On October 19, 2010, the National Committee for Quality Assurance (NCQA) released its draft 2011 Accountable Care Organizations (ACO) criteria for public comment. NCQA’s mission is to improve health care quality through its activities, such as accrediting and certifying health care organizations and recognizing clinicians and practices in key areas of performance. The following advisory provides a summary of the draft ACO criteria, as well as a list of issues on which NCQA requests feedback.

  1.  NCQA Definition of ACO

NCQA defines ACOs as “provider-based organizations that take responsibility for meeting the health care needs of a defined population with the goal of simultaneously improving health, improving patient experience and reducing per capita costs.” NCQA notes that while providers will differ in how they organize themselves as ACOs and what components of care delivery they include in their organization, they all “must include a group of physicians with a strong primary care base and sufficient other specialties that support the care needs of a defined population of patients.” Also, clinical and financial incentives should be aligned for providers; this requires an administrative infrastructure to perform functions including managing budgets, collecting data, reporting performance, making payments related to performance and organizing providers around shared goals.

  1.  Draft ACO Criteria

There are seven proposed categories of reflecting core ACO capabilities: (1) program structure operations; (2) access and availability; (3) primary care; (4) care management; (5) care coordination and transitions; (6) patients rights and responsibilities; and (7) performance reporting. Within each of the criteria are a number of standards consisting of elements and factors that are scored. Attached to this memorandum is a table outlining the categories, standards and elements included in the draft ACO criteria.

The draft criteria are geared toward assessing whether an ACO has the infrastructure needed to reduce costs, improve health care quality and improve patient experience. In the draft ACO criteria, greater focus is placed on the organization’s capabilities rather than performance. Noting that it will be some time before organizations can be judged primarily on performance measurement, NCQA believes that there must be “clear standards that assess capabilities that improve the likelihood of a potential ACO’s success and that provide a blueprint and a pathway (with clear stages) to full ACO capacity.”

  1.  Comments Requested for Specific Issues

In addition to comments on the individual standards and elements in the draft criteria, NCQA is requesting feedback on the following issues concerning the criteria:

  1.  Should certain individual standards or elements reflect a core capability that all ACOs should possess?
  2.  NCQA is proposing four levels of scoring for ACOs, and the levels would be based on the organization’s demonstrated capability to function as an ACO and improve quality, increase patient satisfaction and lower per capita costs. NCQA is requesting feedback on what should be the expected capabilities for each ACO level.
  3.  Does the eligibility criteria capture the organization types that have the capability to act as ACOs (i.e., provide the full continuum of services, coordinate care, manage resources effectively, report performance)? Also, should additional arrangements or structures be considered?
  4. Should the types of specialists included in the ACO be specified in the criteria? If so, must they be part of the organization’s legal structure (i.e., subject to the direct authority of the ACOs governance)?
  5. NCQA provides a list of available standardized measures for clinical quality and patient experience in an appendix. These measures come from NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS®), the Centers for Medicare & Medicaid Services Requirements of Meaningful Use of Electronic Health Records, the Dartmouth Atlas and the Integrated Healthcare Association California Pay for Performance Program. Not all of these measures have been endorsed by the National Quality Forum. NCQA requests feedback on how these currently available measures might be used immediately to report performance.
  6.  Do the criteria align with stakeholder expectations for ACOs? Are there gaps or areas not addressed but should be?
  7.  For organizations seeking to become ACOs, does the organization have materials or documents to demonstrate compliance with the criteria? If not, which areas are challenging?
  8.  Are there critical functions not included in the current draft standards?  
  1. Next Steps

Public comments to the draft criteria are due by November 19, 2010. The comments will be considered as the criteria are finalized for release in mid-2011.

To see tables of the draft criteria please clickhere.