Final ACO rule released

CMS released the final ACO rule on 10/20/11.  The following is a summary of the conference call CMS held and the documents that were released regarding the final rule. MedPak, the committee which recommends Medicare payment changes to Congres has recently suggested that in order to move more providers off of fee for service there may need to be bigger fee for service cuts in payments to physicians and hospitals. That's why this recent final rule on ACOs and medicare shared savings is important as it may be the beginning of the new payment system in American healthcare. In following blogs we will be addressing the Physician Self Referral law and anti-trust regulations associated with ACOs. The following is a summary of the call Dr. Berwick led on 10/2011.   "CMS Administrator Dr. Donald Berwick gave opening remarks highlighting the importance of the ACO program.  He stated that ACOs represent a major step forward in transforming not only Medicare but Medicaid, CHIP and the entire health care system.   Dr. Rick Gilfillan, Acting Director of the CMMI, then introduced the ACO Advance Payment Model.  He stated that the model will help support shared savings ACOs with up front investments.  The program will provide payment in advance, which will be recouped as the ACO achieves shared savings.  This is intended to provide an “on-ramp” for organizations that want to achieve the three part aim.  Dr. Gilfillan stated that through the shared savings program, advance payment model, pioneer program and accelerated learning sessions, CMS is seeking to meet providers where they are in terms of their ability to deliver safe, seamless care.   Jonathan Blum, Deputy Administrator and Director of the Center for Medicare, then described a high level overview of the changes in the final rule.  He stated that the agency sought to make a stronger business case for organizations to participate in the program.  He stated that there are still two tracks, but track one now has only one-sided risk while a second track has two-sided risk.  He said that combined with the Pioneer program, these options create multiple opportunities for participation.  He stated that they have scaled back the quality measures in response to comments and have selected 33 key quality measures for organizations to focus on.  CMS has changed the rules for governance to provide more flexible governing structures.  The final rule will allow services provided by FQHCs to count for beneficiary assignment to give those organizations the opportunity to participate.  He stated that there is a more flexible beneficiary assignment process and what he called “preliminary prospective assignment” that seeks to strike a balance between providing information up front, protecting beneficiaries, and not holding an organization responsible for care when the beneficiary is no longer receiving care from that organization.  He said that they are providing more up to date Part A, Part B and Part D claims information while maintaining patient privacy.   The call was then opened for questions and answers.   Q: If a primary care physician (PCP) is on staff at two hospitals and invited by both to participate in their ACOs, can the PCP participate in both? A: Yes, a PCP could participate in more than one ACO under the assignment methodology in the final rule.  The assignment algorithm looks at Medicare-enrolled TINs that bill Medicare.  The TINs that join together to create an ACO and those that bill primary care services must be exclusive to single Medicare shared savings ACO.  As a practitioner that bills through a TIN, it’s the one with the ACO that has to be exclusive.   Q: When will patients receive care in ACO? A: CMS will begin receiving applications on January 1.  The first start dates for the shared savings program are April 1 and July 1.  Pioneer ACOs will be announced later this fall.  CMS anticipates that new ACOs will join the program in years to come.   Q:  Can a subset of PCPs in a large group participate or is it all or nothing for the group in terms of participation? A: All or nothing.  Physicians are assigned to the ACO as a TIN, so the entire TIN has to participate. Q: With regards to proposed quality measures, must we achieve all 33 to receive funding? A: CMS is finalizing 33 measures, including clinical outcome and process measures.  ACOs will be required to report on all measures each year.  However, the measures are phased in over the 3-year period.  In performance year 1, the quality requirement is satisfied by complete and accurate reporting of all measures.  In subsequent years, quality requirements are phased in to performance on tiered basis.   Q: Can an organization participate in the bundling pilot and shared savings ACO?  And if so, how does the discount in bundling initiative apply? A: CMS expects that organizations may participate in both and will make adjustments to prevent giving double credit for the same patients.  More specifics will be forthcoming. Q: Why is home health excluded from the ACO program? A: Any Medicare supplier can choose to participate within an ACO, issue is what counts for assignment or how CMS assigns patients to an ACO.  However, we hope that ACO participating providers build stronger networks and processes for post acute care and creates opportunities for home health and other services". To read more about the ACO rule, please click here - 2011-27461_PI (2)  

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