Principles for Accountable Care Organizations
At the Interim Meeting of the AMA House of Delegates in November 2010, delegates approved the following 13 principles for how accountable care organizations would be configured and operate. Here is a summary of those principles:
The goal of an accountable care organization (ACO) is to increase access to care, improve the quality of care, and ensure the efficient delivery of care. Within an ACO, a physician's primary ethical and professional obligation is the well-being and safety of the patient.
ACOs must be physician-led to ensure that a physician's medical decisions are not based on commercial interests but rather on professional medical judgment that puts patients' interests first. Where a hospital is part of an ACO, the governing board of the ACO should be separate and independent from the hospital governing board.
Physician and patient participation in an ACO should be voluntary. Any physician organization or other entity that creates an ACO must obtain the written affirmative consent of each physician to participate in the ACO. Physicians should not be required to join an ACO as a condition of contracting with any public or private payer or being admitted to a hospital medical staff.
Any savings and revenues of an ACO should be retained for patient care services and distributed to the ACO participants. (Savings might accrue if, for instance, an ACO provides care for a defined population for less than the capitated amount or the expenditure target established by a payer.)
Federal and state anti-kickback and self-referral laws should be sufficiently flexible to allow physicians to collaborate with hospitals in forming ACOs without being employed by the hospitals or ACOs.
Additional resources should be provided up-front to encourage ACO development, and the Centers for Medicare and Medicaid Services should provide grants to physicians to finance up-front costs of creating an ACO.
The ACO spending benchmark should be adjusted for differences in geographic practice costs and risk adjusted for individual patient risk factors.
Quality performance standards must be consistent with AMA policy regarding quality, including the use of nationally accepted, physician specialty–validated clinical measures developed by the AMA Physician Consortium for Performance Improvement (in which APA is a participant).
An ACO must be afforded procedural due process if a contract with any payer—public or private—is terminated because of ACO failure to meet quality performance standards.
ACOs should be allowed to use different payment models, including fee-for-service, capitation, partial capitation, medical homes, care management fees, and shared savings. Any capitation payments must be risk-adjusted.
The Consumer Assessment of Healthcare Providers and Systems Patient Satisfaction Survey should be used as a tool to determine patient satisfaction and whether an ACO meets the patient-centeredness criteria required by the ACO law.
Interoperable health information technology and electronic health record systems are key to the success of ACOs. Medicare must ensure systems are interoperable to allow physicians and institutions to effectively communicate and coordinate care and report on quality.
If an ACO bears risk (as may be possible in a capitated payment arrangement), the ACO must abide by the financial solvency standards pertaining to risk-bearing organizations.
The full text of the AMA's principles for ACOs is posted at <www.ama-assn.org/assets/meeting/2010i/i-10-ref-comm-j.pdf>.
