Accrediting Body Issues Proposed Standards for ACOs, Asks for Comment

The National Committee for Quality Assurance, which accredits managed care organizations, has released a set of draft standards for accountable care organizations and is asking for public comment through Nov. 19, according to a release by NCQA.

NCQA currently develops quality measures for health plans, including Medicare Advantage plans, and recognizes organizations as patient-centered medical homes. The draft criteria were developed by an NCQA task force to assess "core capabilities" for ACO success.

"Criteria should provide a blueprint for ACO development and assess core capabilities that improve the likelihood of success," the task force stated. "While performance measurement is critical to evaluate ACO success, it will take some time before organizations can be judged on the outcomes they achieve."

Here are 13 key parts of the proposed standards.

1. ACO structure. The organization has the infrastructure to coordinate providers and works to increase quality, improve patient experience and effectively manage its financial resources.

2. Resource stewardship. The organization has the capability to manage its resources effectively. This involves use of a clinical utilization management plan that includes a process for verifying patient eligibility and benefits, information systems to track utilization, risk adjustment methodology used to determine required reimbursement-levels and shows how it works with payors to determine reimbursement requirements.

3. Health services contracting. The organization arranges for pertinent healthcare services and determines payment arrangements and contracting. At least a portion of practitioners’ compensation is based on the performance of the ACO as a whole, using clinical quality, cost and satisfaction indicators, and there is a process to monitor utilization patterns for inappropriate restrictions on care that may arise unintentionally from existing payment arrangements.

4. Availability of practitioners.
The practice provides patients and families with access to appropriate routine and urgent care. It establishes quantifiable and measurable standards for the number of practitioners providing primary care.

5. Practice capabilities. The practice provides patients and families access to appropriate routine and urgent care. It must develop an individualized care plan in collaboration with patient/family that includes treatment goals that are reviewed and updated at each relevant visit for at least 75 percent of patients. Identifies patients/families who might benefit from additional care management support for at least 50 percent of patients.

6. Data collection and integration.
The organization collects and integrates data from various sources, including, but not limited to electronic sources for clinical and administrative purposes.

7. Initial health assessment.
Assessment of patient health is relevant to the management of clinical needs. The organization has a process to assess a new patient’s health status within 90 days of the patient’s assignment to the organization. The process includes how the organization follows up with patients that it could not reach or assess in its initial attempts.

8. Population health management. Accurate identification of care needs and the provision of population health management programs enables organizations to provide quality patient-centric care. There is a documented process to identify patients who are eligible for wellness or preventive care services, chronic disease management services and complex case management.

9. Practice support. The organization encourages practice sites to engage in registry data collection, electronic prescribing and patient self-management.

10. Information exchange for care coordination and transitions. The organization has a coordinated system of care between multiple providers to offer integrated, timely and effective care. 

11. Patient rights and responsibilities.
The organization has a coordinated system of care between multiple providers to offer integrated, timely and effective care.

12. Performance reporting. The organization measures and reports clinical quality of care, patient experience and resource stewardship. At least once a year, the ACO monitors at least three preventive care measures, at least five chronic care clinical measures, at least one acute-care clinical measure and at least two measures of expenditures, resource use or appropriateness.

13. Quality improvement. At least annually, the organization measures and analyzes the results of performance measurement activities and takes action to improve effectiveness in key areas.

In addition, the NCQA asked stakeholders for input on the following issues:

  1. Should the types of specialists that should be included in the ACO be specified in the criteria? If so, must they be part of the organization’s legal structure, that is, subject to the direct authority of the ACOs governance?
  2. The task force is proposing four levels of scoring for ACOs.  What capabilities would you expect to see for each ACO level?
  3. Does the eligibility criteria capture the organization types that have the capability to act as ACOs?
  4. How might currently available measures such as HEDIS, Meaningful Use, and California IHA be used? Do the criteria align with stakeholder expectations for ACOs? Are there areas not addressed that should be?
  5. For organizations seeking to become ACOs: Does your organization have materials/documents, etc. to demonstrate compliance with the criteria? If not, which areas are challenging?
  6. Are there critical functions not included in the current draft standards?

In addition to the chair, Robert J. Margolis, MD, of HealthCare Partners Medical Group, task force members include the following:
  • Lawrence P. Casalino, MD, PhD, Weill Cornell Medical College
  • Jay Crosson, MD, the Permanente Federation
  • Nicole G. DeVita, RPh, MHP, Blue Cross Blue Shield of Massachusetts
  • Duane E. Davis, MD, FACP, FACR, Geisinger Health Plan
  • Joseph Francis MD, MPH, Department of Veterans Affairs
  • George Isham, MD, HealthPartners
  • Phil Madvig, MD, Permanente Medical Group
  • Dolores Mitchell, Group Insurance Commission
  • Edward Murphy, MD, Carilion Clinic
  • Gordon Norman, MD, Alere Medical
  • Cathy Schoen, MS, the Commonwealth Fund
  • Kirsten Sloan, National Partnership for Women & Families
  • Jeff Stensland, PhD, MedPAC
  • Susan S. Stuard, MBA, THINC
  • John Toussaint, MD, ThedaCare
  • Woody Warburton, MD, Duke University
  • Nicholas Wolter, MD, Billings Clinic
  • Mara Youdelman, National Health Law Program

Read the NCQA release on accountable care organizations.

Read the full NCQA draft criteria (pdf).

Read the NCQA's questions for stakeholders.

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