Governance

Governance refers to the structures by which policy decisions around the accountable care model are made, and the specific stakeholders (including patients and community stakeholders) who assume responsibility for the project.

 

Alabama
The Alabama Medicaid Agency is responsible for the development and oversight of the Regional Care Organization (RCO) program. RCOs would be largely governed by provider organizations that agree to share in the risk in a particular region of the state. Because they are provider-based organizations, the state would establish criteria and oversight procedures that will be managed within the Medicaid Agency (separate and apart from traditional insurers). The state will have the power to approve governing board members and to approve the selection process for RCO advisory committees.
 
Act 2013-261 requires that RCOs have a governing board of directors which includes 12 members will represent risk-bearing participants in the RCO (i.e. via contributing cash, capital, or other assets to the RCO) and 8 members representing other stakeholders. Of these eight members there will be:
  • 5 medical professionals who provide care to Medicaid beneficiaries in a region served by a RCO (consisting of 3 Primary Care physicians, 1 Optometrist, 1 Pharmacist)
  • 3 Community representatives, including
    • The chair of citizens advisory committee
    • An elected citizens’ advisory committee member
    • A business executive nominated by Chamber of Commerce in the region

Each RCO will have a Citizens’ Advisory Committee (at least 20% of members must be Medicaid beneficiaries).

Alaska No known activity at this time.
Arizona No known activity at this time.
Arkansas

The Arkansas Department of Human Services (which oversees Arkansas Medicaid) partnered with two large private payers, Arkansas Blue Cross and Blue Shield and Arkansas QualChoice, to form the Arkansas Care Payment Improvement Initiative. This group worked with providers, health administrators, patients and advocacy groups to design the payment reform that has begun to be put into effect. For more information, visit the state’s archive for this initiative.

California
The California Public Employees’ Retirement System (CalPERS) accountable care organization (ACO) pilot utilizes a shared governance model based on a Pilot Board. The board includes members of the executive leadership of the payer and provider organizations involved in the pilot: Blue Shield of California, Dignity Health, and Hill Physicians Medical Group.
 

A senior-level ACO Core Team made up of the pilot partners’ clinical, financial, and operational leadership provide day-to-day direction to the project.

Colorado  

Under the Accountable Care Collaborative (ACC) Program, primary care medical providers contract with one of seven Regional Care Collaborative Organizations (RCCOs) to provide medical home services to Medicaid enrollees. More information can be found in the RCCO RFP.

 

The Department of Health Care Policy & Financing has developed an ACC Program Improvement Advisory Committee—representing RCCO staff, Primary Care Medical Providers, other provider groups, clients and families, and Department staff—to provide guidance and make recommendations for improvements in the ACC program.

 

The ACC Program included stakeholder input through public forums and a formal Request for Information process.

Connecticut No known activity at this time.
Delaware No known activity at this time.
District of Columbia No known activity at this time.
Florida No known activity at this time.
Georgia No known activity at this time.
Hawaii The Accountable Healthcare Alliance of Rural Oahu (AHARO) serves as a contracting arm for three Federally Qualified Community Health Centers (FQHCs): the Koolauloa Community Health and Wellness Center, Waimanalo Health Center, and Waianae Coast Comprehensive Health Center. AHARO was established via an interagency agreement and answers to the three community-elected governing boards of the participating FQHCs.
No known activity at this time.
An Accountable Care Entities (ACE) is defined as “An organization comprised of and governed by its participating providers, with a legally responsible lead entity, that is accountable for the quality, cost, and overall care of its Enrollees.”
 
Care Coordination Entities (CCEs) are collaborations of community providers and community agencies. Groups of providers that wish to become a CCE may create a new corporate entity or they may designate a lead entity to serve as the legal entity responsible for executing the CCE contract with the state.
 
Managed Care Community Networks (MCCNs) are entities that are owned, operated, or governed by health care providers; MCCNs must submit their articles of incorporation and by-laws with their application.
 
Each organization works under contract with the Illinois Department of Healthcare and Family Services.
Indiana No known activity at this time.
Under a draft accountable care organization (ACO) agreement released by Iowa Medicaid, an ACO must possess the corporate resources and structure necessary to perform its responsibilities under the agreement and successfully implement and operate the ACO. ACOs must enter into written agreements or contracts with the patient managers (PMs).
 
ACOs must also established a governing body with responsibility for setting policy, developing and implementing a model of care, establishing best practices, setting and monitoring quality goals, and assessing PM performance and addressing deficiencies. The ACO must also demonstrate meaningful involvement of a Chief Medical Officer and PMs in the governance structure.
 
The agreement also stipulates that the ACO shall have a consumer advisory board that meets regularly and advises on ACO policies and programs including cultural competency, outreach plans, member education materials, prevention programs, member satisfaction surveys, and quality improvement programs.
Kansas No known activity at this time.
Kentucky No known activity at this time.
Coordinated care networks contract with Louisiana’s Department of Health and Human Services.
 
Requirements for the makeup of the coordinated care network shared savings (CCN-S) entities are not specified, but the Request for Proposals released by the Louisiana Department of Health and Hospitals establishes that on-site readiness reviews of the CCN-S will focus on the performance of the governing body, among other areas.
The Maine Department of Health and Human Services released a Request for Applications (RFA) for its Accountable Communities initiative in October 2013. The RFA clarified that while the Accountable Community need not be an incorporated entity, each Accountable Community must establish a governance structure that is responsible for oversight and strategic direction of the Accountable Community and it must designate a Lead Entity. The Lead Entity must contract with all providers participating in the Accountable Community and the Lead Entity is responsible for receiving and distributing shared savings payments (or making shared loss payments to the Department of Health and Human Services).
No known activity at this time.
Accountable care organizations (ACOs) are required by the Chapter 224 of the Acts of 2012 to have a governance structure that includes an administrative officer, a medical officer, and patient or consumer representation. They must be organized as a separate legal entity from the ACO participants.
No known activity at this time.
As explained in a memorandum on flexibility under the Demonstration from the Department of Human Services, providers participating in the Health Care Delivery Systems demonstration are not required to form new legal or financial entities.
Mississippi No known activity at this time.
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Montana No known activity at this time.
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Nevada No known activity at this time.
New Hampshire No known activity at this time.
 

The authorizing legislation, P.L. 2011, Ch. 114, states that any organization applying for certification as an Accountable Care Organization (ACO) must have a governing board which includes:

 

 

  • “Individuals representing the interests of: health care providers, including, but not limited to, general hospitals, clinics, private practice offices, physicians, behavioral health care providers, and dentists; patients; and other social service agencies or organizations located in the designated area; and
  • “Voting representation from at least two consumer organizations capable of advocating on behalf of patients residing within the designated area of the ACO. At least one of the organizations shall have extensive leadership involvement by individuals residing within the designated area of the ACO, and shall have a physical location within the designated area. Additionally, at least one of the individuals representing a consumer organization shall be an individual who resides within the designated area served by the ACO.”

 

Organizations that apply for certification as ACOs are required to have board representation that includes representatives of local hospitals, physicians, behavioral health care providers, and dentists.

 

Statute requires that organizations applying to act as ACOs be “organized with the voluntary support of local general hospitals, clinics, pharmacies, health centers, qualified primary care and behavioral health care providers, and public health and social services agencies.”

No known activity at this time.
New York’s ACO law, NYS Public Health Code Article 29-E, requires that accountable care organizations (ACOs) provide for meaningful participation in the composition and control of the ACO’s governing body for ACO participants or designated representatives. ACO governing bodies must have at least one representative from each of the following groups:
 
  • Recipients of Medicaid, Family Health Plus, or Child Health Plus;
  • Persons with other health coverage; and
  • Persons who do not have health coverage.

ACO participants must hold at least 75 percent control of the ACO’s governing body. Further detail on ACO governance requirements will be issued in forthcoming regulations from the Department of Health.

No known activity at this time.
North Dakota No known activity at this time.
Ohio No known activity at this time.
No known activity at this time.
 

Coordinated Care Organizations must ensure their governance structure makeup reflects community needs and supports the goals of health care transformation and meets governance structure criteria from ORS 414.625. The law requires that each CCO’s governance structure include a majority interest consisting of the persons that share financial risk of the organization. Major components of the of the health care delivery system and the community at large must also be represented.

 

CCOs are also required to convene regular meetings of community advisory councils (CACs) to obtain community perspectives. These councils include representatives of the community and of county government, but with consumers making up a majority of the membership.

No known activity at this time.
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South Carolina No known activity at this time.
South Dakota No known activity at this time.
Tennessee No known activity at this time.
Texas
Health care collaboratives (HCCs) are required by SB 7 to be governed by a board of directors whose members are elected by physicians and health care providers who participate in the HCC. If all participants in the HCC are physicians, each member of the board must be a physician. If the HCC consists of physicians and other providers, there must be an equal number of physician and health care provider representatives on the board.
 
The board of directors of an HCC is responsible for establishing a compensation advisory committee that develops recommendations regarding charges, fees, payments, distributions, or other compensation assessed for health care services provided by physicians or other providers participating in the HCC.

Oversight of ACO contracts would remain the responsibility of the Utah Department of Health, as it is under existing Medicaid managed managed care contracts.

Governance standards for Vermont’s Medicaid Shared Savings Program (SSP) released in 2013 mirror the requirements of the federal Medicare Shared Savings Program. The state requires that accountable care organizations (ACOs) establish and maintain a governing body, separate and unique to the ACO (and not the governing body of any ACO participant) with adequate authority to execute the statutory functions of an ACO.
 
Participants in the governing body must be representative of practitioners participating in the ACO, include a Medicaid beneficiary served by the ACO, and 75 percent of the governing board must be chosen by ACO participants.
 

The SSP standards also require that ACOs have a leadership and management structure that includes clinical and administrative systems.

Virginia No known activity at this time.
No known activity at this time.
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Wisconsin No known activity at this time.
Wyoming No known activity at this time.