DOH Invites LeadingAge NY to Participate in New ACO Work Group

The Department of Health (DOH or the Department) convened a new work group, last week, to review proposed regulations governing Accountable Care Organizations (ACOs) and explore the integration of ACOs into the state's Medicaid program. Jim Clyne, LeadingAge New York's president and CEO, was invited to participate in the work group, which included representatives of other associations, ACOs, the Department of Financial Services and the Legislature. Under legislation enacted in 2012, the work group's charge is to consider whether ACOs should be permitted to manage the care of Medicaid enrollees in lieu of managed care plans.

An ACO is a network of clinically-integrated health care providers that work together to coordinate and deliver care for a defined population and are held accountable for the quality and costs of such care. There are 27 Medicare ACOs approved to operate in New York State. ACO-like networks are also contracting with commercial insurers to provide coordinated, cost-effective care. Many ACOs are developing relationships with post-acute care providers to improve care coordination and outcomes and reduce readmissions. 

The Department envisions Medicaid managed care plans contracting with ACOs to coordinate and deliver care to their members, with health homes as the leading candidates to become ACOs. The Department has also pointed to the ACO as a potential model to provide the governance structure for Delivery System Reform Incentive Payment (DSRIP) projects under the pending Medicaid waiver application.

The proposed regulations set forth requirements that ACOs must meet in relation to obtaining a certificate of authority, governance, quality, and reporting. Consistent with the statute, the regulations also relax for ACOs certain prohibitions in relation to antitrust, fee splitting, and self-referrals. The major issue to be resolved by the proposed regulations is the standards and requirements that ACOs must meet when taking on risk -- that is, when they assume liability for health care expenses through shared loss or capitation arrangements.

The slides presented at the work group meeting can be found here.

Contact: Ami Schnauber, aschnauber@leadingageny.org, 518-867-8383