Accountable Care Trends, Strategies and Best Practice Compliance
Copyright 2014 by Virgo Publishing.
Posted on: 02/24/2012


By Justin T. Barnes

Movement within the nation’s healthcare system has been swift and broad based in the months between the Centers for Medicare and Medicaid Services (CMS) shared savings proposal in March 2011, and the issuance of the Final Rule approximately half a year later in October.

As a provider or the leader of a provider system, the challenges of meeting the requirements and determining the right organizational structure are technological, financial, legal – and simply finding a seat at the table. As consensus grows that care coordination is key to healthcare sustainability and improved quality, best practices are emerging toward making operational communities of care a reality.

The reality for healthcare providers is that the time has come to examine the models being proposed (or already forming) in your area that could impact your future. It is becoming essential to engage peers in discussions of their knowledge and strategies, as well as attending informational sessions by payor or insurance groups, employers, hospitals or regional CMS offices.

What quickly emerged strategically is that while the shared savings plans target America’s nearly 50 million Medicare patients, private payors such as UnitedHealthcare, Aetna, Cigna, Blue Cross/Blue Shield and others – mindful of the savings accountable care can bring to their operations along with the promise of better care – are seeking entry into or are forming accountable care models by approaching hospitals and physician groups. Doing so is accomplishing the greater goal of bringing more patients into the process, and healthcare providers are welcoming multiple payor options.

As part of the greater shared savings proposal, the final rule is a structuring of Accountable Care Organizations (ACOs) built upon primary care providers and beneficiary patients. It broadened the scope of the initial proposal to allow provisions for specialists and nurse practitioners to become ACO members, encouraged home health agencies to participate, and embraced eligible critical access hospitals, federally qualified health centers and rural health clinics. While participating organizations must maintain minimum patient levels at 5,000 and a three-year commitment, in return, they experience logistical flexibility such as allowing providers to participate in more than one ACO when billing from more than one hospital setting.

The resulting best practices are aligning around the core elements of: comprehensive health information technology, the emergence of multiple payor options, patient-centric engagement and retention strategies to assure that patients comply with preventive care plans, and the ability to mine existing claims and care data that offer providers a clear pathway to their own clinical best practices.

The possibilities of what ACOs and coordinated care can accomplish are bringing other factors and strategies forward that could merge within the CMS Shared Savings models, or as commercial ACOs outside the purview of CMS and the federal government:

• The emergence of employers – many self-insured – who are examining accountable care inclusion for their own future health plans;

• Considerations of coordinated care formation resulting from a 2009 ruling1 by the Federal Trade Commission (FTC) allowing physician hospital organizations to clinically integrate and negotiate fees;

• Examination of how the advent of health insurance exchanges (the other/next HIEs) proposed to begin in 2014 could also play a role in care coordination based on portability factors; and

• Enhanced revenue cycle adjustments that can account for health-based outcomes data within the marketplace.

Realizing the options and needs at hand that can drive healthcare organizations to seek an accountable care model that suits them best, much of the movement between March and October 2011 came from CMS itself.


The Pioneer model program – offering coordinated care entities already underway benefits beyond the scope of basic shared savings – has been met with capacity applications nationwide. In August, CMS and its Innovation Center announced a bundled payments program to further encourage hospitals, physician groups and other provider organizations to embark on care coordination. That was followed in September by a beneficiary payment structure combining private and public payors that also, as the Comprehensive Primary Care initiative, offers a shared savings element. The Final Rule was then accompanied by an advanced payment model, offering startup funds to healthcare facilities in rural or underserved areas to broaden participation. The rule additionally expanded the reach of ACOs by providing for specialist and nurse practitioner participation.

The latest model program to make waves is the Advanced Payment Model, which was co-announced in fall 2011 with the final rule. This program was created to bring much of the broader participation into the shared savings program. CMS is incentivizing advanced payment participation by offering three tiers of startup funding options to healthcare organizations with limited or no inpatient facilities and annual revenue below $80 million, though the startup fees would be paid back out of future shared savings. Only ACOs entering the program in April or July of 2012 with no health plan ownership qualify. Furthermore, CMS is funding the first two years of patient engagement surveys required of an ACO as a further incentive to participate and promote its own financial and programmatic commitment.

That care coordination and accountable care can stem the growth in healthcare costs – which CMS estimates2 rising from 2010’s $2.6 trillion to $4.6 trillion in 2020 if left unchecked (per capita $8,000 to nearly $14,000) – is being recognized as vital to America’s economic and quality of life future.


At the heart of care coordination technology is an integrated electronic health record (EHR) providing clinical, financial and administrative functions. The EHR must be able to exchange data among care providers, payors and patients, and be capable of interoperability with private and/or public health information exchange (HIE) infrastructures. The EHR, while storing digital patient data and care plans, must also be able to adhere to quality reporting criteria such as those within the CMS Physician Quality Reporting System (PQRS) and the EHR meaningful use initiative.

Core functionalities such as evidence-based clinical alerts and clinical decision support within the EHR must be aligned with patient data elements such as allergies, lab results, imaging tests such as MRI and ultrasound, therapies and medication history, and even family history to complete the care plan picture.

Integrated analytics solutions are equally important to understand predictive care and subsequent cost modeling in conjunction with risk assessments of medication or surgical care, further enhanced by access to comparative research. Integrated revenue cycle management elements include the ability to compile and submit claims along multiple payment structures, complete with the real-time coding efficiencies.

Patient-centric technologies that focus on beneficiary care plan adherence and understanding range from online personal health records accessible to patients and providers, telehealth capabilities and the emergence of remote monitoring, all again integrated into the longitudinal EHR.

Even the CMS realizes the importance of EHR technology and how they can promote health IT adoption through its accountable care models. The Final Rule speaks to the key component of EHRs as the data-sharing connectivity and clinical support core of necessary health information technology. CMS recognized that the requirement for 50 percent of ACO participants to be meaningful-use users by year two was a tall order, especially as EHR adoption rates are still maturing nationally. To address this, the Final Rule placed EHR adoption as its highest-scoring quality measure, consistently rewarding increased adoption with higher sharing rates, demonstrating the importance of EHR adoption in ACOs.

The importance of accessible, sharable and pertinent data cannot be overstated. Kaiser Permanente, for example, houses a national Total Joint Replacement Registry of more than 100,000 cases offered for clinician review via standardized formats within an EHR infrastructure. Such data must continue to be unearthed and put into the public realm in conjunction with the Medicare Parts A, B, D and claims data that CMS is to provide for care plan benchmarking.


For Rebecca Little, clinical operations director at Genesis OB/GYN, Tucson, Ariz., using technology to manage patient enrollment and identification is a key component of her practice’s membership collaboration with the Tucson Medical Center ACO.

Through the EHR network of Genesis’ 40 providers in 11 locations. “We can get data out to the ACO’s HIE in a mappable fashion and generate summaries and fact sheet documents. Providing data to not only manage patients – but identify who they are – is a huge component of coordinating care," Little states. “We are  developing a flagging functionality with our EHR provider to bridge those patients in the ACO but not yet in the HIE data share, for example. A lot of women who see us don’t go to their primary care doctors, and to manage the provisions for patients who can opt-in or opt-out of a given ACO means fashioning technology for that tracking, and how you get that information to an ER when patients come in."

The Tucson Medical Center ACO is one of the more high-profile models that has so far emerged, in part due to its design and managerial structure by the Brookings Institution and the Dartmouth Institute for Health Policy and Clinical Practice. The model is to be funded by both UnitedHealthcare and CMS. Within this model, providers are to receive a monthly fee covering the costs of coordinated care, with the addition of a performance bonus based on quality components.

“I believe you must have private and public payors involved for an ACO to work, and we know that self-funded employers are also talking to the management structure about joining as well," Little shares. She is confident the model will prove successful, but to be so, she circles her emphasis back to the patient. “We talk about patient retention every day in terms of identifying them within the system, keeping them in the system, and keeping them compliant with care plans. How do you bring them in and then prevent them from leaking out into the community?"

To that end, Little is focused on the concept of incentivizing the patient, whether that’s through the ACO strategies already underway at Genesis, or via new ideas for the ACO going forward. “We have a huge emphasis in our model of nurse case managers being in the field, and for the ACO, we are upstaffing on that side. Genesis already provides incentives to some of our patients through gift cards they receive for ongoing compliance," she says. “In the ACO, we also believe patient incentives through co-pay options could work, and we plan to propose that idea when we go to the payors."


According to a national survey3 published just prior to the issuance of the Final Rule, employers are gaining interest in accountable care. If companies seek entry into an ACO plan, the obvious result is their ability to be a driver of where employees are eligible to seek care, which would impact the patient load of providers weighing their own future benefit of practicing within an accountable care community.

The survey included 674 respondents providing healthcare coverage to more than 5 million employees and dependents. It found that 77 percent are likely to remain in employee healthcare management when external health insurance exchange options become available in 2014 as planned. Sixty-five percent expressed interest in the use of an ACO for providing healthcare benefits.

When factoring the importance of accountable care goals, more than 80 percent listed quality of care and the ability to manage care costs as top ACO factors. Those surveyed were largely evenly split on who should share in the cost of an ACO among health plans (21 percent), hospitals (22 percent), medical groups (23 percent), employees (15 percent) and employers (18 percent). That result speaks to the necessity for multiple payors or flexibility within the ACO structure.

Employers may also look for their own flexibility in a coordinated care community structure by seeking to create their own ACO or pursuing a corporate on-site clinic. Another option would be direct contracting with a provider group within an existing or forming ACO, or accessing an ACO through a private health insurer.


It is clear from the assembled information that a new healthcare community paradigm based on evidence-based, preventive medicine within a coordinated provider structure that includes elements of payment reform is gaining widespread acceptance. The historic existence of public and private “P4P" or quality reporting programs has shown that incentive-driven programs can work. At the same time, health information technology has advanced and innovated to the point where there is confidence it can produce, share and categorize the needed data to coordinate care.

As coordinated care models continue to emerge from multiple resources and options, they are striving to put best practices to work and to create a smarter, more sustainable healthcare system. The Final Rule has furthered the possibilities by broadening the scope of providers and institutions that can partake of shared savings, and by broadening the programmatic pathways to pursue accountable care. For providers and healthcare organizations, there is much to consider. Prior to the issuance of the Final Rule, CMS’ Pioneer Model, Bundled Payments for Care Improvement Initiative, Primary Care Initiative, and Final Rule all offer additional routes and choices for the pursuit of incentivized care coordination – and even allow for some dual participations as a further incentive.

As commercial payors, employers and health plans are increasingly entering the conversation and shaping other forms of accountable care models, the time has come to determine which model being discussed or planned in your region fits with your best practices. Engaging your peers and seeking out informational gatherings that are assuredly taking place is a starting point toward inclusion into these new models of healthcare delivery and payment.

Justin Barnes is a vice president with Greenway Medical Technologies and also serves as co-chairman of the national Accountable Care Community of Practice (ACCoP), in addition to chairman emeritus of the HIMSS Electronic Health Record Association (EHR Association). Barnes has formally addressed and/or testified before Congress as well as the last two presidential administrations on 15 occasions between 2005 and 2011, with statements relating to accountable care, ACOs, EHR meaningful use, health IT innovation, interoperability, health information exchange (HIE), patient safety and quality.


1. Federal Trade Commission, Bureau of Competition, Health Care Division: TriState Health Partners Inc. Advisory Opinion, April 13, 2009

2. Centers for Medicare and Medicaid Services (Online)

3. 2011 Employer Driven Accountable Care Organizations Survey Report; Aon Hewitt and Polakoff Boland, authors.