In an accountable care relationship, doctors and other health care providers work with each other and their patients to manage their patients’ overall health, all while considering their patients’ personal health goals and values. These relationships can improve patients’ quality of care in the following ways:
Health care providers may agree to work together as a group, forming an Accountable Care Organization (ACO) to help coordinate their patients’ care. ACOs may consist of:
ACOs are designed to put patients at the center of their care and help them navigate a complex health system. Patients whose health care provider participates in an ACO may get:
Health care providers participating in an ACO are typically required to use Certified Electronic Health Record Technology, which can give them vital access to health information when and where they need it and make it easier for providers to spot potential problems before they become more serious – like harmful prescription drug interactions if one doctor isn’t aware of what another doctor prescribed.
When ACOs provide higher quality, coordinated care that improves patient health outcomes and reduces Medicare spending, they may be eligible to share in a portion of those savings. Conversely, ACOs could pay a penalty if they provide fragmented care that increases Medicare costs. ACOs can invest any financial rewards they receive into more patient care services and supports, or they can share a portion with health providers participating in the ACO.
The example below illustrates how patients can benefit from accountable care.
John, a 69-year-old African American man with multiple chronic conditions, including diabetes and heart failure, has several visits to the emergency room. The hospital is part of an ACO where he is easily referred to a primary care doctor and specialists who can address his specific health care needs. John’s primary care provider and specialist regularly communicate and coordinate regarding his care, and his care strategy includes monthly in-home visits with a dedicated nurse practitioner and social worker. He receives a scale to monitor his weight and talks with his primary care doctor about when to go to a primary care doctor and when to use the emergency room. This type of accountable care leads to better follow up with his primary care provider, improved management of his chronic condition, and a decrease in unnecessary emergency room visits.
Many ACOs are dedicated to reaching and caring for people who historically have not been able to get health care that meets their needs. Providers in an ACO may help underserved populations, for example, by making it easier to get care, such as by offering at-home or telehealth visits. Additionally, ACOs may examine social factors that may have an effect on someone’s health – like safe housing and access to nutritious food – and connect their patients with social services in their area. Because ACOs provide more coordinated care and individualized treatment plans, underserved patients are less likely to get lost in the health care system.
An ACO is not an insurance plan. Patients who have Original Medicare and have doctors in an ACO retain all of their rights and privileges under Original Medicare, including the freedom to see any health care provider that accepts Medicare, even if that provider is not part of an ACO. And they can opt out of Medicare sharing certain health information by calling 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
Learn how our models measure ACOs’ impact on quality of care.
For information about how Accountable Care Organizations in Original Medicare differ from Medicare Advantage plans, view our fact sheet (PDF).
For more information about the CMS Innovation Center’s new strategy and the future of value-based care, visit our Strategic Direction webpage.