NEJM publishes ACO perspectve from Dr. Berwick

Last week the NEJM published Don Berwick's perspective on the ACO proposed rules just released two weeks ago.  There are concerns with these proposed rules some of which are documented below.

 The following is a quote from the NEJM article:

"A critical foundation of the proposed rule is its unwavering focus on patients. We envision that successful ACOs will honor individual preferences and will engage patients in shared decision making about diagnostic and therapeutic options. Information  management — making sure patients and all health care providers have the right information at the point of care — will be a core competency of ACOs". We are concerned that the rules as proposed are too focused on Medicare saving money and not enough focused on improving patient care. While this is understandable as the Medicare program is in trouble financially and Congress is eyeing major cuts which could be a serious threat to delivering care that many seniors rely on, we encourage more experimentation with how ACO's can improve quality of care and simultaneously reduce cost.  At this point, the ACO is only a theory which is based on little evidence. Making hospitals and doctors come together in a formal structure when they don't necessarily want to may or may not garner better patient care. We need to experiment with this new idea before etching into the fabric of CMS. The notion of running experiments to test the ACO hypothesis is specifically allowed by federal law.  The Affordable Care Act created the Center for Medicare and Medicaid Innovation , which is designed to allow for such rapid tests of change to determine what works and what doesn't  with pdsa cycles allowing for improvement quickly. We are concerned about CMS first pursuing broad ACO regulations that are 428 pages long despite their length can't possibly address all the issues that will come up in testing a radically new way to to pay hospitals and physicians.  It may be difficult to get organizations to take the leap to try a new way when there is not much incentive to do so. On this site we have argued vigorously that Medicare and other payors should pay based on value created for the patient. Value defined as Quality/Cost. This value is created at the level of the patient condition not in structures far removed from what the patient experiences. In a value based world bigger is not better. Accepting risk is not important but delivering higher quality lower cost care to patients is rewarded by insurers and government payors. The following are just 5 of many questions we will need to get answers to for ACOs to be successful. 1.        Since there is no risk adjustment for the performance period how do participants know they have been fairly compensated for the types of patients they are caring for? 2.        There are no waivers for fraud and abuse so how closely can doctors and hospitals actually work together without getting into legal trouble? 3.        There is no prospective analysis of performance so how do organizations that participate know if the new process they put in place to reduce cost and improve quality actually worked for the Medicare enrollees. 4.        There is no clear definition of what quality performance needs to be until after the participants sign up and no data sharing until that happens either. How does the ACO know whether the targets are even achievable. 5.        In the shared savings approach the upside potential in the "two sided" model is tiny so why would any organization opt for this model?

These are only a few of the problems identified by our team. The Center will be commenting on the proposed rules. My hope is CMS and Dr. Berwick will carefully review the many issues and make good decisions that will improve value delivery to patients.

The following is his NEJM article -

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