Gov’t Will Share Medicare Patients’ Data With New ‘Accountable Care Organizations’

By Susan Jones | December 20, 2011 | 9:38am EST

( - The new year will bring a new phase of Obamacare to an estimated 860,000 Medicare patients.

Under the new system, individual medical claims filed with the federal Centers for Medicare & Medicaid Services (CMS) will be shared with doctors and hospitals unless Medicare patients opt out of the data-sharing.

Starting on Jan. 1, 32 health care organizations from across the country will take part in a "Pioneer Accountable Care" initiative, Health and Human Services Secretary Kathleen Sebelius announced on Monday.

Accountable Care Organizations (ACOs) -- made possible under the Democrats’ Affordable Care Act -- are supposed to provide "coordinated care" by having a patient's multiple doctors communicate with one another -- and with the hospital -- about the best course of treatment.

The goal is to achieve better health care for patients at a lower cost, Sebelius said.

To help doctors provide "better care," CMS says it "will share with participating ACOs some types of Medicare data" -- including a "history of medical claims that can provide ACOs with a more complete view of the beneficiary’s complete medical needs."

Medicare patients may opt out of having their “identifiable data” shared with ACOs, CMS said. Medicare patients will receive written notification from the ACO regarding their right to opt-out, as well as information on how to do so. They will have 30 days to respond before CMS starts sharing their medical claims with an ACO, although "beneficiaries maintain the ability to opt out at any time."

The automatic sharing of Medicare claims does not apply to treatment for substance abuse, CMS said. Those records will be shared only if the Medicare patient "provides explicit written permission to do so."

Under the Accountable Care model, Medicare patients do not enroll in an ACO -- their doctors do. However, ACOs are required to notify beneficiaries of their participation in the new "coordinated care" system.

CMS says it will "reward" ACOs based on how well they meet their obligations to provide "quality care" at a lower cost to Medicare. When successful, the elimination of duplicative, unnecessary processes should improve quality of care and generate savings to the Medicare program, says a CMS fact sheet. However, ACOs "will be responsible for sharing in losses if they can’t help reduce costs while maintaining quality standards."

CMS says it takes its commitment to quality care seriously, and therefore it will guard against ACOs that may try to withhold necessary health care to cut costs.

"CMS will routinely analyze data surrounding utilization of services, and will take steps to further investigate any suspect trends, including steps such as beneficiary surveys, audits, and other means." CMS also said it will compare the health of ACO beneficiaries with Medicare patients who are not part of an ACO.

The coordinated care effort could save up to $1.1 billion over five years, CMS estimates.

The Pioneer ACO initiative is one of several options for providers looking to reduce costs through coordinated care for patients. The Medicare Shared Savings Program and the Advance Payment ACO Model, both announced in October 2011, are other ACO options for providers.

HHS said the Pioneer ACO "will test the effectiveness of several innovative payment models and how they can help experienced organizations to provide better care for beneficiaries, work in coordination with private payers, and reduce Medicare cost growth.”

ACOs that achieve better care and lower cost growth will be able to move away from a payment system based on volume under the fee-for-service model, towards one where the ACO is paid based on the value of care it provides.

Selected Pioneer ACOs include physician-led organizations and health systems, urban and rural organizations, and organizations in various geographic regions of the country, representing 18 states and the opportunity to improve care for about 860,000 Medicare beneficiaries.

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