Reading the Future in the Alphabet Soup of the Present

Gerald N. Yorioka, MD, SCMS President

In October 2007 the Institute of Healthcare Improvement (IHI) under the leadership of Donald Berwick launched the “Triple Aim” for the improved future of health care.  The components are 1) Contain costs, 2) Improve quality, and 3) Population health.  They are to be attained simultaneously, rather than achieving one at a time, at the expense of the other.

Meanwhile the National Committee of Quality Assurance (NCQA) established a task force in2011 to create an accreditation process  for Accountable Care Organizations (ACOs) which would be tasked with achieving the Triple Aim, and in 2013, these criteria were published.  The NCQA since the 1990’s had been working with Healthcare Effectiveness Data and Information Set (HEDIS) quality standards, which was generated in the 1980’s by think tanks of large employers and health experts.

In June 2015 the Center for Medicaid and Medicare Services (CMS) published the Final Rule in the Federal Register that outlined the Medicare Shared Savings (MSS) Program and its companion definition of the Accountable Care Organization (ACO) needed for its implementation. The initial proposed rule had been published in December of 2014.  The origins of this Medicare Shared Savings Program can be traced back to the Affordable Care Act (ACA) of 2010. ACOs will share in the achieved savings, and are an integral and essential part of the Shared Savings Program.

Dr. Burwick, a pediatrician, was placed as head of the CMS by President Obama in a “pocket-appointment” in June of 2010, when the Senate was in recess. As a result, he was never confirmed by the Senate and eventually resigned in December of 2011. During his tenure the ACO was codified and written into federal rules and into the NCQA certification process.

Superimposed on these concepts is another entity, the Accountable Communities of Health (ACH).  While the ACO’s are generally coalition of health providers, the ACH’s have a broader base within the community as a whole. Washington State is implementing  this concept in its Medicaid program design and has divided the state into nine  geographical areas called Regional Service Areas (RSAs) that will cover the entire state, each with an exclusive territory.  CMS awarded the state an innovation grant in December 2014 to launch this process.  At this point only three are “certified,” and Snohomish County is included in one of these as the five county North Sound ACH.

In summary of all these interrelated terms, we see the “Triple Aim” leading to the Medicare Shared Savings, enacted in the Affordable Care Act. This in turn, gave rise to the ACO’s for Medicare and then the initial ACH’s in Medicaid.  While each of these two has a different domain, they do converge through one federal agency, CMS.  It is quite likely that the ACOs and ACHs will spread into other sectors of health care. Furthermore, all of this ties to payment reform, which pulls in new goals of population outcomes and Patient Centered Medical Homes.  Here also, the NCQA had codified criteria for a PCMH.

A specific purpose for this article is to urge you, as an individual in the medical community, to willingly engage in the Accountable Communities of Health process when the opportunities arise.  These opportunities may take the form of committees, boards, task forces, focus groups, or hearings.  Your voice is needed to define the health goals for our community.