Recently, the National Committee for Quality Assurance (NCQA) announced the launch of its Accountable Care Organization (ACO) Accreditation Program, which provides first-of-its-kind standards and guidelines that provider-led organizations can use to demonstrate their ability to reach the health care industry’s desired Triple Aim of reduced cost, improved quality, and enhanced patient experience. Dr. Robert Margolis, managing partner and CEO of HealthCare Partners, chaired the multi-constituent task force that developed the ACO criteria and capabilities. Here, in an interview with the Council of Accountable Physician Practices, Dr. Margolis explains how the criteria were developed and its potential going forward.
CAPP: Can you give us a little background on how this accreditation program came about?
Margolis: NCQA has long stood for measuring and reporting on the quality of American healthcare. Historically, it did this primarily for HMO reporting around patient satisfaction (CAHPS data) and the HEDIS reports on care and service that are pretty well known in the industry. However, with regard to fee-for-service patients and PPO members, there wasn’t a lot of comparable data. Over the last few years, NCQA has seen an upsurge in PPO health plans willing to start to gather and report similar kinds of data. With the advent of the Affordable Care Act and the pieces of it that emphasize delivery system reform and development of accountable care organizations, clearly there was an opportunity for NCQA and others to take a look at how to measure the effectiveness of these kinds of care models.
CAPP: But until relatively recently, an ACO was just an idea, a theory . . .
Margolis: Right. When we were working on this, we didn’t know if the ACO movement would be potentially a game changer. Is it in some form and format going to develop more coordinated systems of care — integrated systems of care? Would those systems likely be hospital driven, health-plan driven, physician-group driven, or other entrepreneurial driven? Because what an ACO may or may not look like was in flux and the legislation was relatively broad, it made sense that NCQA, with its history of measuring and monitoring quality and systems, try to interject its thinking into the policy world, both on the commercial and federal levels. So a task force was convened; I was asked to chair it. It was not an NCQA task force; it was a multi-constituent task force of consumer groups, health plans, hospital executives, physician group executives, academics, folks from MedPAC and the federal world, as well as state regulators. We spent the course of four to six months trying to come up with a set of potential criteria around structure, governance, reporting, coordination capabilities, care management capabilities, health IT capabilities, and patient protections, as well as quality and satisfaction metrics, to measure ACO success and capabilities. None of us felt we could prejudge what the best future form of the ACO might look like or whether there wouldn’t be many forms of ACOs that would evolve. So our guiding set of principles was to not be too prescriptive about structure and governance. However, we knew it would be important that an ACO should have a strong primary care base, it should have clinical leadership involved in it, it should have a lot of patient-centricity and patient feedback.
CAPP: The program allows for three levels of ACO accreditation. What was the thinking there?
Margolis: We all believed that there would be the need for a glide path for a lot of organizations to move from traditional fee- for-volume, fee-for-service structures to ones that were capable of taking on shared- savings programs or increasing degrees of population health risk, and start measuring themselves. So the result was a recommendation for a fairly open certification accreditation process for newly forming ACOs, ones that had very little history in the space but saw that this was the future and wanted to get onto that glide path, then a level-two analysis and accreditation for more mature organizations. For the more advanced organizations–presumably ones that had a history of taking and managing population risk; had good care coordination; were capable of measurement and transparency of results; had processes to constantly improve results; and the like — those would be level three.
CAPP: The NCQA press release implied that some of the work had already been done through their medical homes accreditation program.
Margolis: There was a belief that if you expanded the “medical home” into the concept of a “medical neighborhood,” that would be an interesting way to start the thinking around ACOs. We used some of the learnings, analyses, and feedback on the medical homes certification as a base to do this, but with an understanding that a medical home really took no financial risk and was not really a “shared-savings” kinds of place. So ACO criteria were really an evolution way and above the medical home capabilities.
CAPP: NCQA’s historical credentialing was for health plans. This accreditation process is for the providers of care. So is this a significant change in accountability from health plans to provider-led organizations being responsible for collecting and reporting on their own performance?
Margolis: Again, yes, the discussion is that the future, we hope—and this may be an editorial comment—is that the accountable care world is one where a delivery system actually manages a population and improves their health, and the health plan assists in sales, marketing and benefit design and the like. There are actually capabilities in an improved health care delivery system that most of us believe are best handled in the direct provider or physician/patient interaction. Those are capabilities that include well-informed shared decision-making around good care choices, a lot of emphasis on health, prevention and wellness, patient compliance—all of the things that should and do work best for improved care and resource stewardship.
CAPP: Were the criteria tested with any provider groups?
Margolis: Yes, there were pilots that my organization, HealthCare Partners, and a half a dozen other major physician groups went through to test the criteria as to their feasibility and practicality. I believe that some of organizations among the CAPP groups have indicated an early willingness to be accredited.
Essentially, this accreditation process is to put, you know, Good Housekeeping Seal of Approval on provider organizations that want to say to their patients and community, “We’ve met certain level of scrutiny and have measurable criteria by which you can judge us.” We will have to see if the market—patients, health plans or employers—are going to want to see that kind of seal of approval. In the past, employers have been the ones that have sort of driven health plans to deploy accreditation-type processes, such as the NCQA health plan accreditation, so I believe that they will welcome this type of accreditation as well.
I would say that this kind of process has a couple of important potential outcomes. One is to be seriously at the table talking to policy makers about how to define and monitor the ACO movement, which was broadly and very scantily defined in legislation and is subject to HHS regulation. And it is also potentially a product offering for customers. We have to see if the market finds this attractive and creates demand.
CAPP: Has CMS indicated a willingness to use this program as kind of a tool for themselves for their Medicare Shared Savings programs and other initiatives?
Margolis: I think that that’s still an open item. I’d say that there are a lot of discussions that go on between groups like NCQA and Joint Commission and the like that are trying to help establish a more uniform measurement system for all of these federal programs. NCQA has a history of being deemed as an accreditor for Medicare Advantage and in many states for Medicaid for meeting state regulations. All of that is still to be defined. I don’t believe that CMS or HHS is at that point yet. I think they’re still gathering information. They just released again the final rules on the Medicare Shared Savings program. But clearly the 33 quality metrics or quality and reporting metrics in the latest Medicare rules are closer aligned now to NCQA and HEDIS than they were.
CAPP: Do you feel that the first level—level one ACO accreditation—is going to be difficult for providers to manage who are new to the accountable care world?
Margolis: I don’t honestly think so. But hundreds or even thousands of medical homes have been certified now, and the physicians and physician groups that signed up for the medical home accreditation have found that the process was not daunting. I think these accreditation levels were designed to be more inclusive than exclusionary.
CAPP: You said the ACO Accreditation process was kind of a “glide path.” Do you mean that the ACO criteria and all of the supporting information that NCQA will be offering will provide a framework to help these newly forming ACOs move forward?
Margolis: I generally think so. The joke out there is that ACO stands for Another Consulting Opportunity—there are thousands of consultants out there trying to explain how to be in an ACO. I think this is a framework that any organized system — integrated system or hospital driven system—can use to look at and start to assess “how many of these capabilities do we actually honestly think we have? Which ones do we need to build? How do we get from here to there?” I think to some degree it’s a learning and teaching tool as well.
I just want to say that the basic reason that many of us spend a lot of time trying to define the ACO space is because we are strong believers that coordinated care and population health management is an avenue towards improved care and quality for Americans. The Affordable Care Act legislation that was passed pushes us in that direction. The ACO concept and programs—federal and commercial—start to move more and more people in a direction that many of us believe is critical to improving the health and well being of our populations. The NCQA criteria support this. It supplies us with a unified set of standards that everybody can strive for and measure to see if we are doing the right things. We have a lot still to learn, but this is a good step forward for the public and for doctors looking for alternatives to a relatively inefficient and high cost fee-for-service system that we all live with now.