Fact Sheets

PIONEER ACCOUNTABLE CARE ORGANIZATION MODEL BENEFICIARY PROTECTIONS, DATA SHARING AND QUALITY MEASURES

Update as of May 23, 2011

Overview

On May 17, 2011, the Centers for Medicare & Medicaid Services (CMS) published a request for applications (RFA) for the Pioneer Accountable Care Organization Model (Pioneer ACO Model).  This initiative, which was developed and will be operated by the Center for Medicare and Medicaid Innovation (Innovation Center), is designed to test the movement of organizations experienced in providing coordinated care across settings more rapidly to population-based payment arrangements and to work in coordination with private payers in order to achieve cost savings and improve quality across the ACO, thus improving health outcomes for Medicare beneficiaries. 

As part of the Innovation Center’s commitment to improving the quality of care provided to Medicare beneficiaries, the Pioneer ACO Model will include extensive protections for beneficiaries.  Provider participation in an ACO is purely voluntary and participating patients will see no change in benefits and will keep their freedom to see any Medicare provider.  The Pioneer ACO Model’s aim is to promote accountability in highly experienced provider organizations for a population of Medicare beneficiaries; improve the coordination of care; encourage investment in infrastructure and redesigned care processes for high quality and efficient service delivery; and reward higher value care.

Beneficiary Participation

Under the Pioneer ACO Model, beneficiaries do not enroll in a specific ACO. Instead, the Innovation Center anticipates that beneficiaries who are aligned to the ACO will be identified prospectively, allowing care providers to know at the beginning of a performance period for which patients’ cost and quality they will be held accountable.  However, Pioneer ACOs will have the option of pursuing a retrospective assignment of beneficiaries in lieu of a prospective assignment, the terms of which would be developed through negotiations with CMS.  However, beneficiaries are free to seek care from any provider regardless of whether the provider is affiliated with the Pioneer ACO.

Improving Care for Patients

Any patient who has multiple doctors probably understands the frustration of fragmented and disconnected care: lost or unavailable medical charts, 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. 

Unlike in a Medicare Advantage plan, Medicare beneficiaries whose doctors participate in an ACO will still have a full choice of providers and can still choose to see doctors outside of the ACO.  Patients choosing to receive care from providers participating in ACOs will have access to information about how well their doctors, hospitals, or other caregivers are meeting quality standards. 

Program Monitoring

CMS emphasizes that payment arrangements in the Pioneer ACO should not reduce necessary care. To safeguard against this possibility, CMS will routinely analyze data on service utilization, and may investigate utilization patterns through comparison surveys of beneficiaries aligned with the ACO and those in the general beneficiary population, medical record audits, or other means.  CMS will also determine whether there are systematic differences in health status or other characteristics between patients who remain aligned with a given ACO over the life of the Pioneer ACO Model, and those who do not.

Beneficiary Protections

The Pioneer ACO Model contains strong protections designed to ensure that patients will not experience disruptions in accessibility or quality of services.  Pioneer ACOs will notify beneficiaries that they can call 1-800-Medicare with questions and concerns regarding care received from the providers who are part of the ACO or for more information about the initiative in general. Pioneer ACOs will also be conducting surveys of their aligned beneficiaries on an annual basis.  CMS may investigate the practices of ACOs that generate beneficiary complaints.

CMS will publicly report the performance of Pioneer ACOs on quality metrics, including patient experience ratings, on its website. 

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 patient care decisions, Pioneer ACOs will be required to include both patient representatives and consumer advocates on their governing body.

Quality Measures

The ACO model is intended to encourage providers of services and suppliers to coordinate patient care and improve communications with each other to effectively meet each individual Medicare beneficiary’s needs.  To accomplish this goal, Pioneer ACOs will be held financially accountable for improving the health and health experience of care for individuals, improving the health of populations, and reducing the rate of growth in health care spending.

The Pioneer ACO Model will be utilizing the set of quality measures and assessments defined in the final rule for the Shared Savings Program.  The rule proposes quality measures in five domains that affect patient care:

• Patient/caregiver experience of care
• Care coordination
• Patient safety
• Preventive health
• At-risk population/frail elderly health

The Shared Savings Program proposed rule sets out proposed performance standards for these measures and a proposed scoring methodology.  CMS has published a fact sheet “Improving Quality of Care for Medicare Patients: Accountable Care Organizations” that details the Shared Savings Program’s proposed quality measures and performance scoring method and that can be found at: http://www.cms.gov/apps/media/fact_sheets.asp.  The method used in the Pioneer ACO Model to calculate an ACO’s expenditure benchmark will also prevent providers in ACOs from being penalized for treating patients with more complex conditions. 

Data Use

Under appropriate data use agreements, CMS will provide Pioneer ACOs with several types of Medicare data to support care improvement efforts on a timely basis, consistent with all relevant laws and regulations to protect beneficiary privacy.

At any time, beneficiaries may opt out of having their identifiable data shared with the Pioneer ACO. At the beginning of each performance period under prospective alignment beneficiaries will receive written notification from Pioneer ACOs and CMS regarding data sharing. If CMS does not receive any electronic, telephone, or written notice that the beneficiary wishes to opt out of data sharing within 30 days, the ACO may request that CMS begin to release that beneficiary’s data in a secure manner to approved users at the Pioneer ACO.  However, beneficiaries may opt out of data sharing at any time during the performance period. Pioneer ACOs must make available to beneficiaries, upon their request, an explanation of which ACO providers will receive the beneficiary’s data. Beneficiaries may opt out via a telephone hotline to 1-800-Medicare, or through various modes of communication with their ACO provider and ACO.  Procedures for beneficiaries to opt out of data sharing will be modified under retrospective alignment, through negotiations between the Pioneer ACO and CMS.

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