Payers, providers agree - and disagree - on ACOs

Senior payer and provider executives say the Medicare Shared Savings Program and competition from other organizations, rather than pressure from employers, are driving the formation of commercial ACOs.

The findings are part of a report commissioned by MedeAnalytics, a healthcare performance management technology vendor, which polled two dozen payers and providers nationwide.

The Medicare Shared Savings Program is the Medicare accountable care organization provision within the Affordable Care Act. Commercial ACOs are distinct from Medicare ACOs in that a commercial payer, rather than Medicare, provides the financial incentives to providers for quality and cost performance.

[See also: CMS ramps up for ACOs, seeks physician input.]

The MedeAnalytics study revealed that payers believe the top two challenges to starting an ACO are the financial implications (risks, model for shared savings) and gaining agreement on quality and cost/efficiency measures.

Both groups agreed that electronic medical records, with the capability to share data between providers, and a strong base of primary care physicians are the essential components or competencies for a successful ACO.

In addition, MedeAnalytics' research identified the following areas of agreement between payers and providers:

• Factors driving the formation of commercial ACOs – i.e., Medicare ACOs and competitive pressures;
• The top challenges to starting an ACO, including financial implications and gaining agreement on quality and cost/efficiency measures;
• Key performance indicators (KPIs) for cost/efficiency – admissions, length of stay and use;
• The necessity of an EMR for the success of the ACO; and
• The need for improved reporting and clinical data exchange capabilities to make an ACO model work.

But payers and providers also had some divergent views:

• Who should develop quality measures for the ACO? In contrast with the payers – a majority of which favored a collaborative approach involving payers, hospitals and physicians – a third of the providers surveyed felt that hospitals alone should develop quality KPIs, equal to the number who supported a collaborative approach.
• KPIs for quality. Payers identified the National Center for Quality Assurance's Healthcare Effectiveness Data and Information Set (HEDIS) as a preferred umbrella measure set – which many use. In contrast, providers specified CMS core measures, hospital-acquired infections, readmissions, mortality and patient satisfaction.

[See also: NEJM article spotlights financial risks associated with ACOs.]

Researchers in the MedeAnalytics study spoke to senior executives from integrated delivery networks, physician practices and commercial payers that were already involved in commercial ACOs or planning to do so within a year.

The objectives of the research were to assess perceptions, drivers, challenges and the developing needs related to creating or participating in a commercial ACO. The research was conducted in December 2010.