CMS releases ACO guidelines

Plus, check out new ACO resources for family physicians

After months of delays, 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 among 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 time 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.”

Organizations must apply to join the program, providing information such as how they plan to deliver high-quality care at lower costs for their patients. But not all will be accepted. Those who are approved must participate for three years and, during that time, must comply with a monitoring program that includes analysis of claims, financial data, and quality data; site visits; patient surveys; and quarterly and annual reports.

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 repay Medicare if it does not meet the benchmarks, a key difference from initial proposals. However, even the poorest performer would repay, at most, 10 percent of what Medicare would have spent on those patients if they weren’t in the ACO.

Additionally, “shared losses” wouldn’t start immediately depending on which track the ACO chooses. One track allows an ACO to operate on a shared-savings-only basis for the first two years, then assume the risk for shared losses in the third year. These ACOs would be eligible for smaller bonuses of up to 50 percent of any savings it generates and would face potential penalties of up to 7.5 percent 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—up to 60 percent—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.

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.

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. This only applies to ACOs that cover less than a third of the local market unless they are blatantly violating competition laws. Larger ACOs would be evaluated by the Federal Trade Commission within 90 days of application to determine if they would violate antitrust laws. ACOs in rural areas may be eligible for additional exemptions.

Stakeholders have until June 6 to submit comments on the draft regulations for CMS to consider when developing the final regulations. Those should be published later this year.

AAFP, TAFP release new ACO resources for family physicians

To assist members in exploring practice style options and ACOs, AAFP and a coalition of six state chapters—including TAFP—have developed new resources.

The first resource, “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, all from the perspective of a family physician. The guide considers 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 second resource, “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 to the family physician.

Both of these documents and more are available on TAFP’s website, www.tafp.org/practice-resources. 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.