ACO Overview

Eligibility and quality measures

Eligible ACO membership

An accountable care organization (ACO) can be composed of the following member structures:

  • Primary care physicians, specialists, nurse practitioners and clinical nurse specialists in a group practice arrangement
  • Networks of individual practices of accountable care organization professionals
  • Joint ventures between hospitals, providers and commercial payer organizations
  • Hospitals employing accountable care organization providers
  • Federally qualified health centers (FQHC), rural health clinic (RHC) facilities, eligible critical-access hospitals, and home health networks
  • Other Medicare providers and suppliers as determined by the Secretary of the U.S. Dept. of Health and Human Services (HHS)

The Shared Savings Final Rule offers flexible start dates for Medicare Accountable Care Organization entities. To participate as a Medicare ACO, an entity must maintain the 5,000-patient minimum required under the final rule. Providers may join more than one entity. Membership is available to a wide range of care providers in an effort to coordinate care among various settings. Medicaid ACOs follow a similar structure.

Commercial or private accountable care organization arrangements aren’t subject to PPACA regulations and continue to form around the country. Models involve payers, hospitals and physician groups. Health insurers are also implementing payment systems that reward quality care outcomes.

ACO quality measures

The Centers for Medicare & Medicaid Services (CMS) currently has 33 quality measures for members of a Medicare ACO to report against to determine whether the entity qualifies to share in the savings.

Commercial ACOs enter into similar risk-sharing payment models; however, quality measures may vary significantly between various private payers. Organizations that meet agreed-upon performance levels on a range of specific quality measures are rewarded financially and are penalized for exceeding spending targets.