A BETTER CARE EXPERIENCE THROUGH A NEW MODEL OF CARE THE PIONEER ACO MODEL
The Pioneer ACO Model is a CMS Innovation Center initiative designed to test the effectiveness of particular payment arrangements in providing beneficiaries with a better care experience through Accountable Care Organization (ACO), while also reducing Medicare costs.
To help ensure beneficiaries receive high quality care, CMS has instituted robust quality measures for participating ACOs that will help track the health of beneficiaries as well as the quality of their experience. In addition, beneficiaries aligned to the Pioneer ACO Model will maintain the full rights and benefits of original, fee-for-service Medicare, including the right to see any provider accepting Medicare at any time.
This fact sheet provides a general description of the benefits offered to Medicare beneficiaries participating in the Pioneer ACO Model.
A Better Care Experience Through a New Model of Care
Any patient who has multiple doctors probably understands the frustration of fragmented and disconnected care: lost or unavailable medical charts, doctors who don’t coordinate their decisions with one another, duplicated medical procedures, or having to share the same information over and over with different doctors.
Accountable Care Organizations are designed to lift this burden from patients, while improving the partnership between patients and doctors in making health care decisions. Medicare beneficiaries will have better control over their health care, and their doctors can provide better care because they will have better information about their patients’ medical history and can communicate more readily with a patient’s other doctors.
Under the Pioneer ACO Model, beneficiaries do not enroll in an ACO. Primary care providers and other healthcare providers make the decision to participate in ACOs, meaning a beneficiary will not need to take proactive action to receive the benefits offered through an ACO. ACOs are required to notify beneficiaries of their participation, ensuring the beneficiary is aware of the new arrangement, and his or her rights described in this document. In addition, beneficiaries may affirmatively attest that their primary provider is in a Pioneer ACO, and can then be aligned with the ACO and benefit from the enhanced care coordination that it offers.
Beneficiary Rights and Protections
A beneficiary aligned to an ACO maintains complete freedom to visit any healthcare provider accepting Medicare, just as all Medicare beneficiaries participating in original, fee-for-service Medicare do. These beneficiaries do not need a referral to see a specialist outside the ACO. Unlike a managed care arrangement, like an HMO or a Medicare Advantage plan, a beneficiary aligned to an ACO is free to see any healthcare provider accepting Medicare at any time. In addition, beneficiaries maintain all the benefits to which they are entitled in original, fee-for-service Medicare.
Beneficiaries will have direct channels of communication to CMS to ask questions and relay concerns. Through the initial notice of participation, beneficiaries will be informed that they can call 1-800 MEDICARE at any time to ask questions about the program, alert CMS of any concerns they may have about the ACO. Beneficiaries will also be surveyed each year to assess their experience with the new program.
The Pioneer ACO Model is designed to encourage the delivery of more seamless care that can reduce Medicare expenditures through better, more coordinated care. When successful, the elimination of duplicative, unnecessary processes should improve quality of care and generate savings to the Medicare program. ACO participants will be responsible for sharing in losses if they can’t help reduce costs while maintaining quality standards.
CMS takes seriously its responsibility to prevent any attempts to reduce the delivery of necessary care. Under the Pioneer ACO Model, CMS will routinely analyze data surrounding utilization of services, and will take steps to further investigate any suspect trends, including steps such as beneficiary surveys, audits, and other means. As part of this work, CMS will also compare the experience and health of beneficiaries who are aligned to an ACO in the Pioneer ACO Model against comparable beneficiaries not aligned to an ACO.
Governance Structure – Giving Beneficiaries a Seat at the Table
The Innovation Center believes it is important that patients and their advocates be meaningful partners in improving care delivery. To ensure patient concerns are considered in all ACO decisions, Pioneer ACOs will be required to include both a patient representative and a consumer advocate on their governing body. The Model’s rules allow both roles to be filled by a single person, but the vast majority of Pioneer ACOs have one of each.
Under the Pioneer ACO Model, ACOs will be held financially accountable for both the care delivered to and the health of their aligned populations. In order to effectively track this care and health, CMS has established quality measures by which ACOs will be judged. These quality measures are identical to those in place for the Medicare Shared Savings Program, as established by the final rule released in November 2011. More information about the Shared Savings Program is available at www.cms.gov/sharedsavingsprogram.
These final quality measures are a reflection of extensive feedback CMS received during the comment period on the Shared Savings Program proposed rule. This feedback came from sources ranging from consumer advocates to healthcare providers.
CMS published a fact sheet on these new measures in October 2011: “Improving Quality of Care for Medicare Patients: Accountable Care Organizations.” This fact sheet is available on the website of the Medicare Shared Savings Program at www.cms.gov/sharedsavings program.
To help primary care providers and other providers participating in ACOs offer beneficiaries the right care at the right time in the right setting, CMS will share with participating ACOs some types of Medicare data about aligned beneficiaries. This data will include a history of medical claims that can provide ACOs with a more complete view of the beneficiary’s complete medical needs.
At any time, beneficiaries may opt out of having their identifiable data shared with the Pioneer ACO. Beneficiaries will receive written notification from Pioneer ACOs regarding this right, along with information about how to perform this opt-out. In addition, beneficiaries will be able to opt out of sharing this data through calling 1-800 MEDICARE or completing a form provided to beneficiaries with their notification. Beneficiaries will have 30 days to respond before this information will be shared with ACOs, though beneficiaries maintain the ability to opt out at any time.
The automatic sharing detailed above does not apply to treatment a beneficiary received for substance abuse. This sharing may only take place if the beneficiary provides explicit written permission to do so.
Each of the processes detailed here may only occur under appropriate data use agreements, and in compliance with all relevant federal laws.