New ACO 20 and ACO 30 products give members savings and flexibility
Small groups have a new choice that delivers more savings, more flexibility and better-coordinated care. Our new Accountable Care Organization products (ACO), ACO 20 and ACO 30, give employers the flexibility of a PPO, with the cost and care advantages of an HMO.
Within each plan, members have three network tiers to choose from. They can save the most when they stay in ACO network. But they also have the flexibility to choose PPO and non-PPO benefits. This is the only plan like it in California.*
Here’s how it works:
Tier 1: A member’s health care dollar goes the farthest here. This is a specialized ACO network of doctors, specialists, labs and hospitals. Being a tight-knit group makes it easier for doctors to coordinate and collaborate on care. There are ACO networks in Los Angeles, Santa Clara and San Diego, and we’re looking to expand throughout the state.
Tier 2: This is our Anthem PPO network. Members pay a little bit more for care here, but still save money by staying in the broader network. Our PPO plans feature access to more than 57,000 California PPO network doctors and specialists and more than 300 hospitals.
Tier 3: These are out-of-network doctors and hospitals. Members have some coverage here, but they’ll share more of the costs – usually 20% – 50% of the bill, depending on the plan.
Coverage starts April 1, 2012
An accountable care organization (ACO) is a type of payment and delivery reform model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. A group of coordinated health care providers form an ACO, which then provides care to a group of patients. The ACO may use a range of different payment models (capitation, fee-for-service with asymmetric or symmetric shared savings, etc.). The ACO is accountable to the patients and the third-party payer for the quality, appropriateness, and efficiency of the health care provided. According to the Centers for Medicare and Medicaid Services (CMS), an ACO is “an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it.”
While the ACO model is designed to be flexible, Dr. Mark McClellan, Dr. Elliott Fisher and others defined three core principles for all ACOs: 1) Provider-led organizations with a strong base of primary care that are collectively accountable for quality and total per capita costs across the full continuum of care for a population of patients; 2) Payments linked to quality improvements that also reduce overall costs; and, 3) Reliable and progressively more sophisticated performance measurement, to support improvement and provide confidence that savings are achieved through improvements in care.[2]
The ACO-model builds on the Medicare Physician Group Practice Demonstration and the Medicare Health Care Quality Demonstration, established by the 2003 Medicare Prescription Drug, Improvement, and Modernization Act. Kaiser Permanente and HealthCare Partners Medical Group are two notable examples of successful ACOs.
While ACOs have become increasingly more common in the last few years, a recent study by the Medical Group Management Association(MGMA) has shown that the implementation of ACOs is one of the toughest challenges facing the MGMA members today.
Section 3022 of the Patient Protection and Affordable Care Act (ACA) creates the Medicare Shared Savings program, allowing ACOs to contract with Medicare by January 2012