The Affordable Care Act was brought into law on March 23, 2010, and in 2011 a rule was added to create affordable care organizations (ACOs). These organizations were groups of physicians and hospitals that work together to provide patient care at the most affordable cost. They are unlike HMOs in that patients don't have to go to a referral within the ACO, but it benefits the providers when they do. Since their inception in 2011, ACOs have undergone a few regulation changes to better serve the patients within them.
There have been six proposed rules since the ACOs came into being in 2011. Most of these rules involve changes to payment structure and benchmarks needed by ACOs. One of the first changes to be brought up involved the continuing education of physicians’, especially family physicians. The issue was that when a patient goes to the hospital they have two types they can go to, teaching and non-teaching hospitals. Patient's that are seen at teaching hospitals incur a higher overall cost than those that don't because included in the cost is GME funding. The proposed change is to exclude GME funding from the Medicare cost calculations. The recommendation by CAFM is that there be a part of the ACO model that rewards innovative educational models.
Among the changes seen in late 2011 was the exclusion of indirect medical education costs for teaching hospitals and the addition of a cost-sharing agreement. The cost-sharing agreement is to offset the cost of those hospitals that treat a higher number of low-income patients.
The next major regulation change was proposed in 2014 and finalized in 2015. Changes made involved updating the benchmarks ACOs must obtain, revising who is qualified under primary care and create a 3rd track within the ACO program for ACOs that want beneficiary assignments, higher sharing and the ability to use new case coordination programs. Qualifications for primary care were changed to include specialty positions such as nurse practitioners and physician assistants. The reasons for these changes was to broaden the scope of who was able to participate in ACOs and update or clarify currently parts of the ACO model.
In 2015 another rule was proposed and finalized not long after the previous rule. This rule simply added clarification to definitions as to how different provider's report and what satisfactory ACO reports should be. It also added Electing Teaching Amendment hospitals as a primary care entity but took away SNFs under certain claims.
2016 saw the coming of a second or in some cases 3rd three-year agreement for ACOs. In the inception of the program, the ACOs were agreed to be operational for a set time, which in late 2011 was determined to be three years. Many ACOs had come up to the limit on their initial agreements and wanted to remain part of the program. This required a rewording of how the ACOs benchmarks would be reset so that they don't end up with impossible benchmarks due to success in the previous period. One of the changes was a change from a national level of data to a regional level when comparing providers. This will change providers from being compared to their past success and instead compare them to other providers within the same region.
There was also a change from a one-sided model to the option of a two-sided model. The two-sided model offered a higher percentage of shared saving's reimbursement among other incentives. The two-sided model would later become more mandatory going into 2017.
In both 2016 and 2017, there were also changes to the physician fee schedules. The changes were modifications to algorithms when a beneficiary has chosen a specific provider and updates to various wording or definitions in the act. It also included more revisions to quality reporting to assist physicians.
In late 2017 there was the most recent proposed and finalized rule. This rule was directed at how ACOs performance is measured in extreme and uncontrollable circumstances such as natural disasters. This meant that when ACOs fell within this ruling, they were able to receive better scores due to the uncontrollable circumstances. It also changed how performance-based risk is calculated because it was adjusted to include the effects of the extreme and uncontrollable events on beneficiaries.
Since their inception in 2011, ACOs have undergone a few changes to their program. Most of the changes were revisions needed to better serve patients in different situations or ensure that the providers aren't being told how to provide care. The changes involved how to make the program more successful and rarely seemed to mention failures outside of situations that were not initially thought of. Some of these situations included the use of nurse practitioners as primary care providers and the effect of natural disaster's on a patient's overall health.