Part II – Accountable Care Organizations (ACO’s): The Role of Post-Acute Provider

By Elizabeth E. Hogue, Esq.

Section 302 of the Affordable Care Act (ACA) includes provisions related to Medicare payments to providers of services and suppliers that participate in Accountable Care Organizations (ACO’s).  Providers of services and suppliers who participate in ACO’s will continue to receive payments under Parts A and B of the Medicare Program, but will also be eligible for additional payments if they meet certain requirements related to quality of care and cost savings.  The Secretary of the U.S. Department of Health and Human Services is required to establish ACO’s no later then January 1, 2012.

Proposed regulations to implement these provisions were published in the Federal Register on April 7, 2011.  Comments regarding the proposed regulations must be received by the Centers for Medicare and Medicaid Services (CMS) no later than sixty days after the date of publication. This is the second in a series of articles about ACO’s.  The purpose of this article is to address the issue of the role of post-acute providers in ACO’s. As indicated above, ACO’s will share in cost savings if they meet performance standards for both quality of care and cost savings.  Post-acute providers may assist ACO’s to meet standards related to quality of care.

The Centers for Medicare and Medicaid Services (CMS) proposes to establish five “domains” related to quality of care.  These domains are:

1. Better care for individuals, including patient/caregiver experiences, care coordination and patient safety.
2. Better health for populations, including preventive health and at-risk population/frail elderly health.

Post-acute providers have specialized expertise with regard to care coordination, patient safety and at risk populations/frail elderly health. Specifically, there are sixty-five proposed measures for use in establishing quality performance standard that ACO’s must meet in order to share in savings.  Post acute providers may be especially helpful to ACO’s regarding the following performance measures:

Care Coordination/Transitions 
The rate of readmissions within 30 days of discharge from acute care hospitals for assigned or aligned ACO beneficiary populations. Post-discharge visits to physicians within 30 days. 

Ambulatory Sensitive Conditions Admissions: Diabetes, Short-term Complications (AHRQ Prevention Quality Indicator #1).  All discharges of age 18 years and older with ICD-9-CM principal diagnosis code for short-term complications (ketoacidosis, hyper- osmolarity, coma) per 100,000 population.

Ambulatory Sensitive Conditions: Congestive Heart Failure (AHRQ Prevention Quality Indicator #8).  All discharges of age 18 years and older with ICD-9-CM principal diagnosis code for CHF, per 100,000 population. Ambulatory Sensitive Conditions Admissions: Urinary Infections (AHRQ Prevention Quality Indicator #12). 

All discharges of age 18 years and older with ICD-9CM principal diagnosis code of urinary trace infection, per 100,000 population.

Preventive Health
Influenza Immunization: Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February).

At Risk Population/Frail Elderly Health
Falls: Screening for All Risk: Percentage of patients aged 65 years and older who were screened for fall risk at least once within 12 months. Monthly INR for Beneficiaries on Warfarin: Average percentage of monthly intervals in which Part D beneficiaries with claims for warfarin do not receive an INR test during the measurement period. 

Post-acute providers can certainly assist participants in ACO’s to meet the performance measures described above.  The crucial role of post-acute providers in meeting the above goals should be recognized and acknowledged by other types of providers.

Elizabeth E. Hogue is an attorney in private practice with extensive experience in health care.  Her clients are professional associations, physicians, managed care providers, and institutional health care providers, which includes hospitals, long-term care facilities, home health agencies, durable medical equipment companies, and hospices.  © 2011 Elizabeth E. Hogue, Esq.  All rights reserved.   No portion of this material may be reproduced in any form without the advance written permission of the author.