(ACO) regulations - American Society of Anesthesiologists

CMS-1345-P 94
others involved in the beneficiary's care, and providing it in a format that is actionable by
the beneficiary.
We are requesting comments on our proposal that ACOs be required to
demonstrate use of individualized care plans for targeted beneficiary populations in order
to be eligible for the Shared Savings Program. In order to satisfy this requirement fully,
we propose that the development of such individualized care plans must grow from
adherence of a related patient-centeredness criterion, that is, their development should be
a result of shared decision-making which fully engages beneficiaries and their families,
taking into account their values and preferences in developing a unique plan of care for
each individual.
The individualized care plans should include identification of community and
other resources to support the beneficiary in following the plan. To this end, we believe
that a process for integrating community resources into the ACO is an important part of
patient centeredness. A wide variety of organizations, although not necessarily ACO
participants, may be considered a community resource, including: employers, commercial
health plans, local businesses, State/local government agencies, local quality
improvement organizations or collaboratives (such as health information exchanges).
Collaboration with these types of community resources can be an important part of
enabling ACOs to take account of the entirety of Medicare beneficiary population's needs
relative to their environment. Community stakeholder engagement in an ACO could be
explicitly incorporated via community representation on the governing body, by having a
community representative on an advisory board, or by other innovative mechanisms.