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Accountable Care Organizations in California: Programmatic and Legal Considerations

Manatt Health Solutions

Health reform includes ambitious experiments to improve coordination of care. This report examines whether California's regulatory framework can support new ACO models.

The Affordable Care Act (ACA) authorizes the federal government to test new health care payment and delivery models through accountable care organizations (ACOs). New federal rules have been proposed for two ambitious ACO programs: the Medicare Shared Savings Program (MSSP) and the Pioneer program. These proposed rules, together with a companion framework for granting waivers under federal Stark and antikickback laws, and gainsharing provisions of the Civil Monetary Penalties Law, present a bold framework for care delivery and payment.

As California's state lawmakers and stakeholders examine the ACO marketplace, they will need to assess whether the state's policy and regulatory framework supports or hinders ACO growth, as well as consider changes that would enable ACOs to thrive.

This paper provides a starting point for the identification and discussion of policy and regulatory issues likely to arise in connection with MSSP, Pioneer, and commercial ACOs in California. It addresses:

  • The MSSP Proposed Rule, the ACO Pioneer program, and background information on the California marketplace
  • Past and current efforts to launch delivery system reforms with goals similar to the federal ACO initiatives
  • How California's statutes and regulations may influence ACO development
  • Policy issues that will need to be addressed should lawmakers decide to support and foster ACOs

The complete paper is available as a Document Download.

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