CMS releases ACO guidelines

Plus, check out new resources for family physicians

posted 04.04.11

After months of delay, the Centers for Medicare and Medicaid Services released the draft regulations for the Medicare Shared Savings Program on Thursday, March 31. This program aims to improve the quality and reduce the cost of providing care to Medicare patients by encouraging collaboration of physicians, hospitals, and long-term facilities.

Accountable Care Organizations have long been popular among academic and policy groups, but ACOs began gathering steam recently when the concept appeared as part of the Patient Protection and Affordable Care Act. Described in just six pages of the health care reform bill, stakeholders have waited for the draft regulations to answer their lingering questions. How will incentive payments work? How will quality improvement be assessed? Will patients be assigned to an ACO or will they “pick” one in which to participate? Where do anti-trust laws come in?

Though it will take longer than a few days to sort through the new 429-page document, some of these questions can be addressed immediately. According to a CMS fact sheet, “The Medicare Shared Savings Program will reward ACOs that lower growth in health care costs while meeting performance standards on quality of care and putting patients first. Patient and provider participation in an ACO is purely voluntary.”

Regarding anti-trust, two sections give the secretary of Health and Human Services the authority to waive fraud and abuse laws to achieve the goals of ACOs. These include the physician self-referral law, the anti-kickback statute, and the civil monetary penalty law.

Under the rule, patients are not assigned to ACOs. Rather, Medicare will take a retrospective look at where a beneficiary received services to determine whether a particular ACO should be credited for improvements in care and costs. Physicians would need to notify a patient that the practice is participating in an ACO, and whether they share the patient’s claims data with an ACO.

Physicians who choose to join an ACO would continue to receive payments under the current fee-for-service system. The proposed rule calls for CMS to establish a benchmark for savings to be achieved by each ACO. While an ACO would receive a share of the savings it generates, the organization could have to pay Medicare if it does not meet the benchmark.

These “shared losses” wouldn’t start immediately, depending on which track the ACO chooses. The first track allows an ACO to operate on a shared-savings-only track for the first two years, then assume the risk for shared losses in the third year. The second track allows ACOs to share in savings and risk liability for losses from the start, but receive a higher share of any savings it generates.

The rule calls for the establishment of quality performance measures and a method for linking quality and financial performance. The ACO would have to establish procedures to promote evidence-based medicine and patient engagement.

Stakeholders have 60 days to submit comments on the draft regulations for CMS to consider when developing the final regulations.

AAFP releases new ACO resources for family physicians

AAFP and a coalition of six state chapters—including TAFP—have developed two new resources to assist members in exploring practice style options and ACOs. From the strategic perspective of a family physician, The Family Physician’s Practice Affiliation Guide explores the trends driving physicians toward collaboration and affiliation, weighs the advantages and disadvantages of various affiliation options, and provides a detailed analysis of the hospital employment model. It looks at legal implications of various practice affiliations, and how the patient-centered medical home can be incorporated into these models. According to the guide’s introduction, “There are compelling ‘offensive’ and ‘defensive’ reasons to consider integration and specific guideposts to assure a successful and sustainable partnership.”

The Family Physician’s ACO Blueprint for Success is a two-part guide to help family physicians develop their strategy to evaluate and implement a successful accountable care organization. Part one examines these new organizations and identifies essential elements, generally addressing specialties and facilities. Part two applies the principles and processes of the guide specifically for the family physician.

Both of these documents are available on AAFP’s Practice Affiliation Options webpage. Other members-only materials on the webpage include:

• Resources for Employed Physicians,
• State Restrictions on Owning a Practice,
• Interested in ACOs?, and
• Other Practice Affiliation Options.

As federal and state health care reforms roll out, AAFP and TAFP will continue working together to provide you with the most up-to-date information for your practice. View additional resources on the new Health Care Reform Resources page of the TAFP website.