Beneficiary Obligation Cemp Law Case

Healthcare is often driven by consumers and insurance companies; there is strong pushes for insurance companies to start paying better through Patient Care Medical Homes (PCMH) or Accountable Care Organizations (ACO) rather than paying at a per-visit basis (Hamlin, 2015). With PCMH or ACOs payment is made on a continuum of care, encouraging the provider to be involved in all aspects affecting health of the patient (Derksen, & Whelan,

Such mechanisms are hardly a novelty or cutting edge innovations. Such operational strategies are not much different from those used by their predecessors. Why should anyone expect more success just because the 3-letter name of this managed care group changed? ACOs are simply attempting to replicate the performance of HMO in holding down the cost of care while avoiding the features that gave the HMO control, and hence its success, and created a consumer backlash in the 1990s. However, unlike HMOs, the ACOs must meet a long list of quality measures to ensure they are not saving money by being frugal on necessary care. Patient trust in the ACO model is not well established. To earn patients’ trust, they will need to prove their value.

Service users should be given sufficient information about any treatment they are offered so that they can make an informed decision about whether or not to take it.  Information should include the benefits and possible risks of the treatment, the likely duration of treatment and any financial costs. The service user should also be given information on alternatives to the treatment being offered.

H.R. 6261promotes the utilization of not only primary care services provided by Accountable Care Organizations (ACO’s) physicians, but also those provided by other ACO such as nurse practitioners, to increase patient access to quality care while reducing costs in underserved areas.

The Accountable Care Organization (ACO) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients (McCarty, B., 2016). For example, Medicare Shared Savings Program was created by The Center for Medicare & Medicaid Services to monitor and establish that all ACO’s are meeting the quality performance benchmarks and reduce Medicare spending by certain percentages (H., 2017). The growth of ACO’s from 2011 to 2016 is astonishing, in 2011 there was 64 ACO’s and by 2016 they have risen to 838 in the U.S. (H., 2017).

Although the Stark law does not apply to ASCs, the federal Anti-kickback Statute does apply. The Anti-Kickback statute prohibits any person from “knowingly and willfully” providing any remuneration to induce referrals, or in exchange for referrals, of federal health care program patients or business.2 Accordingly, the Anti-kickback Statute applies to any physician-owned ASC that treats federal health care program patients (including Medicare and Medicaid), in that the potential return on investment, arguably, could be viewed as an inducement for physician investors to refer to the ASC. However, there is an ASC “safe harbor” under the Anti-kickback Statute, which protects various types of physician-owned ASCs as well as hospital/physician ASC

Currently, the Affordable Care Act establishes nurse practitioners as providers whom are eligible providers in ACOs; however, the current Medicare Shared Savings program statute prevents beneficiaries of Medicare, who are receiving primary care service from a nurse practitioner, from being assigned to Accountable Care Organizations inside the program (AANP, 2015). The American Association of Nurse Practitioners (2015) also claim the exclusion of nurse practitioners must be repealed if ACOs want to develop further as models of practice, which improve cost effectiveness, patient access and quality.

The Affordable Care Act created a new approach to care which is called the Accountable Care Organization. ACO is a system of doctors and hospitals that share a financial and medical responsibilities. If the ACO is successful in meeting quality and cost savings targets, these organizations qualify for financial incentives or shared saving from Medicare programs. The goal of the ACO is to coordinate

The concept of an Affordable accountable cCare oOrganization (ACO) is still evolving. Generally, an ACO is a group of health care providers (including primary care physicians, specialists, and medical facilities) that work in partnership and are collectively accountable for the cost and quality of health care they deliver to a specific population of patients. At the heart of each patient's care is a primary care physician.

The Medicare Shared Savings Program was established by section 3022 of the Affordable Care Act and aims to improve beneficiary outcomes and increase the value of care by providing better care for individuals, better health for populations, and lowering growth in expenditures (Lieberman, & Bertko, 2011). The Affordable Care Act created ACOs, which is part of Medicare since January 2012, together with a Shared Savings Program it has the potential to lower costs, improve the quality of care, facilitate delivery system reform, and promote innovation in health care ( Lieberman, & Bertko, 2011).

One of these examples is the Meridian Health Accountable Care Organization. “In January 2013, Meridian was selected by the Centers for Medicare &Medicaid Services (CMS) to participate as a Medicare Accountable Care Organization (Meridianhealth.com). When a system is selected to become an Accountable Care Organization it can choose one of three routes. They are Medicare Shared Savings Program, Advanced Payment ACO Model, and Pioneer ACO Model. Meridian Health chose the shared savings program. This program goals include better care for individuals, better health for populations and lowering growth in expenditures. The Shared savings program also rewards “ACOs that lower growth in health care costs while meeting performance standards on quality of care and putting patients first” (CMS.gov). The next type of ACO is the Advanced Payment Model. This model is “designed for physician-based and rural providers who have come together voluntarily to give coordinated high quality care to the Medicare patient they serve… selected participants will receive upfront monthly payments”(CMS.gov). This form of ACO is for systems that do not meet the requirements for Shared Savings because they are too small in size and they do not have access to capital so that they can invest in upgrading their system. So far there are 35 ACO using this model and so that they can

The viewpoint of their proponents, there is a difference from historical managed care arrangements in ACOs predominantly HMOs since they are centered around providers ahead of insurers and usually are not detained at complete monetary peril for the price of health care. In an ideal world, ACO payment approaches will include improvements in quality of care measurement that take into account the range of service delivery ACOs are designed to provide. If legislated, nationally health reform could most likely include more or less research with ACO incentives. On November 7th , 2009 the United States House of Representatives passed, the Affordable Healthcare for America Act (H.R. 3962) which called for pilot payment incentive that would encourage ACOs in both Medicaid and Medicare, along with other policies on payments alterations and authorized demonstrations and pilots (Huntington, Covington, Center, Covington, and Manchikanti,

​Kaiser Health News recently published an article on a new trend in healthcare. This trend introduces the Accountable Care Organization (ACO). The Centers for Medicare and Medicaid services defines it as “groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients” (“Accountable Care Organization,” 2015). According to the Affordable Care Act (ACA), the goal of the ACO is to be able to share health cost-savings with providers who are able to save money by eliminating unnecessary procedures and reduce health costs while increasing quality of care. ACOs make health professionals become more accountable in maintaining good-quality, coordinated healthcare for a patient through a value-based system that is evaluated through a number of criteria and benchmarks (Ronai, 2011).

The ACA included reductions in Medicare payments to plans and providers and introduced delivery system reforms that aims to improve efficiency and quality of patient care and reduce costs including accountable care organizations (ACOs), medical homes, bundled payments, and value-based purchasing initiatives”(Cubanski & Neuman, 2016, p. 2).

According to Shi and Singh an accountable care organization, also known as an ACO, describes an integrated group of providers who are willing and able to take responsibility for improving the overall health status, care efficiency, and satisfaction with care for a defined population. The ACO was established by the Patient Protection and Affordable Care Act (PPACA) Section 3022 mainly to better the quality of care to beneficiaries and to save money for Medicare (Golden). The accountable care organization is voluntary for provider participation and Medicare beneficiaries still can choose treatment from any provider they wish which is beneficial. The ACO has been viewed as a potential tool for rebuilding the traditional Medicare coverage according to Medicare Payment Advisory Commission known as MedPAC (Rosenbaum). According to CMS,