NCQA Releases Draft Criteria for Accountable Care Organizations (ACOs)

The National Committee for Quality Assurance (NCQA), a private, not-for-profit organization that accredits and certifies health plans and other healthcare related organizations published on Oct. 19, 2010, its 2011 Draft Accountable Care Organizations Criteria. The draft criteria describe the standards NCQA believes ACOs should meet in order to ensure that an ACO has the infrastructure necessary to function as an accountable entity and achieve improvements in quality and reductions in costs. The draft criteria were developed with the guidance of a multistakeholder Accountable Care Organization Task Force assembled by NCQA.

The draft criteria are arranged into seven categories that reflect the core capabilities ACOs should possess:

1. Program Structure Operations
2. Access and Availability
3. Primary Care
4. Care Management
5. Care Coordination and Transitions
6. Patient Rights and Responsibilities
7. Performance Reporting

There is no indication at this time that the Centers for Medicare and Medicaid Services (CMS) or any other regulatory agency will adopt these criteria in establishing requirements for ACOs under the Medicare Shared Savings Program or any other ACO initiative under the Medicare or Medicaid programs, but it is possible that they could be relied upon by CMS and other regulatory agencies in determining how ACOs should be structured and how their performance should be measured.
NCQA is accepting public comments on the draft criteria until Nov. 19, 2010. NCQA has specifically requested comments on a number of issues related to the ACO criteria, including:

• Whether the types of specialists that should be included in the ACO should be specified in the criteria.
• Whether the eligibility criteria captures the organization types that have the capability to act as ACOs and whether additional structures should be considered.
• Whether measures such as Healthcare Effectiveness Data and Information Set (HEDIS) and Meaningful Use align with stakeholder expectations for ACOs.
• Whether there are critical functions of ACOs that are not included in the draft criteria.

It is unclear at this time what impact the NCQA criteria will have on the development of ACOs, but it is likely that NCQA will continue to have a voice in the public dialogue about the evolution of this healthcare delivery model and its role in improving quality and reducing costs under healthcare reform.

If you would like to submit comments to the NCQA or if you would like to discuss the draft criteria for ACOs, please contact one of the authors.