Organizations participating in the Physician Group Demonstration Program from CMS outline why they won't participate in the ACO as structured. And the Center for Medicare and Medicaid Innovation introduces a potentially different approach to ACOs.
CMS is trying to calm the raging waters of the proposed ACO rules by writing editorials in national newspapers and, most recently a webinar from Dr. Berwick and Dr. Gilfillan that suggest things will change in the proposed rules.
In the meantime organizations who have been working with CMS on a shared savings model have suggested that it's time to throw in the towel on the existing rules. Subsequently now CMMI has suggested there may be other ways to participate as an ACO which begin to address the concerns by the PGP demo group and others.
Below read the written summary of the subsequent webinar referenced above and a link to the letter sent to Dr. Berwick by the PGP demonstration program participants.
"Earlier today the Center for Medicare & Medicaid Innovation (CMMI) hosted a teleconference to announce three new initiatives related to the development of accountable care organizations (ACOs). Dr. Berwick opened the call restating the importance of the Three Part Aim: better care, better health, and lower cost. Dr. Berwick stated that he believes that ACOs are one important route to that vision. He explained that there are many competing considerations in developing the ACO rules, such as providing incentives for providers to achieve savings but also ensuring that ACOs do not stint on care, providing data to ACOs but guaranteeing that beneficiary privacy is protected, and ensuring coordination of care but also ensuring that beneficiaries retain the freedom of choice among Medicare providers. Dr. Berwick emphasized the importance of striking the right balance across these competing interests. He then announced three new initiatives:
Pioneer ACO program – an accelerated pathway to forming an ACO for providers that already have the infrastructure and care coordination models in place. This program would allow more sophisticated ACOs to move rapidly from shared savings to a population-based payment model. The Pioneer program would have synergies with the Medicare Shared Savings Program and would be designed to work in coordination with private payers.
Request for comments – on a proposal to provide up-front payments to providers who want to form ACOs. Dr. Berwick stated that some of the early comments on the proposed rule suggest that providers lack access to capital they need to invest in ACOs. The CMMI requests comments on potentially providing early access to shared savings that would allow these ACOs to make such necessary investments.
ACO Learning Sessions – the CMMI will offer four ACO learning sessions to help providers learn to build ACOs. Participation will not be a factor in selecting providers for the ACO programs, but these sessions are designed to give providers access to necessary information.
The call was then opened for questions and answers. Dr. Berwick, Dr. Rick Gilfillan, Peter Lee and Jonathan Blum responded to questions from the audience.
Q: The request for application calls for 50% of total revenues to come from outcomes-based contracts by the end of the second performance year. What does this include, and what is an outcomes-based contract?
A: Pioneer ACOs will be responsible for care coordination and management across their patient panel, including both Medicare and commercial business. For example, commercial payers might account for 25% and Medicare might account for 25%. Outcomes-based means that whether it is shared savings or some other approach, the organization is focusing on outcomes rather than volume of services provided. Pioneer ACOs are encouraged to think about how their contracts will result in achieving the Three Part Aim.
Q: How many quality measures will be required for this program and will they be different from the shared savings proposed rule?
A: We have to look closely to ensure that quality of care is improving. We intend to align the quality metrics with the Shared Savings Program metrics. We will also seek alignment with private payers and look at how this alignment works to achieve the Three Part Aim.
Q: Will there be flexibility on the 50% mandatory EHR requirement in the Pioneer program?
A: In the Pioneer Program, 50% must meet the requirement by 2012. In the Shared Savings Program, the agency is taking comments on the proposed requirement.
Q: Will CMMI look at a methodology where they can meet and help promote ACOs?
A: We realize that there exists a spectrum of care delivery today. The CMMI is offering a range of products that provide opportunities along the spectrum. The pioneer model is intended to move rapidly and show the country what is possible in terms of FFS Medicare. For those who are not as far along on the spectrum, the CMMI is requesting comments on an assistance program and an advance payment program so that advance payment can be made available to establish those capabilities.
Q: Can you go into more detail on the methodology for population-based payments?
A: There is a model approach in the request for applications but the idea is that there would be a reduction in FFS payments and a per-beneficiary population-based payment.
Q: Are there any planned discussions about inclusion of sectors that were excluded from participating in the Shared Savings program? In particular, home care and mental health.
A: Although the statutory model is a primary care-based model, we believe that the overall ACO effort will encourage the development of integrated delivery systems that better manage and coordinate care. ACOs that are serious about the Triple Aim will be reaching out to behavioral health and other providers because that is how you improve population health and shared savings.
In addition, the ACO effort is part of a broader set of activities to support delivery system as it transforms into the future of a seamless coordinated care system. One is the Medicaid health home initiative under which states can apply for reimbursement at 90% for health home services. CMS is working with states to develop programs with a focus on behavioral health and home health services."
To read the letter, click here - PGP ACO Letter (May 12, 2011)2
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