Last Thursday (March 31), the Centers for Medicare and Medicaid Services (CMS) released their proposed rules governing Accountable Care Organizations (ACOs). ACOs are part of the 2010 Affordable Care Act, and are intended to promote a coordinated, cooperative, results-oriented and patient-centered approach to health care.
The Notice of Proposed Rulemaking (NPRM) that was released about ACOs is a 429-page document, and is open for public commentary for a 60-day period. CMS will then respond to all the comments in a final rule to be issued later this year.
About ACOs
First, it is important to recognize that ACOs are a CMS proposal intended for traditional (fee-for-service) Medicare. It is not about commercial care, Medicare Advantage (“Medicare HMO”), or Medicaid.
ACOs are therefore different than other physician and hospital organizations that are focused on commercial-insurance patients. In the 1990s, when Health Maintenance Organizations (HMOs) arose to address the escalating cost of commercial health insurance, there were areas of success and failure. In some parts of the country – notably California, the “home of the delegated model” – large risk-taking physician organizations grew and were successful in managing costs, measuring quality and patient satisfaction, and assuming risk. In fact, the California Association of Physician Groups (CAPG) is a vocal advocate for the “delegated model,” which can offer experience (in the commercial as well as Medicare Advantage areas) that can be useful for ACOs.
ACOs, we must remember, are about fee-for-service Medicare. However, CMS-led programs have a great influence on the rest of the insurance field (CMS has been described as “the 800-lb gorilla in the room”), and it would not be surprising if ACOs – once they are up and running and demonstrating effectiveness – become a platform that private, commercial insurers may want to use to deliver a number of their products.
Why ACOs?
The NPRM describes who can form an ACO – (1) ACO professionals (i.e. physicians and hospitals meeting the statutory definition) in group practice arrangements; (2) networks of individual practices of ACO professionals; (3) partnerships or joint ventures between hospitals and ACO professionals; (4) hospitals employing ACO professionals; or (5) other Medicare providers and suppliers as determined by the Secretary.
Cost containment is a big driver for ACOs. In a press interview on the day of the NPRM release, HHS Secretary Kathleen Sebelius estimated that ACOs could yield a savings of up to $960 million over a three-year period. The concept is to give physicians and others in the ACO a financial incentive to make sure patients get the proper care. “One in every five Medicare beneficiaries who leaves the hospital is back within 30 days,” Sebelius said, adding that in many cases, “it is because they failed to receive the correct follow-up care.”
According to Donald Berwick (CMS Director), “An ACO will be rewarded for providing better care and investing in the health and lives of patients. ACOs are not just a new way to pay for care but a new model for the organization and delivery of care.”
Unlike HMO or other risk-sharing structures, however, the ACO proposal allows physicians to continue to bill Medicare in the same fee-for-service fashion they have done in the past, but they also participate at the ACO level in a risk-sharing arrangement with CMS which can reward achievement of specific goals.
What goals must an ACO achieve?
To share in savings, an ACO must meet quality standards in five areas: (1) patient/caregiver care experiences, (2) care coordination, (3) patient safety, (4) preventive health, and (5) at-risk population/frail elderly health.
A set of 63 measures is defined in the NPRM, divided into these 5 domains (see Table 1, on pages 174-194 of the document). Many of these criteria, particularly in the domains of preventive health and management of at-risk populations (e.g. diabetes, heart failure, etc.), overlap with the Clinical Quality Measures of the EHR Incentive Program (“Meaningful Use”).
In fact, one of the requirements of an ACO is that at least 50% of its participants are EHR Meaningful Users.
Of course, the Clinical Quality Measures in Meaningful Use are more limited – an eligible provider needs to demonstrate 3 core, or 3 alternate core measures, plus 3-of-38 menu items (for a total of only 6 items out of 44 possible ones to demonstrate Stage 1 Meaningful Use). An ACO, on the other hand, will need to report on all 63 measures.
The care coordination/information systems domain of ACO standards include the percentage of member physicians who are Stage 1 Meaningful Users, percentage of Primary Care Physicians (PCPs) who are Stage 1 Meaningful Users, percentage of PCPs who use Clinical Decision Support (a Meaningful Use core measure), and percentage of PCPs who are successful electronic prescribers (also a Meaningful Use core measure).
Some of the measures (the patient/caregiver care experiences domain) are based on patient-satisfaction surveys: timely care, doctor communication, respectfulness of the office staff, patient rating of the doctor, health promotion and education, and shared decision making. These items, which have been measured in Pay-For-Performance settings in commercial insurance (HMO) settings, have been done by independent surveys sent to patients. They have not (yet) been systematically embedded into Electronic Health Record systems (via patient-facing portals or post-visit emails), but ACOs may provide impetus to build this functionality.
Conclusions
ACOs represent a new attempt at providing a coordinated infrastructure for delivering health care, which (in theory) will save overall health care costs by keeping people healthier (and incentivizing health care providers to achieve this). There are a set of significant measures that an ACO must achieve to access a portion of these savings. Many of these measures use the Meaningful Use incentives as a starting point, and add additional elements beyond that. In fact, there is a presumption that ACO participants will be EHR Meaningful Users.
Anyone with opinions about how ACOs should be constructed, incentivized, and measured should review the NPRM and respond during this 60-day open-comment period.
Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR
