Structuring Medicaid Accountable Care Organizations to Avoid Antitrust Challenges (original) (raw)
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Emerging Medicaid Accountable Care Organizations The Role of Managed Care
Mathematica Policy Research Reports, 2012
An Accountable Care Organization (ACO) is a provider-run organization in which the participating providers are collectively responsible for the care of an enrolled population, and also may share in any savings associated with improvements in the quality and efficiency of the care they provide. Although the concept of ACOs originated in the Medicare and commercial sectors, several states are actively developing ACO initiatives in an effort to improve the care provided to people through the Medicaid program. Our review of a number of state initiatives indicates that most Medicaid ACOs are currently at an early stage of development, as states engage in relatively lengthy planning and implementation processes, both to accommodate diverse stakeholder concerns and to address state and federal legislative and regulatory requirements. The structure of Medicaid ACO initiatives is influenced by individual states' history and experience with managed care, other existing care delivery arrangements within Medicaid, and the challenges inherent in serving low-income and chronically ill populations. While Medicaid ACOs are a strategy to more directly engage providers and provider communities in improving care, cost-containment is also a significant motivating factor for many states. It remains to be seen how states will balance short-term cost-containment pressures against the investments in partnerships and delivery system redesign necessary for the success of Medicaid ACOs over the longer term. Recently, a number of states have begun to explore the possibility of implementing Accountable Care Organizations (ACOs) in Medicaid. The ACO concept, which originated in the context of the Medicare
The Policy and Practice Legacy of the New Jersey Medicaid ACO Demonstration Project
Journal of Ambulatory Care Management, 2020
The New Jersey Medicaid Accountable Care Organization (ACO) Demonstration was created with a unique combination of features regarding ACO geography, involvement of managed care organizations (MCOs), and shared savings parameters. Ultimately, the Demonstration did not lead to a sustainable accountable care financing model and shared savings were deemphasized. Instead, the ACOs evolved into community health coalitions focused on coordinating and enhancing a wide range of activities in partnership with state government, private health systems, community leaders, and MCOs. Currently, the state is developing policy parameters to reposition the ACOs as regional partners to implement state-directed population health initiatives.
New Jersey's Medicaid ACO Pilot Program, Past and Future: A Baseline Report
Political Economy: National, 2013
New Jersey’s Medicaid Accountable Care Organization Demonstration Project became law in 2011, representing a broad consensus that accountable care organizations (“ACOs”) could improve the delivery of care in the Medicaid system. ACOs offer the promise of providing “the right care, at the right time, in the right place.” The ACO law reflected a commitment to improve the care experience for Medicaid recipients, strengthen public health outcomes, and responsibly control the cost of care.This Report is the first of two that will examine the past and future of New Jersey’s Medicaid ACO Pilot. This Report sets out the background and current status of the Pilot. The second Report, to be released in April 2014, will reflect further discussions with stakeholders and further research and analysis on the sustainability of New Jersey’s Medicaid ACOs.
Accountable care organizations in the USA: types, developments and challenges
Health policy (Amsterdam, Netherlands), 2014
A historically fragmented U.S. health care system, where care has been delivered by multiple providers with little or no coordination, has led to increasing issues with access, cost, and quality. The Affordable Care Act included provisions to use Medicare, the U.S. near universal public coverage program for older adults, to broadly implement Accountable Care Organization (ACO) models with a triple aim of improving the experience of care, the health of populations, and reducing per capita costs. Private payers in the U.S. are also embracing ACO models. Various European countries are experimenting with similar reforms, particularly those in which coordinated (or integrated) care from a network of providers is reimbursed with bundled payments and/or shared savings. The challenges for these reforms remain formidable and include: (1) overcoming incentives for ACOs to engage in rationing and denial of care and taking on too much financial risk, (2) collecting meaningful data that capture ...
Background. The Accountable Care Organization (ACO) model is rapidly being implemented by Medicare, private payers, and states, but little is known about the scope of ACO implementation. Objective. To determine the number of accountable care organizations in the United States, where they are located, and characteristics associated with ACO formation. Study Design, Methods, and Data. Cross-sectional study of all ACOs in the United States as of August 2012. We identified ACOs from multiple sources; documented service locations (practices, clinics, hospitals); and linked service locations to local areas, defined as Dartmouth Atlas hospital service areas. We used multivariate analysis to assess what characteristics were associated with local ACO presence. We examined demographic characteristics (2010 American Community Survey) and health care system characteristics (2010 Medicare fee-for-service claims data). Principal Findings. We identified 227 ACOs located in 27 percent of local areas. Fifty-five percent of the US population resides in these areas. HSA-level characteristics associated with ACO presence include higher performance on quality, higher Medi-care per capita spending, fewer primary care physician groups, greater managed care penetration, lower poverty rates, and urban location. Conclusions. Much of the US population resides in areas where ACOs have been established. ACO formation has taken place where it may be easier to meet quality and cost targets. Wider adoption of the ACO model may require tailoring to local context. Key Words. Accountable care organizations, Medicare, health care reform, incentives in health care, health policy, delivery of health care, health care costs
Rural policy brief, 2014
Accountable Care Organizations (ACOs) are groups of providers (generally physicians and/or hospitals) that may receive financial rewards by maintaining or improving care quality for a group of patients while reducing the cost of care for those patients. The Patient Protection and Affordable Care Act of 2010 (ACA) established a Medicare Shared Savings Program (MSSP) and accompanying Medicare ACOs to “facilitate coordination and cooperation among providers to improve the quality of care for Medicare fee-for-service (FFS) beneficiaries and reduce unnecessary costs.” The MSSP now includes 343 ACOs; an additional 23 ACOs participate in the Medicare Pioneer ACO demonstration program, and there are approximately 240 private ACOs. Based on our analysis, among the Medicare ACOs 119 operate in both rural and urban counties and seven operate exclusively in rural counties. A little over 24 percent of non-metropolitan counties are included in Medicare ACOs. To assist rural providers considering ...