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ACOs bring opportunities for case managers
Proposed rule issued by CMS
When the Centers for Medicare and Medicaid Services (CMS) begins its Medicare Shared Savings Program for Accountable Care Organizations (ACOs) providing care for fee-for service Medicare patients in January, 2012, it's likely to mean new opportunities for case managers, says Bruce Merlin Fried, JD, senior member of SNR Denton's Health Care group and former director of the Center for Health Plans and Providers at CMS.
"For an Accountable Care Organization to be successful, it's going to be essential for care of all its patients to be highly coordinated. It will be especially important for patients with chronic conditions to have their care well coordinated throughout the healthcare continuum. The organizations are going to need case managers to facilitate coordinated care," he adds.
CMS announced proposed new rules for Accountable Care Organizations on March 31 and announced the proposed Medicare Shared Savings Program to reward ACOs that lower healthcare costs and meet quality standards. CMS estimates that Accountable Care Organizations could save the Medicare program an estimated $960 over a three-year period. The agency is expected to publish the final rule in September.
The Shared Savings Program was mandated by the Patient Protection and Affordable Care Act and is intended to encourage providers or services and supplies to better coordinate care for Medicare patients through Accountable Care Organizations.
To participate, providers must form or join an Accountable Care Organization and apply to CMS. If accepted, they would have to serve at least 5,000 Medicare patients and agree to participate in the program for three years. They would continue to receive payment under Medicare fee-for-service but would share in savings if they meet quality and performance standards. Savings would be based on the ACOs performance on 65 quality measures spanning five key areaspatient/caregiver care experience, care coordination, patient safety, preventive health, and at-risk population/frail elderly health.
"There's no cookie cutter formula as to what kind of organizations can be part of an ACO. It's generally believed that most organizations will be made up of physicians groups or hospitals or a combination of both," Fried says.
According to the U.S. Department of Health and Human Services (HHS), more than half of Medicare beneficiaries have five or more chronic conditions, such as diabetes, arthritis, hypertension, and kidney disease. The agency adds that one in seven Medicare beneficiaries admitted to the hospital have been subjected to a harmful medical mistake in the course of their care and nearly 1 in 5 is readmitted with 30 days of hospital discharge.
"The Affordable Care Act is putting patients and their doctors in control of their healthcare. For too long, it has been very difficult for healthcare providers to work together to coordinate and improve the care their patients receive. That has real consequencespatients have gaps in care, receive duplicate care, or at risk of suffering from medical mistakes. Accountable Care Organizations will improve coordination and communication among doctors and hospitals, improve the quality of the care their patients receive and help lower costs," says Kathleen Sebelius, HHS Secretary.
For more information, contact Bruce Fried, JD, senior member of SNR Denton's Healthcare group. e-mail: email@example.com.