Waltham, and Telligen West Des Moines, IA.
NOTE: ACO = accountable care organization; NQF = National Quality Forum; P4P = pay for performance; P= performance; R = reporting.
For more information see: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures-Specs.pdf.