Friday, July 31, 2009

Now it's ACO

Dear Mrs Jones;

I am sorry that I no longer am responsible for your healthcare and you will not be able to pay me for services. I am now a member of the ‘accountable care organization’ of my regional health system.

After much studying and implementing mandatory health insurance coverage in Massachussetts (they discovered there were not enough doctors, nor enough funds to provide the coverage that was promised.

ACO was invented….this is a super large HMO.

1. The development of Accountable Care Organizations (ACOs). (Health delivery entities that can work as a team to manage the provision and coordination of care so that they are accepting responsibility for all - or most - of the care for their enrollees.)

2. Patient choice. Patients will be able to choose their primary care physician, and will not be restricted to only clinicians in their ACO - but may have to pay more for services outside of their ACO.

3. Patient-centered care and a strong focus on primary care. Each patient’s selection of a primary care provider will direct their insurer’s payments to their ACO, which will receive technical support to help develop/create medical homes.

4. Widespread adoption of the medical home model. (The Special Commission concluded that “medical homes overlaid on the current FFS system cannot achieve its vision for a high-value health care system.”)

5. Pay-for-performance (P4P) incentives to ensure appropriate access to care, and encourage quality improvement, evidence-based care, and coordination of care.

6. Sharing of financial risk between ACOs and insurers. ACOs will be held responsible for performance risk—including cost performance and meeting access and quality standards. Insurance companies, (and self-insured companies), will retain the insurance risk for the insurance contracts written to groups and individuals.

7. Strong and consistent risk adjustment. Global payments will be adjusted to reflect providers’ clinical and socioeconomic case mix, and, as appropriate, geography, so that ACOs will not be financially harmed by accepting high-risk patients with complex or chronic health care needs.

8. Cost and quality transparency. ACOs will report performance against common metrics measuring health care quality and access to appropriate care.

9. Participation by both private and public payers to ensure consistent alignment of care delivery incentives and to minimize administrative complexity and costs.

According to this well thought out proposal by legislators and higher ups in the food tree of health care administration, the ACO will provide the ability for global payments. (they don’t define what this is, nor how it is determined)

Real Reform in Massachusetts This report is generated from The Massachusetts Special Commission on Payment Reform recently issued its  recommendations for shifting the state’s health care system from Fee-For-Service (FFS) to Global Payments over a 5 year period.

It’ simple, really !!

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So Mrs. Jones, the above diagram shows you how to obtain your health care. I see one box for health care providers on the lower right portion of the diagram. Where are you, the patient??

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