Under the proposed ACO rules, CMS will assign Medicare beneficiaries to ACOs based on where the patient receives the “plurality” of their primary care services during the year before the relevant ACO performance measurement period.  If medical cost savings can be achieved during the performance period for the ACO’s assigned beneficiaries as compared against the CMS projected benchmark costs for the assigned beneficiaries, then the ACO will share in some of the savings.
It is unclear in the draft rules whether the ACO will be given access to the necessary beneficiary data to help the ACO deliver on the promise of improved care at reduced costs.  The ACO will have access to complete information for beneficiaries who use the ACO and its network of providers exclusively, but the ACO may not have access to complete information for those beneficiaries that go outside the ACO for some of their services.  ACOs will not be permitted to restrict beneficiary access to providers outside the ACO.  Patient choice will be maintained.
CMS acknowledges that giving the ACO access to beneficiary information and data will help the ACO promote coordinated care, better understand the ACO beneficiaries served and have a positive impact on both the quality and cost of care provided.  It appears CMS will provide aggregated data for the ACO beneficiaries to show such things as quality performance scores, high risk score beneficiaries, chronic disease subpopulations, hospital utilization, etc.  What is not clear, however, is whether CMS will provide specific data with respect to individual beneficiaries.
CMS proposes to disclose the name, date of birth, sex and Health Insurance Claim Number for assigned beneficiaries, as permitted by HIPAA and other privacy and security laws.  Beyond that information, CMS proposes to allow the ACO to request beneficiary specific claims data.  While CMS acknowledges it has legal authority to share the data without specific beneficiary consent, the ACO must first provide the beneficiary the ability to opt-out of allowing CMS to share the beneficiary’s claims data with the ACO.
This approach certainly protects the beneficiary’s right of privacy, but it will provide another administrative burden for the ACO and may make it difficult for the ACO to develop the necessary individual care coordination plans and other risk mitigation strategies for its ACO beneficiaries.  It is hard to know how many beneficiaries may opt-out of data sharing.  If many do, this feature of the new program could have a real negative impact on the ACO’s ability to improve the health of the individual beneficiary as well as achieve the desired shared savings.
CMS will require ACOs to develop individual care plans.  The ACO program may be better served if CMS shared data with the ACO, when legally permitted to do so without beneficiary consent.  The current proposal to allow the beneficiary to opt-out of CMS data sharing could prove to be counterproductive to the overall goals of the ACO program.