National Committee for Quality Assurance (NCQA) has published for public comment a detailed set of draft criteria for evaluation of Accountable Care Organizations (ACOs) participating in the shared savings program created pursuant to Section 3022 of the Patient Protection and Affordable Care Act (PPACA). As provided in PPACA, groups of providers who undertake responsibility for the health care of a designated population and meet certain quality standards and per capita cost-savings benchmarks may share in a portion of the cost savings achieved for the Medicare program.

A variety of provider organizations will be eligible to apply for the ACO survey. However, in contrast to the relatively sparse details in the legislation, and pending CMS rules on ACOs expected later this fall, the NCQA criteria set out very detailed standards for ACOs that extend from its governance processes to the content of its provider directories.

The NCQA draft ACO criteria were developed based on input from its ACO Task Force, which included representatives of health plans, physician groups, medical schools, MedPac and other community representatives. The Task Force formulated certain guiding principles for these criteria: ACOs are to have a strong foundation in primary care; be committed to improving quality and the patient experience and reducing per capita costs; measure and report data to support quality improvement and reduction of cost through the elimination of waste and inefficiencies; work cooperatively with other stakeholders in the community toward these goals; and create and support a sustainable workforce to meet demands for access to primary care.

The NCQA draft criteria focus on performance measurement of ACOs across “the triple aim of cost, quality and patient experience.” Starting with the premise that ACOs cannot be judged at the outset primarily on their outcomes, NCQA draft criteria focus on ACO infrastructure: The draft criteria define measures for structure and processes that are intended to identify “with reasonable accuracy which ACOs have the infrastructure necessary to achieve the triple aim.” Further, observing that most organizations “are by no means ready to deliver on the triple aim,” the NCQA draft standards propose four levels of scoring designed to provide a clear pathway through defined stages to full ACO capability.

The draft defines seven categories of standards that reflect the “core capabilities” ACOs should possess. For each of these standards, a number of elements are set out, which are the components of the standard that are scored. The draft criteria are categorized as follows:

•Program Structure Operations: Elements in this category address the organizational and leadership structure of the ACO (including physician/clinician leadership and participation of stakeholders such as primary care physicians and specialists, consumers/community representatives, and hospitals); capability to manage resources effectively (including written utilization management criteria, involvement of appropriate practitioners in developing and reviewing these criteria, information systems to track utilization, and ongoing monitoring of the cost of services rendered compared to revenue received); and processes for the ACO to arrange for healthcare services, engage in contracting and determine payment arrangements (including provision of primary, specialty, urgent, emergency and inpatient care; detailed contract terms relating to payment procedures; basing a portion of practitioners’ compensation on performance of the ACO as a whole; and processes for monitoring inappropriate restrictions on care).

  • Access and Availability: Elements under this standard address how the ACO assures it has sufficient numbers and types of practitioners who provide primary and specialty care (including processes to assess the needs of its defined population, as well as detailed provisions for the content of physician and hospital directories).
  • Primary Care: These elements pertain to processes for assuring that primary care providers within the ACO provide patient-centered care (including processes for assuring access during and after regular office hours, promoting communication among the care team, tracking tests and referrals for specialist services, managing patients’ medication, promoting patient self-care, and identifying high risk patients).
  • Care Management: Pertinent elements address collection and integration of data from various sources, including electronic sources; conduct of an initial assessment of the health of new patients; use of data to identify health needs of the population and respond to those needs, and ACO support for patient care registries, e-prescribing and patient self-management.
  • Care Coordination and Transitions: Elements under this category address the ACO’s processes for facilitating information exchange among primary care providers, specialists and hospitals in a timely manner for care coordination and transition of patients.
  • Patient Rights and Responsibilities: These elements address organizational policies regarding respect for patients rights, patient responsibilities and privacy.
  • Performance Reporting: These elements define minimum qualitative and quantitative analyses to be conducted relating to specific types of measures, including preventive, chronic and acute care, expenditures, resource use and patient experience. NCQA solicits public comments on how currently available, standardized measures for clinical quality and patient experience could be used by ACOs immediately to demonstrate performance. The “ACO Measure Grid” includes measures derived from HEDIS, CMS Services Requirements of Meaningful Use of Electronic Health Records, and Integrated Healthcare of Association California Pay for Performance Program measures.

NCQA is proposing four levels of scoring for ACOs as its roadmap for basic ACO qualification as well as higher levels of capability. Level 1 scoring will apply to ACOs that meet core qualifying criteria, including standards for infrastructure and processes for care management and transitions that promote quality improvement. Level 4 scoring will apply to ACOs that not only meet core and advanced criteria such as integration of electronic clinical systems, but also demonstrate excellence or improvement in the metrics.

The draft criteria are available on the NCQA website. All comments should be submitted by 5 pm (Eastern) on November 19, 2010 to NCQA’s Public Comment website.