Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP) have a special, limited opportunity to innovate. Waivers exempting MSSP ACOs from certain legal requirements and other benefits enable MSSP ACOs to experiment within certain limits. The Medicare Shared Savings Program requires 33 measure that must be self-reported by the ACO to CMS. After a limited period, self-reporting will not be allowed and third parties will be required to perform reporting.
These are important foundations that enable ubiquitous digital health data in a standard interchange, enabling in-depth analysis and increasingly, Cloud and Software as a Service methods to deploy, store and use the information to improve healthcare. These in turn are important foundations to enable Accountable Care. ICD-10 is the new data standard that will express the condition of the patient and how providers get reimbursed.
If The Patient Protection and Affordable Care Act (PPACA) is repealed it will be interesting to see if it is repealed in whole or in part. The Supreme Court of the United States (SCOTUS) may excise the individual mandate requiring health insurance coverage, or it could strike it down entirely.
One of the key questions will be how the EMR provides a foundation with the Health Information Exchanges (HIEs) for comparative effectiveness data over the life span of a patient (sometimes called the continuum of care) and whether CDA standards currently proposed will accomplish that. Informatics people call this "longitudinal clinical data."
To protect against this high risk of significant financial loss, the Accountable Care Organization should plan at its inception for methods of payment and/or protection for these cases, such as secondary coverage (insurance).
Accountable Care standards may be fluid for some time, however it is clear that there will be a need for core competencies in population management, coordination of care and other areas for an ACO to function effectively. Blum emphasized that CMS will be looking for innovative models, with different payment systems, and with different “on ramps” to formation and approval. It was also acknowledged that improving quality and reducing cost through coordination of care will at times be at odds with and the Accountable Care Act’s continued focus on patient choice of providers.