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As you may know, the proposed Accountable Care Organization regulations were released yesterday.  I’ve posted links to the various documents and some early news reports on my blog:  Accountable care organization proposed regulations released for public comment.  I’ll be participating in the ACO Watch roundtable discussion on the ACO regulations this afternoon – feel free to listen in live (Friday, April 1, 2011, 4 PM ET) or to the recording, at your leisure.

One notable item from the Society for Participatory Medicine’s perspective:

For many of the criteria defining what it is to be an ACO, the federales have said simply: Please explain how you meet criterion x.  (They may change this approach in the future, once they have more experience under their belts.)

When it comes to patient-centeredness, however, an ACO must meet all 8 criteria identified in the proposed reg (this quote starts on page 84 of the 429-page main regulation (it’s linked to from the post above; please note that once the proposed regulation migrates from the “on display” version to the Federal Register’s published version next week, the pagination will change):

We propose that an ACO would be considered patient-centered if it has all of the following:

∙ A beneficiary experience of care survey in place and a description in the ACO application how the ACO will use the results to improve care over time. As discussed in more detail later in the document, and as proposed in section II. E. of this proposed rule,scoring on this survey would help the ACO meet the quality performance standard.

∙ Patient involvement in ACO governance. As discussed in more detail later in the document, the ACO would be required to have a Medicare beneficiary on the governing board.

∙ A process for evaluating the health needs of the ACO’s assigned population, including consideration of diversity in their patient populations, and a plan to address the needs of their population. As discussed in more detail later in this document, the ACO would be required to describe this process as part of the application and describe how it would consider diversity in its patient population and plans to address its population

∙ Systems in place to identify high-risk individuals and processes to develop individualized care plans for targeted patient populations, including integration of community resources to address individual needs. This proposal and application requirements are discussed in more detail later in this document.

∙ A mechanism in place for the coordination of care (for example, via use of enabling technologies or care coordinators). The ACO would be required to describe its mechanism for coordinating care for Medicare beneficiaries. In addition, the ACO should have a process in place (or clear path to develop such a process) to electronically exchange summary of care information when patients transition to another provider or setting of care, both within and outside the ACO, consistent with meaningful use requirements under the EHR Incentive program. The ACO would be required to describe their process or their plan to develop a process to electronically exchange summary of care information during care transitions. Additionally, in section II. E. of this proposed rule, we propose to include care transitions measures as part of the assessment of ACO quality.

∙ A process in place for communicating clinical knowledge/evidence-based medicine to beneficiaries in a way that is understandable to them. This process should allow for beneficiary engagement and shared decision-making that takes into account the beneficiaries’ unique needs, preferences, values, and priorities. The ACO would be required to describe its process, as discussed in section II.E. of this proposed rule, for communicating clinical knowledge/ evidence-based medicine and describe how the ACO providers/suppliers will engage the beneficiary in shared decision-making.

∙ Written standards in place for beneficiary access and communication and a process in place for beneficiaries to access their medical record. As part of its application, the ACO would be required to submit its written standards for beneficiary access and communication. Additionally, the ACO would be required to describe its process for beneficiaries to access their medical record.

∙ Internal processes in place for measuring clinical or service performance by physicians across the practices, and using these results to improve care and service over time. As described previously, the documents submitted to meet leadership and management criteria related to quality assurance and clinical integration program would satisfy this patient-centeredness criterion.

We believe that this list provides a comprehensive set of criteria for realizing and demonstrating patient-centeredness in the operation of an ACO. Accordingly, we are proposing to require that ACOs demonstrate patient-centeredness as required by the statute by addressing all 8 areas outlined previously.

There is a 60-day comment period.  So I ask you: Did the federales get this right?  Is it too much to ask that an ACO go 8 for 8?  What’s missing?  Is shared decisionmaking a step further than patient-centeredness, or is that something that the Society should seek to have baked into this definition?

What do you think?

David Harlow is a health care lawyer and consultant. He serves as the Chair of the Society for Participatory Medicine’s Public Policy Committee. His “home blog” is HealthBlawg.  You should follow him on Twitter.


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