ACO Benchmark Breakdown

ACOs are still a work in progress, and their performance varies substantially. Even if you’re not an ACO, you (and your patients) may benefit by sharing their objectives. Here is a list of the 2016-2017 quality measures, grouped into their respective categories.

Patient/Caregiver Experience:

The following 8 measures are assessed using a Consumer Assessment of Health Care Providers and Systems (CAHPS) :

ACO 1 – Getting Timely Care, Appointments, and Information

ACO 2 – How Well Your Doctors Communicate

ACO 3 – Patients’ Rating of Doctor

ACO 4 – Access to Specialists

ACO 5 – Health Promotion and Education

ACO 6 – Shared Decision Making

ACO 7 – Health Status/Functional Status

ACO 34 – Stewardship of Patient Resources*


  • Timely care and appointments depends upon your scheduling software configuration. What is your provider utilization? What is each specialty’s 3rd available appointment metric? How much time do your providers spend with patients? How much time do they spend doing documentation and paperwork? Does your organization have consistent visit types across providers?
  • Patient portals streamline communication, provide patients access to their information, and ease the burden on your office staff.
  • Communication – Does your practice use a messaging app to communicate internally or externally? If so, is it providing value or consuming provider time?How often do you share information with other health systems? Is your EHR configured to do so? It probably can share information, but is this a part of your physician’s workflow?
  • Access to Specialists – this is a combination of timely care and appointments and your organizations referral workflow. Does your organization have a seamless referral workflow? How much revenue does your organization lose to external referrals each month?
  • Health promotion and education – what does your AVS contain, and how frequently is it distributed?

Care Coordination/Patient Safety:

Many of the remaining metrics will be tracked via claims data, and others will be submitted using the GPRO Web Interface.

ACO 8 – Risk Standardized, All Condition Readmission

ACO 35 – Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)*

ACO 36 – All-Cause Unplanned Admissions for Patients with Diabetes*

ACO 37 – All-Cause Unplanned Admissions for Patients with Heart Failure*

ACO 38 – All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions*

ACO 9 – Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5)

ACO 10 – Ambulatory Sensitive Conditions Admissions: Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8)

ACO 11 – Percent of PCPs who Successfully Meet Meaningful Use Requirements

ACO 39 – Documentation of Current Medications in the Medical Record*

ACO 13 – Falls: Screening for Future Fall Risk


  • How does CMS define readmission rate? The “Risk-adjusted percentage of ACO assigned beneficiaries who were hospitalized and who were hospitalized and readmitted to a hospital within 30 days following discharge from the hospital for the index admission.” Lower rates are better. The denominator is relevant hospitalizations for ACO beneficiaries 65+ at non-Federal, short-stay acute-care or critical access hospitals, and the numerator is unplanned readmissions of those patients within 30 days. See inclusions and exclusions here.
  • Why readmission rate? Preventable readmissions cost at least Medicare $1.9 Billion annually, and readmissions are disruptive to patients and caregivers. I’ll elaborate on readmissions in an upcoming post.
  • The two Prevention Quality Indicator benchmarks – COPD/Asthma and Heart Failure – are best managed in an outpatient setting. How do you proactively and regularly treat these patients? Do you track medication compliance? Do you proactively schedule maintenance visits? The same could be said for diabetes. How do you use your technologies to better manage these populations?
  • Unplanned admissions result in high costs for both the patient and the ACO. How might your technology help you provide more efficient, coordinated, and patient-centered care to your populations with chronic diseases?

Preventative Health

ACO 14 – Preventative Care and Screening: Influenza Immunization

ACO 15 – Pneumonia Vaccination Status for Older Adults

ACO 16 – Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow Up

ACO 17 – Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention

ACO 18 – Preventative Care and Screening: Screening for Clinical Depression and Follow-up Plan

ACO 19 – Colorectal Cancer Screening

ACO 20 – Breast Cancer Screening

ACO 21 – Preventative Care and Screening: Screening for High Blood Pressure and Follow-up Documented

ACO 42 – Statin Therapy for the Prevention and Treatment of Cardiovascular Disease


  • How do you incentivize patients to participate in regular preventative care? Do you alert patients when it’s time to schedule an annual appointment? Do you alert schedulers and office staff that populations of patients are due for annual appointments? You can likely build reports, work queues, alerts, and batch notifications to help you identify and connect with these patients.

At-Risk Population Depression

ACO 40 – Depression Remission at Twelve Months

At-Risk Population Diabetes

ACO 27 Diabetes Composite – Hemoglobin A1c Poor Control

ACO 41 Diabetes Composite – Eye Exam*

At-Risk Population Hypertension

ACO 28 – Hypertension (HTN): Controlling High Blood Pressure

At-Risk Population IVD

ACO 30 – Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

At-Risk Population HF

ACO 31 – Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

At-Risk Population CAD

ACO 33 – Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Reception Blocker (ARB) Therapy – for patients with CAD and Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)


  • For these more specific metrics, clinical content, alerts, and reports can help clinicians identify these patients when necessary. Reporting dashboards can help clinicians track progress across populations. How do your clinicians manage these conditions today?

*New measures that will phase into pay-for-performance for the 2017 reporting year and benchmarks will be released prior to the start of the 2017 reporting year.

CMS has developed a phased-in approach to holding ACOs accountable to the 33 quality standards.  Each ACO agrees to participate in the program for three years.

Pay for performance will be phased in over the ACO’s first agreement period as follows:

  • Year 1: Pay for reporting applies to all 33 measures.
  • Year 2: Pay for performance applies to 25 measures. Pay for reporting applies to eight measures.
  • Year 3: Pay for performance applies to 32 measures. Pay for reporting applies to one measure that is a survey measure of functional status. CMS will keep the measure in pay for reporting status for the entire agreement period. This will allow ACOs to gain experience with the measure and will provide important information to them on improving the outcomes of their patient populations.

In future posts, I’ll delve into research supporting clinical measures like readmission and unplanned admissions.



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